This document discusses the relationship between vitamin D deficiency and iron deficiency anemia. It begins with background on vitamin D and iron, including dietary sources and recommended daily intake. It then examines the high rates of vitamin D deficiency and iron deficiency anemia in India. The document explores the plausible links between the two deficiencies from prevalence data, mechanistic evidence showing how one may contribute to the other, and clinical evidence from studies. One study in particular found that children with low vitamin D had lower hemoglobin and iron, supporting an association between the deficiencies. The document recommends a combined approach to prophylaxis against both deficiencies.
All Time Service Available Call Girls Marine Drive ๐ณ 9820252231 For 18+ VIP C...
ย
vitamin d3 and iron supplementation in pregnancy
1. Veerendrakumar C.M.
MD.,DNB
Associate Professor
Dept of OBG,VIMS,Bellary
Thursday, December 22, 2011 dr.veerendrakumar cm 1
2. Vitamin D & Iron Deficiency:
Deadly Duo
Alien + Predator
Thursday, December 22, 2011 dr.veerendrakumar cm 2
3. Vitamin D vitamin or Hormone ??
("sunshine" vitamin)
๏ Vitamin D is a fat-soluble vitamin. Fat-soluble
vitamins are stored in the body's fatty tissue
๏ Very few foods naturally contain vitamin D.
Thursday, December 22, 2011 dr.veerendrakumar cm 3
6. 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
๏ Summary
Thursday, December 22, 2011 dr.veerendrakumar cm 6
7. 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 milk
Thursday, December 22, 2011 dr.veerendrakumar cm 7
8. ๏ 10 to 15 minutes of sunshine three times weekly is
enough to produce the body's 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
9. 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
10. ๏ 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
11. ๏ 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
12. Pregnancy -The most dangerous journey of
mankind
Thursday, December 22, 2011 dr.veerendrakumar cm 12
13. ANEMIA
๏ 40-90% WOMEN AFFECTED
๏ RESPONSIBLE FOR 65% MATERNAL DEATHS (FOGSI-
WHO 1996)
๏ CHRONIC MORBIDITY
Thursday, December 22, 2011 dr.veerendrakumar cm 13
14. Eradicating anemia can save at least
200 mothers a day!
Thursday, December 22, 2011 dr.veerendrakumar cm 14
15. Public Health Significance
WHO 2008
Prevalence of anemia (%) Public health significance
< 04.9 No PH problem
05.0 โ 19.9 Mild
20.0 โ 39.9 Moderate
> 40.0 Severe
Thursday, December 22, 2011 dr.veerendrakumar cm 15
16. Silver shines Gold glitters
Butโฆ Iron strengthens!
Thursday, December 22, 2011 dr.veerendrakumar cm 16
17. Patients have a right to
Normal Hb and
Receive safe and efficient treatment;
๏ It is the physicianโs responsibility to ensure this and,
๏ Where possible, avoid blood transfusion.
Thursday, December 22, 2011 dr.veerendrakumar cm 17
18. Anemia is on the increase!!
๏ฌ Economy is โbetterโ
๏ฌ More women are educated, empowered
๏ฌ Tons of iron tablets distributed
๏ฌ Fancy iron preparations flood the market
๏ฌ Antenatal clinics are running full !
Iron is not reaching its destination!
Thursday, December 22, 2011 dr.veerendrakumar cm 18
19. Are we producing
a defective generation?
Thursday, December 22, 2011 dr.veerendrakumar cm 19
20. More doctors are finally testing patients for vitamin D
deficienciesโฆ
๏ โUpwards of 70 percent of American adults are vitamin D
deficient or insufficient," said cardiologist James O'Keefe of
St. Luke's Mid-America
๏ Vitamin D prevents heart disease, too
๏ Vitamin D is essential for activating immune system
function
Thursday, December 22, 2011 dr.veerendrakumar cm 20
21. Vitamin D: Optimum status
Ideal >30 ng/ml
Acceptable 20-30 ng/ml
Insufficient 10-20 ng/ml
Deficient <10 ng/ml
Thursday, December 22, 2011 dr.veerendrakumar cm 21
22. Vitamin D Deficiency:
Gender Analysis
Indian J Med Res. 2008;127:211-218
Thursday, December 22, 2011 dr.veerendrakumar cm 22
23. Vitamin D deficiency in Pregnant
women and their New born
โ84% 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
24. 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/ml
Thursday, December 22, 2011 dr.veerendrakumar cm
Indian J Med Res. 2011;133:267-273 24
25. Vitamin D deficient Mother-
Deficient Infant
J Pediatr Endocrinol Metab. 2009;22(3):241-6.
Thursday, December 22, 2011 dr.veerendrakumar cm 25
26. Retards proliferation
and
increases differentiation of cells
Thursday, December 22, 2011 dr.veerendrakumar cm 26
27. Vitamin D Deficiency:
Health Implications
๏ Osteomalacia & Rickets
๏ Osteoporosis
๏ Diabetes
๏ Hypertension & CVD
&
Anemia
Thursday, December 22, 2011 dr.veerendrakumar cm Mayo Clin Proc. 2006;81(3):353-373 27
28. 60-90% Indians have Vitamin D Deficiency
Indians have Vitamin D Deficiency
~ 50% of those have anemia
INDIA
Latitude of 22ยฐ 00โN
Longitude of 77ยฐ 00โW
Thursday, December 22, 2011 dr.veerendrakumar cm 28
29. Vitamin D Deficiency and Iron
Deficiency Anemia: Is there a Link?
Thursday, December 22, 2011 dr.veerendrakumar cm 29
30. 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):e8770
Thursday, December 22, 2011 dr.veerendrakumar cm 30
31. Vitamin D & Iron Deficiency Link in
Toddlers
๏ 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
32. Vitamin D & Iron Deficiency Link in Children
Thursday, December 22, 2011 dr.veerendrakumar cm 32
BMJ. 1998;318:28
33. Vitamin D & Iron Deficiency Link:
The Hen or Egg?
Mechanistic Evidence
Thursday, December 22, 2011 dr.veerendrakumar cm 33
34. 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.2
Endocrinology.2006;147(12):5542-5548
Thursday, December 22, 2011 2. Ann Hepatol. 2010;89:447-452
dr.veerendrakumar cm 34
35. 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
37. 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
Anemia
1. 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
38. 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
39. IDA Causes Vitamin D Deficiency
Plausible Mechanism # 1
Iron Deficiency Anemia
Impaired Epithelial Regeneration & Function
Abnormal GI mucosa
Malabsorption of Fats
Pediatrics.1964;33:83-99
Thursday, December 22, 2011 dr.veerendrakumar cm 39
40. Malabsorption of Fats
Impairment in Bile secretion
Impaired Vitamin D absorption & 25(OH)D reabsorption in the
intestine
Vitamin D Deficiency
Thursday, December 22, 2011 dr.veerendrakumar cm 40
41. 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
42. Vitamin D & Iron Deficiency Link:
The Hen or Egg?
Clinical Evidence
Thursday, December 22, 2011 dr.veerendrakumar cm 42
43. Clinical Evidence for the
relationship: 1
Thursday, December 22, 2011 dr.veerendrakumar cm 43
44. Clinical Evidence for the
relationship: 2
Thursday, December 22, 2011 dr.veerendrakumar cm 44
45. Study Answers the Crucial
Question
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 infantsโ 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
47. Clinical Evidence for the
relationship: 3
Thursday, December 22, 2011 dr.veerendrakumar cm 47
48. 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
49. Vitamin D & Iron Deficiency Link:
The Hen or Egg?
OR BOTH?
Thursday, December 22, 2011 dr.veerendrakumar cm 49
50. 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 Anemia
1.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
51. Thus....
Vitamin D & Iron Deficiency
The Never-ending Vicious Cycle leads toโฆโฆ
A Twin Epidemic
To Break the Cycle.......
Supplementation with IRON + VITAMIN D would provide optimum benefit
Thursday, December 22, 2011 dr.veerendrakumar cm 51
52. Recommended Dietary intakes of Vitamin D for patients at
risk 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
53. Thus, at a minimum, lactating women may need to take
1400โ1500 IU/d, and to satisfy their infantโs
requirement, they may need 4000โ6000 IU/d
Thursday, December 22, 2011 dr.veerendrakumar cm 53
54. Evidence of Vitamin D supplement in
adults 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 4โ11% gain in lower extremity
strength or function and up to 28% improvement
in body sway.
Thursday, December 22, 2011 dr.veerendrakumar cm 54
55. 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
56. More news onโฆ
๏Non calcemic benefits of
vitamin D
Thursday, December 22, 2011 dr.veerendrakumar cm 56
57. ๏ 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 Parkinson's disease
Thursday, December 22, 2011 dr.veerendrakumar cm 57
58. ๏ 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 Parkinson's disease
๏ Diabetics with low vitamin D have high risk of death
Thursday, December 22, 2011 dr.veerendrakumar cm 58