vitamin d3 and iron supplementation in pregnancy
TRANSCRIPT
Veerendrakumar C.M.
MD.,DNB
Associate Professor
Dept of OBG,VIMS,Bellary
Thursday, December 22, 2011 1dr.veerendrakumar cm
Alien + Predator
Vitamin D & Iron Deficiency: Deadly Duo
Thursday, December 22, 2011 2dr.veerendrakumar cm
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 3dr.veerendrakumar cm
Thursday, December 22, 2011 4dr.veerendrakumar cm
Thursday, December 22, 2011 5dr.veerendrakumar cm
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
Contents
Thursday, December 22, 2011 6dr.veerendrakumar cm
Vitamin DVitamin 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 7dr.veerendrakumar cm
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 8dr.veerendrakumar cm
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 9dr.veerendrakumar cm
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 10dr.veerendrakumar cm
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 11dr.veerendrakumar cm
Pregnancy -The most dangerous journey of mankind
Thursday, December 22, 2011 12dr.veerendrakumar cm
ANEMIA
40-90% WOMEN AFFECTED
RESPONSIBLE FOR 65% MATERNAL DEATHS (FOGSI-WHO 1996)
CHRONIC MORBIDITY
Thursday, December 22, 2011 13dr.veerendrakumar cm
Thursday, December 22, 2011 14
Eradicating anemia can save at least
200 mothers a day!
dr.veerendrakumar cm
WHO 2008
Prevalence of anemia (%) Public health significance
< 04.9 No PH problem
05.0 – 19.9 Mild
20.0 – 39.9 Moderate
> 40.0 Severe
Public Health Significance
15Thursday, December 22, 2011 dr.veerendrakumar cm
16
Iron strengthens!
Gold glittersSilver shines
But…
Thursday, December 22, 2011 dr.veerendrakumar cm
It is the physician’s responsibility to ensure this and,
Where possible, avoid blood transfusion.
Patients have a right to
Normal Hb and
Receive safe and efficient treatment;
17Thursday, December 22, 2011 dr.veerendrakumar cm
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 producinga defective generation?
Thursday, December 22, 2011 19dr.veerendrakumar cm
More doctors are finally testing patients for vitamin D deficiencies…
“Upwards 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 20dr.veerendrakumar cm
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 21dr.veerendrakumar cm
Indian J Med Res. 2008;127:211-218
Vitamin D Deficiency: Gender Analysis
Thursday, December 22, 2011 22dr.veerendrakumar cm
Am J Clin Nutr 2000;72:472-5. Am J Clin Nutr 2005;81:1060-4.
≈84% Indian women have 25(OH)D values < 22.5 ng/L.
Vitamin D deficiency in Pregnant women and their New born
Thursday, December 22, 2011 23dr.veerendrakumar cm
Indian J Med Res. 2011;133:267-273
Deficiency: <15 ng/ml
Insufficiency: 15-20 ng/ml
Severe Deficiency: <5 ng/ml
81.1%
66.7%
11.6%19.8%
23.2% 27.1%
Vitamin D deficiency in Lactating Women and Breastfed infants
Thursday, December 22, 2011 24dr.veerendrakumar cm
J Pediatr Endocrinol Metab. 2009;22(3):241-6.
Vitamin D deficient Mother-Deficient Infant
Thursday, December 22, 2011 25dr.veerendrakumar cm
Thursday, December 22, 2011 dr.veerendrakumar cm 26
Retards proliferation and
increases differentiation of cells
Mayo Clin Proc. 2006;81(3):353-373
Vitamin D Deficiency:Health Implications
Osteomalacia & Rickets
Osteoporosis
Diabetes
Hypertension & CVD
&
Anemia
Thursday, December 22, 2011 27dr.veerendrakumar cm
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’W
Thursday, December 22, 2011 28dr.veerendrakumar cm
Vitamin D Deficiency and Iron Deficiency Anemia: Is there a Link?
Thursday, December 22, 2011 29dr.veerendrakumar cm
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 30dr.veerendrakumar cm
Arch Dis Childhood. 1986;61:843-848
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 31dr.veerendrakumar cm
Vitamin D & Iron Deficiency Link in Children
BMJ. 1998;318:28Thursday, December 22, 2011 32dr.veerendrakumar cm
Mechanistic Evidence
Vitamin D & Iron Deficiency Link: The Hen or Egg?
Thursday, December 22, 2011 33dr.veerendrakumar cm
Endocrinology.2006;147(12):5542-5548 2. Ann Hepatol. 2010;89:447-452
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
Thursday, December 22, 2011 34dr.veerendrakumar cm
Vitamin D
High local concentrations of 1,25(OH)D in hematopoietic tissues may directly activate erythroid precursors cells in a paracrinefashion.
Vitamin D supplementation will help the initial phase of erythropoesis.
Iron supplementation would be required for the latter phase.
Thursday, December 22, 2011 35dr.veerendrakumar cm
Thursday, December 22, 2011 36dr.veerendrakumar cm
Myelofibrosis was observed in children with Vitamin D deficiency induced rickets.1,2,3
1. J Pediatr. 1989;114:213-217 2. Canad Med Assoc J. 1966;94:395 3. Indian Pediatr. 2005;42:482-484
Vitamin D Deficiency
Reduced activation of Vitamin D receptors in bone marrow
Myelofibrosis
Impaired Erythropoesis
Anemia
Vitamin D Deficiency causes Anemia Plausible Mechanism # 2
Thursday, December 22, 2011 37dr.veerendrakumar cm
1. Am J Clin Nutr. 1992;56:533-536 2. Proc Soc Exp Biol Med. 1975;149:570-572
(Enterohepatic circulation)
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 as glucuronides) & is reabsrobed by enterohepaticcirculation.1,2
Thursday, December 22, 2011 38dr.veerendrakumar cm
Iron Deficiency Anemia
Impaired Epithelial Regeneration & Function
Abnormal GI mucosa
Malabsorption of Fats
Pediatrics.1964;33:83-99
IDA Causes Vitamin D Deficiency Plausible Mechanism # 1
Thursday, December 22, 2011 39dr.veerendrakumar cm
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 40dr.veerendrakumar cm
Iron deficiency inhibits the metabolism of Vitamin D to 25(OH)D.
Am J Clin Nutr. 1992;56:533-536
IDA Causes Vitamin D Deficiency Plausible Mechanism # 2
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.
Thursday, December 22, 2011 41dr.veerendrakumar cm
Clinical Evidence
Vitamin D & Iron Deficiency Link: The Hen or Egg?
Thursday, December 22, 2011 42dr.veerendrakumar cm
Clinical Evidence for the relationship: 1
Thursday, December 22, 2011 43dr.veerendrakumar cm
Clinical Evidence for the relationship: 2
Thursday, December 22, 2011 44dr.veerendrakumar cm
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 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 45dr.veerendrakumar cm
Study Recommendations
Thursday, December 22, 2011 46dr.veerendrakumar cm
Clinical Evidence for the relationship: 3
Thursday, December 22, 2011 47dr.veerendrakumar cm
A combined approach to prophylaxis against iron and vitamin D deficiency should be considered.
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.
Thursday, December 22, 2011 48dr.veerendrakumar cm
OR BOTH?
Vitamin D & Iron Deficiency Link: The Hen or Egg?
Thursday, December 22, 2011 49dr.veerendrakumar cm
Vitamin D Deficiency
Increased inflammation or marrow myelofibrosis
Ineffective erythropoesis
Iron Deficiency Anemia
Impaired intestinal absorption of fats.
Inhibition of Vitamin D Metabolism
Impaired Vitamin D absorption & 25(OH)D reabsorption
1. Am J Clin Nutr. 1992;56(3):533-6 2. Plos One2010;5(1):e8770 3. Ann Hematol. 2010;89:447-452Thursday, December 22, 2011 50dr.veerendrakumar cm
Thus....
Vitamin D & Iron DeficiencyThe Never-ending Vicious Cycle leads to……
A Twin Epidemic
To Break the Cycle.......
Supplementation with IRON + VITAMIN D would provide optimum benefit
Thursday, December 22, 2011 51dr.veerendrakumar cm
Age (Year) IOM(Institute of Medicine) Endocrine Society
IU/ DayRDA
ng/mlIU/ Day
RDA
ng/ml
1-18 600 20 1000 30
19-50 600 20 1500-2000 30
50 & above 600-800 20 1500 -2000 30
Pregnancy &
Lactation400-600 20 1500-2000 30
Endocrine society guidelines are suitable for Indian Patients to raise the blood level of 25(OH)D consistently above 30 ng/ml
Recommended Dietary intakes of Vitamin D for patients at risk for Vitamin D Deficiency
Thursday, December 22, 2011 52dr.veerendrakumar cm
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/d
Thursday, December 22, 2011 53dr.veerendrakumar cm
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 4–11% gain in lower extremity strength or function and up to 28% improvement in body sway.
Thursday, December 22, 2011 54dr.veerendrakumar cm
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.
Summary
Thursday, December 22, 2011 55dr.veerendrakumar cm
More news on…
Non calcemic benefits of vitamin D
Thursday, December 22, 2011 56dr.veerendrakumar cm
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 57dr.veerendrakumar cm
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 58dr.veerendrakumar cm
The ‘SUN’ god
Thursday, December 22, 2011 59dr.veerendrakumar cm
Welcome to
www.wisdombellary.com
Thursday, December 22, 2011 60dr.veerendrakumar cm
Thank youThursday, December 22, 2011 61dr.veerendrakumar cm