Vitamin C is an essential water-soluble vitamin that plays important roles in collagen synthesis, iron absorption, and as an antioxidant. It supports red blood cell production and helps prevent anemia. The recommended daily intake ranges from 75-90 mg for adults up to 120 mg for lactating women. Large doses above 2g daily can cause side effects like diarrhea. Vitamin C enhances iron absorption when taken together.

1. VITAMIN C (ASCORBIC ACID)
Prepared by Brooke D. Beasley
Typical Usage  Essential water soluble vitamin required for the synthesis of
collagen, an important structural component of blood vessels,
tendons, ligaments, and bone
 Plays an important role in the synthesis of norepinephrine and acts
as an antioxidant
 Enhances absorption of iron; aids in red blood cell production
 Deficiency can lead to anemia, or low red blood cell count
Mechanism of Action  Antioxidant
 Strongly enhances absorption of non-heme iron by reducing ferric
iron to ferrous iron and forming an absorbable, iron-ascorbic acid
complex
Typical Dosage  Concurrent administration of at least 200 mg vitamin C per 30 mg
iron increases iron absorption
RDA recommendations:
Adults (19 yrs+): males 90 mg; females 75 mg
Infants (0-6 mos): 40 mg
Infants (7-12 mos): 50 mg
Children (1-3 yrs): 15 mg
Children (4-8 yrs): 25 mg
Adolescents (14-18 yrs): males 75 mg; females 65 mg
Smokers (19 yrs+): males 125 mg; females 110 mg
Pregnancy: 80 mg
Lactation: 115-120 mg
Safety/DNI  Adverse effects are dose-related and include nausea, vomiting,
esophagitis, heartburn, abdominal cramps, flushing, headache, and
osmotic diarrhea
 UL of 2 g/d recommended to prevent diarrhea and other adverse
effects
 Caution with individuals predisposed to oxalate kidney stone
formation, supplemental vitamin C of 1 g/d may increase stone risk
by 40%
 A number of drugs lower vitamin C levels, requiring an increase in
intake, such as chemotherapy, birth control, PPIs, and aspirin
 Large doses above UL may block the action of Warfarin
Efficacy  Vitamin C improves absorption of non-heme iron when ingested at
the same time. Vitamin C can counteract the effects of substances
which inhibit iron absorption, such as dietary phytates,
polyphenols, and tannins, possibly by chemically reducing iron and
preventing the formation of less soluble ferric compounds.
 Studies demonstrate 250 - 500 mg bid enhances iron absorption

2. Good Manufacturing
Practices
 Vitamin C has been approved by the FDA as a nutrient/dietary
supplement in accordance with good manufacturing practices
(GMP).
 Both natural and synthetic vitamin C are equally recognized and
utilized by the body.
Accessibility  Food Sources
+ Rose hips, 1T tea (2000 mg); red bell pepper, ½C (95 mg);
citrus fruits, medium (40-70 mg); strawberries, 1C (85 mg)
 Supplements
+ Ascorbic acid is widely available in pill, tablet, and powder
forms at many groceries, health food and supplement stores.
+ Vitamin C is available in many forms, but there is little
scientific evidence that any one form is more effective.
Clinical research has used ascorbic acid or sodium ascorbate.
+ Mineral salt forms such as sodium ascorbate and calcium
ascorbate (Ester-C) are buffered and less irritating to GI tract.
+ Supplements commonly contain natural sources of vitamin
C, such as rose hips and/or acerola
+ Costs for supplements range in price from $6.00 (100 caps;
500 mg) to around $40.00 (500 caps; 1000 mg)
Scope of Practice  Green light
 Within scope of practice; be mindful of 2g/d UL
 Ideally suggest food sources first to avoid GI distress
Overall Impressions
and
Recommendations
Plenty of studies available demonstrating enhancements of iron absorption
with consumption of Vitamin C. Some medical providers recommend
Vitamin C supplements along with iron supplements to maximize
absorption. Supplements may be appropriate for some populations with
iron-deficiency anemia that need extra nutritional support. Mineral
ascorbates may be recommended to reduce potential GI distress.
References:
1) Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes for Vitamin A, Vitamin K,
Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese,Molybdenum, Nickel, Silicon, Vanadium
and Zinc. Washington, DC: National Academy Press,2001.
2) National Institute of Health. Office of Dietary Supplement Fact Sheet, “Iron.”
http://ods.od.nih.gov/factsheets/Iron-HealthProfessional/#en17.
3) Linus Pauling Institute. Micronutrient Information Center. "Vitamin C."
http://lpi.oregonstate.edu/infocenter/vitamins/vitaminC/
4) Linus Pauling Institute. Micronutrient Information Center,“Iron.”
http://lpi.oregonstate.edu/infocenter/minerals/iron/
5) Fishman SM, Christian P,West KP. The role of vitamins in the prevention and control of anaemia.
Public Health Nutr 2000; 3:125-50.
6) University of Maryland Medical Center. “Anemia.”
http://www.umm.edu/altmed/articles/anemia-000009.htm

3. SPIRULINA
(ANTHROSPIRA PLATENSIS; BLUE-GREEN ALGAE)
Prepared by Brooke D. Beasley
Typical Usage  Possible use to treat iron deficiency anemia
 High nutritional value (significant source of protein, B vitamins,
beta carotene, Vitamin E, various minerals); used to promote
weight gain, weight loss and for oral leukoplakia
Mechanism of Action  Unclear; chelated iron in spirulina may be more easily absorbed
than many other iron products
 In-vitro studies have suggested spirulina has anti-inflammatory,
antiviral, antitumor, anti-cholesterol, and immunologic properties
Typical Dosage  Insufficient evidence
 Standard dose used for anemia in some studies: 500 mg/d
 500 mg of spirulina typically has 1-3 mg iron
Safety/DNI  Animal studies show little toxicity, even at very high amounts
 Adverse effects may include nausea, vomiting, and
hypersensitivity
 Possible interactions with thyroid medications due to spirulina’s
high iodine content
 Might interfere with immunosuppressants as spirulina seems to
stimulate immune function; caution with Lupus, RA and MS
 Caution with children, pregnancy, breastfeeding, PKU,
hypersensitivity, thyroid conditions
Good Manufacturing
Practices
 There is currently no standardization for spirulina supplements
 Poor quality supplements may be contaminated with toxic
substances called microcystins, or heavy metals like mercury
Efficacy  Unknown; little research on human subjects available
 Iron in spirulina is bio-chelated and has been found to be highly
bioavailable in humans: 1.5-2 mg of iron may be absorbed from a
dose of 10 grams of blue-green algae
 Small study on subjects over 50 yrs with anemia treated with 500
mg/d of Spirulina supplements demonstrated significantly
increased hemoglobin levels after 12 wks of tx
 An animal study with rats found that spirulina promoted greater
iron storage and higher hemoglobin content during pregnancy
Accessibility  Foods
+ Fresh plant; component in drinks, cookies, energy bars
 Supplements
+ Whole plant, dried or freeze-dried
+ Available in capsule, pill, flake or powder form at many health

4. food and supplement stores
+ Costs for supplements range in price from $9.00 (100 caps;
380 mg) - $40.00 (powder-151 teaspoon servings)
Scope of Practice  Yellow light
 Within scope of practice; spirulina is a nutrient rich food,
however research is limited on efficacy for anemia tx
Overall Impressions
and Recommendations
 Research looks promising for the use of spirulina to improve
anemia, however, larger human studies are needed to evaluate its
efficacy and safety.
 According to the U.S. National Institutes of Health, presently
there is insufficient scientific evidence to recommend spirulina
supplementation for any human condition, and more research is
needed to clarify any benefits.
 It may be ok to use spirulina as a supplemental source of iron, but
anemia should be primarily handled by a physician.
References:
1) University of Maryland Medical Center. “Spirulina.”
http://www.umm.edu/altmed/articles/spirulina-000327.htm
2) National Institute of Health. Medline Plus Supplements. “Blue-green algae.”
http://www.nlm.nih.gov/medlineplus/druginfo/natural/923.html
3) NaturalMedicines Comprehensive Database. “Blue-green algae.”
http://www.naturaldatabase.therapeuticresearch.com
4) Selmi C, Leung PS, Fischer L, German B, Yang CY, Kenny TP,Cysewski GR,Gershwin ME. The
effects of Spirulina on anemia and immune function in senior citizens. Cell Mol Immunol. 2011 May; 8
(3):248-54. doi: 10.1038/cmi.2010.76. Epub 2011 Jan 31. PubMed PMID:21278762.
5) Skidmore-Roth, Linda. Mosby's Handbook of Herbs& Natural Supplements,4th ed. St. Louis,
MO:Mosby, 2001.