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vitamin d3 and iron supplementation in pregnancy
 

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vitamin d3 and iron supplementation in pregnancy helps in correct hematopoiesis

vitamin d3 and iron supplementation in pregnancy helps in correct hematopoiesis

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    vitamin d3 and iron supplementation in pregnancy vitamin d3 and iron supplementation in pregnancy Presentation Transcript

    • Veerendrakumar C.M. MD.,DNBAssociate ProfessorDept of OBG,VIMS,Bellary Thursday, December 22, 2011 dr.veerendrakumar cm 1
    • Vitamin D & Iron Deficiency:Deadly Duo Alien + PredatorThursday, December 22, 2011 dr.veerendrakumar cm 2
    • Vitamin D vitamin or Hormone ??("sunshine" vitamin)  Vitamin D is a fat-soluble vitamin. Fat-soluble vitamins are stored in the bodys fatty tissue  Very few foods naturally contain vitamin D.Thursday, December 22, 2011 dr.veerendrakumar cm 3
    • Thursday, December 22, 2011 dr.veerendrakumar cm 4
    • Thursday, December 22, 2011 dr.veerendrakumar cm 5
    • Contents  Vitamin D status & Deficiency Recap  Clinical Data  Health Implications  Iron Deficiency Anemia status in India  Vitamin D Deficiency & Iron Deficiency Anemia: is there a Link ?  Prevalence  Mechanistic Evidence  Clinical Evidence  SummaryThursday, December 22, 2011 dr.veerendrakumar cm 6
    • Vitamin D Vitamin D is found in the following foods:  Dairy products  Cheese  Butter  Cream  Fortified milk (all milk in the U.S. is fortified with vitamin D)  Fatty fish (such as tuna, salmon, and mackerel)  Oysters  Fortified breakfast cereals, margarine, and soy milkThursday, December 22, 2011 dr.veerendrakumar cm 7
    •  10 to 15 minutes of sunshine three times weekly is enough to produce the bodys requirement of vitamin D. The sun needs to shine on the skin of your face, arms, back, or legs (without sunscreen).  Skin that is exposed to sunshine indoors through a window will not produce vitamin D. Cloudy days, shade, and having dark-colored skin also cut down on the amount of vitamin D the skin makes.Thursday, December 22, 2011 dr.veerendrakumar cm 8
    • RDA  9 - 70 years: 600 IU (15 mcg/day)  Safe upper limit - 4,000 IU/day for children 9 years and older, adults, and pregnant and breast-feeding teens and women  One microgram of cholecalciferol (D3) is the same as 40 IU of vitamin D.Thursday, December 22, 2011 dr.veerendrakumar cm 9
    •  The greater absorption of iron in vivo from ferrous ascorbate [Fe(HL)2] as compared with ferrous sulfate has been ascribed both to retardation or prevention of Fe(II) oxidation by ascorbate and to the existence of Fe(II) as a chelate with ascorbate. Pharm Weekbl Sci 1984 Dec 14;6(6):245-8.Thursday, December 22, 2011 dr.veerendrakumar cm 10
    •  Ascorbic acid (AA), is the most efficient enhancer of non-heme iron absorption when its stability in the food vehicle is ensured. The number of studies investigating the effect of AA on ferrous sulfate absorption far outweighs that of other iron fortificants.  The promotion of iron absorption in the presence of AA is more pronounced in meals containing inhibitors of iron absorption. Meals containing low to medium levels of inhibitors require the addition of AA at a molar ratio of 2:1 (e.g., 20 mg AA: 3 mg iron).  Int J Vitam Nutr Res. 2004 Nov;74(6):403-19.Thursday, December 22, 2011 dr.veerendrakumar cm 11
    • Pregnancy -The most dangerous journey ofmankindThursday, December 22, 2011 dr.veerendrakumar cm 12
    • ANEMIA  40-90% WOMEN AFFECTED  RESPONSIBLE FOR 65% MATERNAL DEATHS (FOGSI- WHO 1996)  CHRONIC MORBIDITYThursday, December 22, 2011 dr.veerendrakumar cm 13
    • Eradicating anemia can save at least 200 mothers a day!Thursday, December 22, 2011 dr.veerendrakumar cm 14
    • Public Health Significance WHO 2008Prevalence of anemia (%) Public health significance < 04.9 No PH problem 05.0 – 19.9 Mild 20.0 – 39.9 Moderate > 40.0 SevereThursday, December 22, 2011 dr.veerendrakumar cm 15
    • Silver shines Gold glitters But… Iron strengthens! Thursday, December 22, 2011 dr.veerendrakumar cm 16
    • Patients have a right to Normal Hb and Receive safe and efficient treatment;  It is the physician’s responsibility to ensure this and,  Where possible, avoid blood transfusion.Thursday, December 22, 2011 dr.veerendrakumar cm 17
    • Anemia is on the increase!!  Economy is ‘better’  More women are educated, empowered  Tons of iron tablets distributed  Fancy iron preparations flood the market  Antenatal clinics are running full !Iron is not reaching its destination!Thursday, December 22, 2011 dr.veerendrakumar cm 18
    • Are we producing a defective generation?Thursday, December 22, 2011 dr.veerendrakumar cm 19
    • More doctors are finally testing patients for vitamin Ddeficiencies…  “Upwards of 70 percent of American adults are vitamin D deficient or insufficient," said cardiologist James OKeefe of St. Lukes Mid-America  Vitamin D prevents heart disease, too  Vitamin D is essential for activating immune system functionThursday, December 22, 2011 dr.veerendrakumar cm 20
    • Vitamin D: Optimum status Ideal >30 ng/ml Acceptable 20-30 ng/ml Insufficient 10-20 ng/ml Deficient <10 ng/mlThursday, December 22, 2011 dr.veerendrakumar cm 21
    • Vitamin D Deficiency:Gender Analysis Indian J Med Res. 2008;127:211-218Thursday, December 22, 2011 dr.veerendrakumar cm 22
    • Vitamin D deficiency in Pregnantwomen and their New born ≈84% Indian women have 25(OH)D values < 22.5 ng/L.Am J Clin Nutr 22, 2011 Thursday, December 2000;72:472-5. dr.veerendrakumar cmAm J Clin Nutr 2005;81:1060-4. 23
    • Vitamin D deficiency in Lactating Women and Breastfed infants 81.1% 66.7% 23.2% 27.1% 19.8% 11.6% Deficiency: <15 ng/ml Insufficiency: 15-20 ng/ml Severe Deficiency: <5 ng/mlThursday, December 22, 2011 dr.veerendrakumar cm Indian J Med Res. 2011;133:267-273 24
    • Vitamin D deficient Mother-Deficient Infant J Pediatr Endocrinol Metab. 2009;22(3):241-6.Thursday, December 22, 2011 dr.veerendrakumar cm 25
    • Retards proliferation and increases differentiation of cellsThursday, December 22, 2011 dr.veerendrakumar cm 26
    • Vitamin D Deficiency: Health Implications Osteomalacia & Rickets Osteoporosis Diabetes Hypertension & CVD & AnemiaThursday, December 22, 2011 dr.veerendrakumar cm Mayo Clin Proc. 2006;81(3):353-373 27
    • 60-90% Indians have Vitamin D Deficiency Indians have Vitamin D Deficiency ~ 50% of those have anemia INDIA Latitude of 22° 00’N Longitude of 77° 00’WThursday, December 22, 2011 dr.veerendrakumar cm 28
    • Vitamin D Deficiency and IronDeficiency Anemia: Is there a Link?Thursday, December 22, 2011 dr.veerendrakumar cm 29
    • Prevalence in Pregnant Women &Infants  Pregnant women with low serum 25(OH)D levels had 46% higher risk of developing anemia. Am J Clin Nutr. 1992;56:533-536  > 50% infants with Iron Deficiency Anemia had low 25(OH)D levels. Plos One2010;5(1):e8770Thursday, December 22, 2011 dr.veerendrakumar cm 30
    • Vitamin D & Iron Deficiency Link inToddlers  20% Asian children had both Vit D Deficiency & Anemia.  Children with Vitamin D deficiency had low Hb and serum iron.Thursday, December 22, 2011 dr.veerendrakumar cm Arch Dis Childhood. 1986;61:843-848 31
    • Vitamin D & Iron Deficiency Link in Children Thursday, December 22, 2011 dr.veerendrakumar cm 32BMJ. 1998;318:28
    • Vitamin D & Iron Deficiency Link:The Hen or Egg? Mechanistic EvidenceThursday, December 22, 2011 dr.veerendrakumar cm 33
    • Vitamin D Deficiency causes Anemia Plausible Mechanism # 1  Vitamin D receptors are present in bone marrow.  Hematons (buffy coat of bone marrow containing erythroid precursors) shown to contain high concentration of D25 & 1,25-hydroxyvitamin D.  Thus Vitamin D deficiency could result in reduced activation of erythroid precursors, causing anemia.2Endocrinology.2006;147(12):5542-5548 Thursday, December 22, 2011 2. Ann Hepatol. 2010;89:447-452 dr.veerendrakumar cm 34
    • High local concentrations of 1,25(OH)D in hematopoietic tissues may directly activate erythroid precursors cells in a paracrine fashion. Vitamin D Vitamin D supplementation will help the initial phase of erythropoesis. Iron supplementation would be required for the latter phase. Thursday, December 22, 2011 dr.veerendrakumar cm 35
    • Thursday, December 22, 2011 dr.veerendrakumar cm 36
    • Vitamin D Deficiency causes Anemia Plausible Mechanism # 2 Myelofibrosis was observed in children with Vitamin D deficiency induced rickets.1,2,3 Vitamin D Deficiency Reduced activation of Vitamin D receptors in bone marrow Myelofibrosis Impaired Erythropoesis Anemia1. J Pediatr. 1989;114:213-217 2. Canad Med Assoc J. 1966;94:395 3. Indian Pediatr. 2005;42:482-484 Thursday, December 22, 2011 dr.veerendrakumar cm 37
    • Iron Deficiency Causes Vitamin D Deficiency Background Dietary/supplementary Vitamin D absorbed from the intestine, is converted to 25(OH)D in the liver. Some of the 25(OH)D in liver is secreted into bile (mainly (Enterohepatic circulation) as glucuronides) & is reabsrobed by enterohepatic circulation.1,2 Thursday, December 22, 2011 1. Am J Clin Nutr. 1992;56:533-536 dr.veerendrakumar cm 2. Proc Soc Exp Biol Med. 1975;149:570-572 38
    • IDA Causes Vitamin D DeficiencyPlausible Mechanism # 1 Iron Deficiency Anemia Impaired Epithelial Regeneration & Function Abnormal GI mucosa Malabsorption of Fats Pediatrics.1964;33:83-99Thursday, December 22, 2011 dr.veerendrakumar cm 39
    • Malabsorption of Fats Impairment in Bile secretion Impaired Vitamin D absorption & 25(OH)D reabsorption in the intestine Vitamin D DeficiencyThursday, December 22, 2011 dr.veerendrakumar cm 40
    • IDA Causes Vitamin D Deficiency Plausible Mechanism # 2 Iron deficiency inhibits the metabolism of Vitamin D to 25(OH)D. Clinical evidence > 50% Infants with IDA had decreased concentration of 25(OH)D & 24,25(OH)2D despite receiving daily supplements of Vitamin D. Treatment with iron increased the concentrations of both iron & vitamin D metabolites. Increase in serum vitamin D metabolites occurred even when no change was made in the diet or vitamin D supplements. Am J Clin Nutr. 1992;56:533-536 Thursday, December 22, 2011 dr.veerendrakumar cm 41
    • Vitamin D & Iron Deficiency Link:The Hen or Egg? Clinical EvidenceThursday, December 22, 2011 dr.veerendrakumar cm 42
    • Clinical Evidence for therelationship: 1Thursday, December 22, 2011 dr.veerendrakumar cm 43
    • Clinical Evidence for therelationship: 2Thursday, December 22, 2011 dr.veerendrakumar cm 44
    • Study Answers the CrucialQuestion Why is Vitamin D deficiency disease (rickets) prevalent in tropical countries (India) with abundant sunlight?  IDA contributes to the high prevalence because the amount of Vitamin D synthesized in the skin is insufficient. Does not satisfy the infants’ requirements.  Moreover, the absorption of vitamin D in the small intestine is limited, due to IDA resulting in the development of rickets.Thursday, December 22, 2011 dr.veerendrakumar cm 45
    • Study RecommendationsThursday, December 22, 2011 dr.veerendrakumar cm 46
    • Clinical Evidence for therelationship: 3Thursday, December 22, 2011 dr.veerendrakumar cm 47
    • Study Snapshot Significant association, not a mere overlap of the two deficiencies. Children with low Vitamin D concentration had lower hemoglobin and serum iron concentrations. This was particularly noticeable in winter. 50% of children with low Vitamin D concentration were anemic compared to none with vitamin D sufficiency. A combined approach to prophylaxis against iron and vitamin D deficiency should be considered. Thursday, December 22, 2011 dr.veerendrakumar cm 48
    • Vitamin D & Iron Deficiency Link:The Hen or Egg? OR BOTH?Thursday, December 22, 2011 dr.veerendrakumar cm 49
    • Vitamin D Deficiency Impaired Vitamin D absorption & 25(OH)D reabsorption Ineffective Increased erythropoesis inflammation or marrow Impaired myelofibrosis Inhibition of intestinal Vitamin D absorption of Metabolism fats. Iron Deficiency Anemia1.Thursday, December 22, 2011 Am J Clin Nutr. 1992;56(3):533-6 2. Plos One2010;5(1):e8770 dr.veerendrakumar cm 3. Ann Hematol. 2010;89:447-452 50
    • Thus....Vitamin D & Iron Deficiency The Never-ending Vicious Cycle leads to…… A Twin Epidemic To Break the Cycle.......Supplementation with IRON + VITAMIN D would provide optimum benefitThursday, December 22, 2011 dr.veerendrakumar cm 51
    • Recommended Dietary intakes of Vitamin D for patients atrisk for Vitamin D Deficiency Age (Year) IOM(Institute of Medicine) Endocrine Society RDA RDA IU/ Day IU/ Day ng/ml ng/ml 1-18 600 20 1000 30 19-50 600 20 1500-2000 30 50 & above 600-800 20 1500 -2000 30 Pregnancy & 400-600 20 1500-2000 30 Lactation Endocrine society guidelines are suitable for Indian Patients to raise the blood level of 25(OH)D consistently above 30 ng/ml Thursday, December 22, 2011 dr.veerendrakumar cm 52
    • Thus, at a minimum, lactating women may need to take 1400–1500 IU/d, and to satisfy their infant’s requirement, they may need 4000–6000 IU/dThursday, December 22, 2011 dr.veerendrakumar cm 53
    • Evidence of Vitamin D supplement inadults Older than 51 yr  Participants receiving 800 IU/d  Had a 72% lower rate of falls than those taking placebo or a lower dose of vitamin D.  Resulted in a 4–11% gain in lower extremity strength or function and up to 28% improvement in body sway.Thursday, December 22, 2011 dr.veerendrakumar cm 54
    • Summary  Vitamin D deficiency with Iron Deficiency Anemia is prevalent in Indians of all age groups.  The mechanism of IDA leading to Vitamin D Deficiency or vice versa is not fully established.  The available clinical data indicates a vicious cycle of the twin deficiencies.  Supplementation with 1000 IU Vitamin D + 100 mg Iron daily would synergistically improve the status in Indians.Thursday, December 22, 2011 dr.veerendrakumar cm 55
    • More news on… Non calcemic benefits of vitamin DThursday, December 22, 2011 dr.veerendrakumar cm 56
    •  Vitamin D triggers natural immune response against tuberculosis, study finds  Increased vitamin D in blood adds years to life and helps prevent colon cancer  8000 IUs of vitamin D daily necessary to raise blood levels of "miracle" anti-cancer nutrient, declares groundbreaking new research  Low vitamin D levels linked to Parkinsons diseaseThursday, December 22, 2011 dr.veerendrakumar cm 57
    •  Vitamin D grows hair, prevents the flu and reduces arthritis pain  Scientists say higher vitamin D intake will slash cancer, MS, and diabetes risk by half  Crucial vitamin D discovery: deficiency alters lung growth, harms lung function  Low vitamin D levels linked to Parkinsons disease  Diabetics with low vitamin D have high risk of deathThursday, December 22, 2011 dr.veerendrakumar cm 58
    • The ‘SUN’ godThursday, December 22, 2011 dr.veerendrakumar cm 59
    • Welcome to www.wisdombellary.comThursday, December 22, 2011 dr.veerendrakumar cm 60
    • Thursday, December 22, 2011 dr.veerendrakumar cm Thank you 61