**12. Too much of a good thing?**

A state of hypervitaminosis-B3 is also possible. Many conditions common with affluence and greed with a high meat intake (let alone nicotinamide supplementation), are linked to induction of the enzyme NNMT that includes many cancers, Parkinson's disease and obesity and other aspects of the metabolic syndrome,

#### **Figure 3.**

*A solution needs to be found between a more even supply of animal products to the rich and the NAD deficient poor with better farming techniques and supply chains with less waste. Rather than exacerbate climate change this could help through increased human and social capital and reduced risk of zoonoses and political friction.*

including diabetes [112–117]. NNMT detoxifies nicotinamide and is induced by high doses (being absent in herbivores), but consumes valuable methyl groups and nicotinamide overload might over-inhibit NAD-consumer enzymes that are metabolic master molecules (14–16) [118]. Nicotinamide's methylated derivative resembles the dopaminergic neurotoxin MPTP and may, like nicotinamide, be a "double-edged sword". When nicotinamide fortification was introduced in the 1940's (in processed breads), this was never universal and never monitored or aimed at eliminating even classical pellagra worldwide. Furthermore any adverse effects in countries where meat and milk were in ample supply was never investigated even as manufacturers of foods and "high energy" drinks (such as Red Bull) added far more than was necessary for supplementation. Short term there are few signs of toxicity but any adverse effects of nicotinamide overload may be long-term side-effects and harder to spot.

#### **13. Poverty prevention: looking upstream**

Pellagra's history is well worth remembering given that nobody systematically makes sure that it or "pellagra sine pellagra" was eliminated. In addition several acquired infectious or metabolic or multifactorial genetic diseases may be ameliorated by temporary or permanent adjustments in the dose. Many in poverty are at risk given that variances of meat intake are now extreme and their acute infections will cause further NAD depletion in a vicious cycle. Pellagra should have remained a public health concern, doubtless helped by supplementation, but not helped by never being a universal policy or, as a multi-organ disease not being owned by any single specialty. Nicotinamide's toxicity in high meat economies was never monitored over the long-term and is not short of potential mechanisms through affecting NAD-Consumer controlled metabolism directly or via the methylome.

Recent poverty literature rarely indexes pellagra even though it is a paradigm of how economics and both material absolute and more relational social and cultural needs overlap let alone giving a mechanism for the extraordinarily strong correlations between income and life expectancy across countries and, to some extent, relative measures of income inequality within countries [119, 120]. Pellagra is a proven pathology of poverty that could make disputed behavioural mechanisms, such as high-fat high-calorie "fast food" or addictions or poor (economic) habits, or lack of exercise or even stress and psychosocial processes and other "life style drifts" secondary phenomena. The North–South geographies of poverty and ill-health is both explained and our responsibility to repair it given as reparations for exacerbation in colonial exploitative times. The "Mediterranean paradox" when, despite considerable income inequality, there is less than expected health inequality is also more understandable as a healthier omnivorous diet is more affordable here than elsewhere – and not considered as much of a mark of status or "Bourdieuian" distinction [121, 122].

Pellagra links poverty and poor diet to poor human and social capabilities and, we propose, if this need for meat was corrected in a "Moral economy" – as opposed to the worst of neoliberalism and demonisation of the poor and "Precariats" born of austerity – would allow for more equality of opportunity and education across lives and across generations with less discrimination. It would also create a new dawn for researchers and policy makers [123–128].

Many were surprised at how previous well-meaning policy interventions in the developed and less developed world had failed to reduce health inequalities that included welfare systems, such as the free at the point of need NHS. Since the introduction of the NHS the UK has seen an increase in many measures of health inequality including longevity [129–131]. Low income increases exposure to toxins and pollutants and accidents that may be partly to blame (as may poor

#### *Poverty and Pellagra's Penumbras DOI: http://dx.doi.org/10.5772/intechopen.100001*

access compared with the middle classes) but diet that is often squeezed by costs of housing and other understandable social and less materials needs for entertainment and respect is contender. Diet is thought to be at least as important a risk factor for modern diseases as smoking and those that defined poverty as "a family is poor if it cannot afford to eat" may not have been so wide of the mark particularly if transgenerational teratogenic "cycles of disadvantage" are taken in to consideration as many reports on child development and maternal health even 50 years ago emphasised [132–137]. Sorting diet was largely beyond the reaches of the NHS as it is a preventive factor that starts in very early life whereas medical interventions, important as they are, happen late and that may explain their lack of impact on inequality.

Preston curves more optimistically suggest that modest increases in income improves health and happiness quickly with a low ceiling effect and diminishing returns and this is compatible with a climb up Engels curve rather than with improvements in hygiene, health, education or technology [138–144]. Such a materialist effect as the poor eating more meat could be part of a new win-win "Enlightenment" [145]. Dietary dosage or nicotinamide supplements may in addition need to be boosted when individuals have certain mutations or are under stress, whether genotoxic or anoxic/metabolic – or restrained if there really is a hypervitaminosis B3 contributing to diseases of affluence. High meat diets and being NAD-Replete may even help solve the dangers of antibiotic resistance and the emergence of superbugs [146]. The environmental cost of optimising meat intake would be mitigated by affluent countries eating and wasting less but sharing more. The meat supply needs to be safe with the poor not having to rely on "bush meat" or risk food poisoning or old and new zoonoses, such as COVID-19, that are a danger to all [88, 147–149]. Supplementation of nicotinamide alone may however not be enough as animal products contain other helpful micronutrients such as iron and sources of methyl-groups such as choline and vitamin B12.
