Vitamin E Deficiency

What vitamin E does

Vitamin E is a group of fat-soluble compounds. Alpha-tocopherol is the only form the body actively keeps. It sits in cell membranes and acts as an antioxidant, stopping chain reactions that damage fats in cell walls. Nerve cells, especially long sensory nerves and the spinocerebellar pathways that control balance, are particularly vulnerable when it is lacking. Vitamin E also protects red blood cells and the retina.

Adults need 15 mg of vitamin E a day. Because the body stores it in fat and the liver, deficiency usually takes years to develop in adults, though it appears faster in children.

Causes

Fat malabsorption (most common)

Vitamin E needs bile and pancreatic enzymes to be absorbed with dietary fat. Anything that impairs fat absorption can cause deficiency:

• cystic fibrosis
• exocrine pancreatic insufficiency and chronic pancreatitis
• cholestatic liver disease, such as primary biliary cholangitis and biliary atresia in children
• Crohn's disease and celiac disease
• short bowel syndrome and weight-loss surgery

Genetic disorders

• Ataxia with vitamin E deficiency (AVED): an inherited defect in the liver protein (alpha-tocopherol transfer protein, from the TTPA gene) that loads vitamin E into the bloodstream. It usually starts between ages 5 and 15 and closely resembles Friedreich ataxia. It is more common in North Africa and the Mediterranean.
• Abetalipoproteinemia: a rare disorder that prevents fat transport in the blood, causing fat malabsorption, retinal disease and neuropathy.

Premature babies

Very low birth weight babies are born with low vitamin E stores. Deficiency can cause hemolytic anemia, in which red blood cells break down early. Preterm formulas and feeds are supplemented to prevent this.

Very poor diet

Extremely low-fat diets or severe malnutrition rarely cause deficiency by themselves.

Symptoms

Symptoms usually develop slowly:

• Peripheral neuropathy: numbness and tingling, especially in the feet, and loss of vibration and position sense
• Ataxia: clumsiness, poor coordination and unsteady walking, worse in the dark or with eyes closed
• Loss of reflexes, especially at the ankles
• Muscle weakness from damage to muscle fibers (myopathy)
• Eye problems: weakness of eye movements, and retinal damage causing poor night vision and narrowing of vision
• Slurred speech in advanced AVED
• Weakened immune response
• Hemolytic anemia in premature infants

In AVED, head tremor (titubation) is a characteristic feature.

How it is diagnosed

• Blood alpha-tocopherol level: in adults, a level below about 5 micrograms per milliliter (11.6 micromoles per liter) indicates deficiency.
• Ratio to blood fats: because vitamin E travels with cholesterol and other fats, people with very low or very high blood lipids can have misleading levels. A ratio of vitamin E to total lipids gives a more accurate picture.
• Tests for the cause: stool elastase or fecal fat for malabsorption, liver tests, celiac antibodies and genetic testing for AVED.
• Nerve conduction studies and an eye exam to assess damage.

Doctors also check other fat-soluble vitamins (A, D and K), which are often low at the same time. See vitamin deficiency neuropathy for related nerve problems.

Treatment

• Vitamin E supplements: doses depend on the cause and blood levels and are set by your doctor. People with malabsorption may need much higher doses than the dietary requirement, and water-miscible (water-soluble) forms absorb better when fat absorption is poor.
• AVED: lifelong high-dose vitamin E. Started early, it can halt progression and sometimes improve symptoms.
• Treating the cause: enzyme replacement for pancreatic insufficiency, a gluten-free diet for celiac disease, and management of liver and bowel disease.
• Monitoring: blood levels are rechecked to confirm a response.
• Rehabilitation: physical therapy for balance and strength.

Nerve damage that has been present for a long time may only partly recover, so early detection matters.

Cautions with supplements

Healthy people rarely need vitamin E supplements. High doses can increase bleeding risk, especially with blood thinners such as warfarin or antiplatelet drugs, and a large trial found that long-term 400 IU daily supplements slightly increased prostate cancer risk in men. Adults should not exceed the upper limit of 1,000 mg a day from supplements unless a doctor is treating a deficiency.

Food sources of vitamin E

• sunflower seeds and almonds
• hazelnuts and peanuts or peanut butter
• wheat germ, sunflower and safflower oils
• spinach, broccoli and other green vegetables
• fortified cereals

Frequently asked questions

What are the symptoms of vitamin E deficiency?

The main symptoms are nerve-related: numbness and tingling in the feet, loss of position sense, unsteady walking, poor coordination, muscle weakness and loss of reflexes. Vision problems, especially poor night vision, can occur. Premature babies may develop anemia from red blood cell breakdown.

What causes vitamin E deficiency?

It is usually caused by conditions that prevent fat absorption, such as cystic fibrosis, pancreatic insufficiency, chronic liver disease, Crohn's disease or bowel surgery. Rare genetic disorders, including ataxia with vitamin E deficiency, and premature birth are other causes. Diet alone rarely causes it.

How long does it take to correct vitamin E deficiency?

Blood levels usually rise within weeks of starting the right supplement. Nerve symptoms improve more slowly, over months, and long-standing damage may not fully reverse. People with ongoing malabsorption or AVED usually need lifelong supplements and monitoring.

Can vitamin E deficiency cause ataxia?

Yes. Vitamin E deficiency damages the spinal cord pathways and nerves that control balance and coordination, causing ataxia. The inherited form, ataxia with vitamin E deficiency, looks very like Friedreich ataxia, which is why vitamin E levels are checked in people with unexplained ataxia.

Should I take vitamin E supplements?

Most healthy people get enough vitamin E from food and do not need supplements. Supplements are recommended for people with diagnosed deficiency or fat malabsorption. High doses can increase bleeding risk and interact with medicines, so talk to your doctor before taking them.