decided to enrich foods with the vitamin, since it
was considered that nicotinic acid would be un-
acceptable as a food additive, because of its chemical
(but not metabolic) relationship with nicotine. In the
USA, ‘niacin’ is commonly used to mean nicotinic
acid, and the amide is niacinamide; elsewhere,
‘niacin’ is used as a generic descriptor for nicotinic
acid and/or nicotinamide.
0009 Other early studies showed that feeding additional
protein, and especially the essential amino acid tryp-
tophan, would also prevent or cure pellagra, suggest-
ing that it was a protein-deficiency disease rather than
due to a lack of a vitamin. It was not until 1947 that
the problem was resolved, when it was shown that
tryptophan is a metabolic precursor of the nicotin-
amide moiety of the coenzymes nicotinamide adenine
dinucleotide (NAD) and nicotinamide adenine di-
nucleotide phosphate (NADP). The coenzymes can
be formed in the body either using preformed dietary
niacin or by de novo synthesis from tryptophan.
0010 The reason a maize-based diet predisposes to pel-
lagra is that the proteins of maize are particularly
poor in tryptophan, so that a diet in which there are
few other sources of protein provides insufficient
tryptophan for nicotinamide synthesis. Other cereals,
such as wheat, barley, rye, rice, and millet, contain
enough tryptophan to meet the requirement for niacin
synthesis.
0011 Although maize proteins are poor in tryptophan,
the other cereal associated with pellagra, jowar, pro-
vides a minimally adequate amount of tryptophan to
meet requirements. However, the proteins of jowar
are considerably richer in leucine than most other
proteins, and a diet based largely on jowar provides
a considerable excess of leucine. There is a consider-
able body of evidence that this amino acid imbalance
can be a precipitating factor in the development of
pellagra when the dietary intake of preformed niacin
is extremely low, and the intake of tryptophan is only
marginally adequate. Leucine inhibits kynureninase,
and hence reduces the rate of oxidative metabolism of
tryptophan, resulting in reduced formation of NAD.
In addition, leucine competes with tryptophan for
tissue uptake, and thus has a further inhibitory effect
on the rate of tryptophan oxidative metabolism and
NAD synthesis.
0012 All cereals contain preformed niacin. However, this
is largely present as a variety of nicotinoyl esters,
collectively known as niacytin, which are not hydro-
lyzed by digestive enzymes to any significant extent,
so that most of the niacin present in cereals is nutri-
tionally unavailable. A small proportion of the niacin
present as niacytin (up to about 10%) may be bio-
logically available as a result of nonenzymic hydroly-
sis by gastric acid.
0013Interestingly, pellagra has not been a problem in
Central America, the original home of maize. This is
because of the traditional way in which it is prepared.
Rather than milling the grain, it is steeped overnight
in limewater (calcium hydroxide solution), then
squeezed to form the dough from which tortillas are
made. This alkaline treatment results in hydrolysis of
most of the nicotinoyl esters, so releasing free nico-
tinic acid, which is nutritionally available. Although
maize spread to many countries following its discov-
ery, it was generally milled like other grains rather
than being treated in the traditional Mexican manner.
Clinical Features of Pellagra
Dermatitis
0014Exposure of the skin to modest amounts of sunlight
results in a severe sunburn-like dermatitis in sufferers
(pellagrins). Mechanical pressure can cause similar
lesions, especially around the wrists and ankles. The
skin in the affected areas is red and slightly swollen at
first, and then becomes rough, thickened, cracked,
and dry, with scaling, a shiny surface, and brown
pigmentation.
0015The cause of this photosensitive dermatitis in pel-
lagra is unknown and cannot be attributed to the
known metabolic functions of either tryptophan or
the nicotinamide nucleotide coenzymes. There is some
evidence that there is increased metabolism of the
amino acid histidine in the skin in pellagra, resulting
in a lower than normal concentration of both histi-
dine and an intermediate in its metabolism, urocanic
acid, both of which are believed to have a role in
absorbing ultraviolet light, and so minimizing
damage to the skin from exposure to sunlight. Treat-
ment of pellagrins with niacin both clears the derma-
titis and also increases the concentration of histidine
and urocanic acid in the dermis.
0016The skin lesions of pellagra may be due to second-
ary zinc deficiency when tryptophan intake is inad-
equate or its metabolism is disturbed; they resemble
the lesions seen in acrodermatitis enteropathica,
which is due to a failure to secrete the intestinal
zinc-binding ligand, which is believed to be picolinic
acid – a tryptophan metabolite. There is some evi-
dence that some pellagrins have a poor zinc status,
and the zinc depletion associated with excessive alco-
hol consumption may be a factor in the development
of pellagra among alcoholics.
Diarrhea
0017Although diarrhea is common in pellagrins, it is not a
constant feature of the disease, and indeed in some
PELLAGRA 4457