Americans may not be getting enough of this vitamin, which is essential for immunity, fertility, brain health, and more. Vitamin E deficiency may be associated with cancer, heart disease, and dementia. Read on to learn how to recognize the symptoms and boost your vitamin E levels naturally.
What is Vitamin E?
Vitamin E is a broad term for two types of fat-soluble nutrients – tocopherols and tocotrienols – each containing four different classes: alpha, beta, gamma, and delta. The most abundant forms in food are alpha- and gamma-tocopherol [1, 2].
Alpha-tocopherol is the essential form of vitamin E that can meet your dietary needs and prevent deficiency symptoms [3].
Function and Health Effects
The primary function of vitamin E in your body is to combat oxidative stress by blocking the activity of free radicals. Along with vitamin C, it protects fat molecules from oxidation, maintaining the structure and function of each cell [2, 4].
Vitamin E plays vital roles in your [3, 5]:
- Heart and brain health
- Immunity
- Skin health
- Fertility
Deficiency in this essential nutrient may thus have detrimental health effects. In this article, we’ll cover the main causes, risks, and ways to prevent and treat vitamin E deficiency.
Diagnosis & Tests
Vitamin E Blood Test
A blood test is the most common lab method to check vitamin E status. Values above 5 mcg/mL (11.6 μmol/L) of alpha-tocopherol are considered normal, but some people might benefit from higher levels [5].
High gamma-tocopherol may also imply alpha-tocopherol deficiency because their blood levels increases at each other’s expense. However, both forms have some unique functions and health benefits discussed below [5, 6, 7].
Limitations and Other Tests
Vitamin E is fat-soluble, meaning that lipids must carry it through the bloodstream. High blood lipids (as in older or obese people) increase the amount of vitamin E in the blood but also hinder its transport into other tissues [8, 9, 10].
That’s why blood levels of vitamin E don’t always correlate with its intake and may not provide a clear picture of its status in your body. Experts suggest the ratio of alpha-tocopherol to cholesterol (or total lipids) is a more accurate indicator of vitamin E status [11, 12].
You should fast before your vitamin E blood test to minimize the effect of triglycerides [13].
Besides lab testing, a doctor can perform neurological and physical exams to look for signs and symptoms of vitamin E deficiency. We’ll discuss those in more detail later in this post.
Advanced genetic tests can detect mutations that hinder vitamin E metabolism [14].
Signs & Symptoms
Mild vitamin E deficiency usually goes unnoticed. More severe cases may cause muscle weakness, vision problems, and cognitive impairment [2, 15].
Typical signs and symptoms of vitamin E deficiency are more common in children; they have limited stores and increased needs because of how quickly they grow and develop [10].
Skin Health
Vitamin E is an essential nutrient for your skin as it [16, 17, 18, 19]:
- Inhibits lipid peroxidation
- Combats photoaging and UV damage
- Reduces inflammation
In rats, vitamin E deficiency leads to oxidative damage of the skin, impaired collagen structure, and skin ulcers [20, 21].
Milder deficiency in humans is unlikely to produce visible skin disorders [22, 23].
Nerve Damage
The most common symptoms of AVED (ataxia with vitamin E deficiency), a rare genetic mutation in the tocopherol transporter, stem from nerve damage and include [15, 3]:
- Muscle weakness
- Impaired coordination
- Vision problems
- Slurred speech
- Poor reflexes
- Numbness
If left untreated, it may progress into blindness, heart damage, and eventually death [24, 25].
Causes
Genetic disorders and impaired fat absorption are the leading causes of vitamin E deficiency in developed countries, while most cases in poor regions of the world occur due to inadequate nutrition [26].
1) Impaired Fat Metabolism
Fats carry vitamin E in the food, enable its absorption, and deliver it to our tissues. Any condition that impairs fat absorption – or the production of lipoproteins that carry vitamin E through the bloodstream – can cause vitamin E deficiency; these include [27, 28, 29, 30]:
- Cystic fibrosis
- Short bowel syndrome
- Celiac disease
- Abetalipoproteinemia (a rare inherited disorder)
- Crohn’s disease
The liver produces bile acids, which enable fats to be absorbed. The following disorders can cause vitamin E deficiency by compromising liver function and bile flow into the intestines [1, 31, 10, 32]:
- Primary biliary cholangitis (destruction of the bile duct)
- Cholestasis (reduced or blocked bile flow)
- Nonalcoholic fatty liver disease
2) Genetics
Your liver sends alpha-tocopherol to other tissues using a transport protein called α-TTP. Defects in the TTPA gene (which encodes α-TTP) cause severe vitamin deficiency with blood levels up to 100 times lower than normal [1, 33].
The syndrome that results from this mutation is called ataxia with vitamin E deficiency (AVED). It manifests in late childhood, between 5-15 years of age [1, 14].
Supplementation with high doses of vitamin E from early childhood is essential to prevent permanent nerve damage [34].
3) Malnutrition
Inadequate food intake or malnutrition is the primary cause of vitamin E deficiency in developing countries. In severely malnourished children, a lack of this nutrient can have detrimental health effects [15, 35].
Besides vitamin E content, diets low in fat, protein, and calories increase the risk of deficiency due to general malnutrition.
Vitamin E intake may be problematic in the US, but the data are conflicting. To stay on the safe side, it’s a good idea to be mindful of your diet and food sources of vitamin E, which is essential for immunity [36].
Some estimates that rely on surveys suggest that over 90% of the US population don’t get adequate amounts of dietary vitamin E [10, 37, 38].
On the other hand, national reports that rely on vitamin E blood levels say otherwise. According to them, under 1% of the US population aren’t consuming enough vitamin E. Experts say more high-quality analyses are needed to determine how big of a concern vitamin E intake is for Americans [39].
Choosing the right food source is also important; people who rely on sweets and baked products as their primary source tend to have lower blood levels of alpha-tocopherol [40].
Low Intake of Vitamin C
Vitamins C and E work hand in hand to shield your cells against oxidative damage. Vitamin C regenerates the antioxidant form of alpha-tocopherol that can scavenge free radicals [1].
Low intake of vitamin C may thus increase the risk of vitamin E deficiency, especially in smokers and other people exposed to higher levels of oxidative stress [41, 42].
4) Obesity
Obese children and adults usually have high lipids and normal vitamin E in the blood. Lipids bind to vitamin E, lowering the ratio of alpha-tocopherol to cholesterol.
In other words, high cholesterol and lipids keep vitamin E “trapped” in the bloodstream, so obese people can’t use it well. This may point to deficiency, even with vitamin E in the normal range [43, 44, 45].
Additionally, obese people often suffer from inflammation and oxidative stress, which increases their demand for vitamin E [46, 47].
5) Smoking
Smoking ignites a free-radical storm in your lungs and entire body, drastically increasing demand for antioxidants and depleting vitamin E [48, 49].
Studies have confirmed that smokers, particularly women, have significantly lower blood levels of alpha-tocopherol [50, 51, 52].
Health Risks and Associated Conditions
Healthy people with lower vitamin E intake and blood levels won’t experience typical deficiency symptoms. However, severe deficits in this nutrient may be associated with various chronic conditions.
1) Impaired Immunity
Vitamin E is an essential part of your immune response. It shields the immune cells against oxidative stress and boosts their activity [53].
Vitamin E deficiency impairs T-cell immune response, making the body more prone to infectious and chronic diseases. According to studies on older people, higher vitamin E intake lowers the risk of bacterial and viral infections. Scientists observed the same trend in lab animals [54, 55, 56].
In preliminary trials on HIV patients, vitamin E supplementation improved drug treatment efficacy, slowed down the progression into AIDS, and prevented other infections. Researchers underlined the need for further, well-designed clinical trials [57, 58].
2) Cancer
People with low vitamin E lack its powerful immune-boosting and anticancer properties.
In a meta-analysis of eight clinical trials, higher blood alpha-tocopherol was associated with significantly lower rates of cancer [59].
In a study of over 29,000 male smokers, those with high alpha-tocopherol had 21% lower cancer death rates [60].
Women with the lowest levels of alpha-tocopherol had up to 60% higher rates of cancer in a study of over 15,000 participants [61].
More precisely, low vitamin E levels may be associated with:
- Malignant melanoma (skin cancer) [62]
- Oral cancer [63]
- Prostate cancer [64, 65]
- Pancreatic cancer [66]
- Colorectal cancer [67, 68]
Certain vitamin E-related genetic mutations increase blood alpha-tocopherol, and they are negatively associated with prostate cancer. These include [69]:
- rs964184 (in the ZPR1 gene)
- rs11057830 (in the SCARB1 gene)
However, vitamin E supplements may have opposite effects, discussed in the “Supplements” section [70].
3) Heart Disease and Stroke
Antioxidants like vitamin E are crucial for a healthy heart and blood vessels. They prevent the oxidation of LDL cholesterol particles and reduce plaque buildup. Additionally, Vitamin E lowers inflammation and strengthens the immune system [71, 72].
In a large meta-analysis, people with the highest blood levels of alpha-tocopherol had 18% lower death rates from a stroke or heart failure. A study of over 29,000 male smokers found a similar correlation between vitamin E supplements and heart disease [73, 60].
Among 1,000 patients with irregular heartbeats, those with a low ratio of alpha-tocopherol to cholesterol (less than 4.2 micromol/mmol of cholesterol) had 87% higher rates of heart attack or stroke [74].
However, a meta-analysis of 15 trials failed to confirm the benefits of high vitamin E levels on heart health [59].
4) Reduced Fertility
Scientists discovered vitamin E almost 100 years ago and quickly identified it as an essential food component for reproductive health in animals. Recent findings have confirmed its vital role in human fertility and reproduction [1, 75].
In over 1,600 pregnant women from a poor region in Bangladesh, alpha-tocopherol below 12 μmol/L in the 1st trimester increased miscarriage rates by 83% [76].
Vitamin E may boost ovarian function and fertility in women who are trying to conceive [77, 78].
In 40 infertile men, a supplement with alpha-tocopherol enhanced sperm density by 80%, which resulted in 18 successful pregnancies. Besides vitamin E, the supplement contained L-carnitine, coenzyme Q10 (ubiquinol), and vitamin C [79].
5) Stunted Growth and Birth Complications
Besides conception and early pregnancy, vitamin E is essential for fetal development, childbirth, and an infant’s growth.
A study on 900 infants emphasized vitamin E deficiency as one of the risk factors for low birth weight [80].
High levels of alpha-tocopherol during pregnancy may support fetal growth, increase birth weight, and boost cognitive function in children [81, 82].
6) Cognitive Impairment
Vitamin E supports nervous system function and development, and brain cells are especially vulnerable to deficiency [83].
Clinical trials have observed low vitamin E levels in patients with Alzheimer’s disease and in those with mild cognitive impairment [84, 85].
According to studies of 89 adults and 71 children with cystic fibrosis, low alpha-tocopherol levels are linked with low cognitive scores [86, 87].
In mice, vitamin E deficiency damages neurons in the hippocampus, worsening their memory and cognition [88, 89].
7) Weak Bones
According to a study of over 61,000 older women, lower intake of alpha-tocopherol (less than 4.5 mg/day) is associated with 86% higher rates of hip fractures. In over 1,000 older men, those with a lower intake had hip fractures three times more often [90].
In over 2,500 older subjects, those with the lowest alpha-tocopherol (0.5–22.6 μmol/L) had up to 51% higher rates of hip fractures. Women with higher levels of blood vitamin E also tend to recover faster [91, 92].
However, a trial with over 11,000 older women found no connection between dietary intake or blood levels of vitamin E and bone mineral density [93].
In two studies with older people, those with high levels of alpha-tocopherol actually had lower bone mineral density and enhanced loss of bone tissue [94, 95].
The use of vitamin E supplements has also shown mixed effects on bone health [96, 97, 90].
8) Vision Problems
The eye cells contain high amounts of unsaturated fatty acids, which are vulnerable to oxidation. Vitamin E supports vision by preventing oxidative damage in the eyes [98].
In two trials of 540 older people, those with a higher ratio of alpha-tocopherol to cholesterol (greater than 5.6 μmol/mmol) had two times lower rates of cataracts [99, 100].
Rats with vitamin E deficiency suffer lipid damage in the retina and other parts of the eye, which hinders their eyesight [101, 102].
Vitamin E Deficiency Treatment and Prevention
People at risk of vitamin E deficiency – such as smokers, malnourished people, and those with fat malabsorption – should speak to their doctor about dietary changes, supplements, and monitoring their vitamin E levels.
Treatment
A doctor will first try to identify and address the underlying cause of vitamin E deficiency, such as fat malabsorption or another metabolic disorder.
To correct nutritional status, they may prescribe oral vitamin E supplements (15-25 mg/kg daily or 200 IU of mixed tocopherols). Patients with impaired absorption may receive intramuscular injections [26].
Daily Requirements
The recommended daily intake of vitamin E for adults is 15 mg (22.4 IU). Pregnant women need the same amount, while nursing women need 19 mg (28.4 IU) per day [103].
Increased intake and higher blood levels offer certain health benefits, but, as we’ll discuss shortly, more is not always better when it comes to vitamin E.
Food Sources
The best way to boost vitamin E naturally is to consume a variety of vitamin E-rich foods. The best sources include [104, 105]:
- Wheat germ oil
- Sunflower seeds and oil
- Nuts (almonds and hazelnuts)
- Peanuts
- Spinach
- Broccoli
Other vegetable oils (e.g., corn and canola) are high in vitamin E, but you may want to focus on whole foods, as they contain many other healthy nutrients that will help you balance your diet.
Nutrition Tips
People who eat a lot of sweets, bread, meat, and potatoes tend to have lower alpha-tocopherol levels; it might be a good idea to limit the intake of these foods in favor of green vegetables and nuts [106].
Another way to boost your vitamin E levels is to partly replace saturated fats (such as dairy and animal fats) with polyunsaturated fats from vegetable oils, nuts, and seeds.
Polyunsaturated fatty acids (PUFAs) may also reduce cholesterol, leading to a higher tocopherol:cholesterol ratio [107].
Eggs and high-fat meals will enhance vitamin E absorption from foods and supplements, but you should consume them in moderation and monitor your blood lipids [108, 45, 109].
Vitamin C restores alpha-tocopherol and supports its antioxidant effects. To keep your vitamin E status high, make sure to eat vitamin C-rich foods such as [1, 110]:
- Citrus fruits
- Red pepper
- Kiwi
- Strawberries
- Tomatoes
Lifestyle
Smoking depletes vitamin E and increases your demand for dietary antioxidants [50, 51, 52].
Obesity may cause higher blood levels of vitamin E, but it impairs uptake into the tissues, increases your vitamin E needs, and worsens your tocopherol:cholesterol ratio [43, 44].
Supplements
If you notice the symptoms of nerve damage and suspect vitamin E deficiency, seek medical attention immediately. Using high-dose vitamin E supplements without medical supervision can be dangerous and may not address your condition properly.
Who should take them?
Severe vitamin E deficiency – due to genetic defects or chronic diseases – requires lifelong supplementation with high doses of vitamin E to prevent nerve damage and other complications [14, 10, 111].
According to a study on smokers, vitamin C supplements (1000 mg daily for 2 weeks) can help retain vitamin E in the bloodstream 25-45% longer [48].
Vitamin E supplements may also be an option for those who struggle to maintain adequate intake or have increased needs. However, they come with certain health risks.
Toxicity and Side Effects
You can’t overdose on vitamin E from food sources, but high-dose supplements are a potential threat. The safe upper limit is 1000 mg daily, which is equivalent to 1100 IU of synthetic or 1500 IU of natural alpha-tocopherol [103].
Higher doses might cause cell damage and symptoms such as [112, 113]:
- Fatigue
- Acne
- Cramps
- Diarrhea
- Mood swings
Drug Interactions
People on blood thinners should avoid vitamin E supplements as high levels may increase the risk of bleeding [114].
Health Risks
Excess alpha-tocopherol from supplements reduces blood levels of gamma-tocopherol and may increase the risk of [115, 6, 96, 116, 117, 70, 97]:
- Inflammation
- Atherosclerosis
- Prostate and breast cancer
- Fractures
According to a large meta-analysis of 19 clinical trials (over 136,000 participants), daily doses above 400 IU may even be associated with increased mortality. However, most studies were conducted on people with advanced chronic diseases, which likely influenced the results [118].
An additional review, which included even more data, confirmed the impact of other diseases and sex difference, with a higher risk for men. High doses of vitamin E are therefore not recommended unless prescribed by a doctor [119].
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Takeaway
Vitamin E (alpha-tocopherol) is essential for nerve development, fertility, skin health, and immunity. Extremely low vitamin E levels may reduce fertility and cause muscle, nerve, and skin damage.
An inadequate diet, smoking, and obesity can cause a mild deficiency. More severe deficiency occurs due to genetic disorders or diseases that impair fat metabolism. The lack of this nutrient is associated with impaired immunity, heart disease, cancer, and dementia.
To boost vitamin E naturally, eat a variety of nuts, seeds, green vegetables, and other whole foods. You should also refrain from smoking, keep weight in check, and get enough vitamin C. To prevent unwanted side effects, avoid high doses of vitamin E supplements and consult with your doctor first.
