Iron, B12 and Folate: a Dynamic Trio
Iron, B12 and Folate: A Dynamic Trio
By Karen Raterman
INNATE-EDU Fostering Community & Dialogue TABLE OF CONTENTS
3 INTRODUCTION
4 CHAPTER 1: A SYNERGISTIC COMBINATION
5 CHAPTER 2: HEALTH IMPLICATIONS OF IRON, B12 AND FOLATE DEFICIENCIES
7 CHAPTER 3: SUPPLEMENTATION - CAPITALIZING ON THE SYNERGY 3 | INTRODUCTION
Introduction
Iron, B12 and folate are critical for optimal overall health. These three compounds work together synergistically to provide a result that is far greater than the sum of their parts. All three nutrients work together to help promote metabolic function1 which contributes to normal cognitive function2 and physical development3* as well as to enhance overall health by supporting normal heart function4 and production of energy.*
However, it’s a delicate balance. Because all three nutrients are not produced by the body and must be obtained through outside sources, many patients, especially those with existing health issues or a poor diet, may need nutritional support to get enough of these essential nutrients. Beyond good diet and a healthy lifestyle, practitioners will want to particularly advise, at risk patients, about the importance of these nutrients. Because a proper balance is essential, clinicians should also educate patients about proper dosing and supplementation to maintain adequate iron, B12 and folate levels. Doing so will help patients ensure the benefits of these synergistic nutrients.
1. Roddie C, Davis B. Iron, B12 and Folate. J. Medicine 2009 Mar;37(3):125-128. DOI:org/10.1016/j.mpmed.2008.12.009. 2. Sandstead HH et al. Causes of Iron and Zinc deficiencies and their effects on thebrain. The American Society for Nutritional Sciences, 2000. 3. Hall CA. Function of vitamin B12 in the central nervous system as revealed by congenital defects. Am J Hematol 1990;34(2):121-127. 4. Selhub J et al. 1993) Vitamin status and intake as primary determinants of homocysteinemia in an elderly population. JAMA. 270:2693-2698.
*These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease. 4 | CHAPTER 1
A Synergistic Combination
Iron is essential to the formation of the haemoglobin in red blood cells. Iron is absorbed from certain foods and then transported in the blood to the bone marrow where blood cells are produced. It is then combined with protein to make haemoglobin. Without enough iron and oxygen, a patient may feel frequently tired, the immune system will not function optimally and the brain may also not perform as well as it should.5,6* Iron is also an important nutrient aiding the body in the production of enzymes, hormones and other substances needed for healthy growth and development.7*
The problem is that the body will not absorb 100 percent of the iron in food, in particular, non-heme iron present in plant-based foods. As such, getting enough iron from diet alone can be difficult, especially for patients who practice vegan or vegetarian diets since a primary source of iron is beef. However, it is well known that the bioavailability of iron can be enhanced by increasing the intake of fish or ascorbic acid, which will enhance its absorption.8
Folic acid and vitamin B12 are critical for normal growth and development.* Like iron, neither can be made by the body and must be consumed in the diet or via supplementation. Folic acid is the synthetic form of vitamin B9 and is called folate referring to its Latin name folium. It is found naturally in dark green leafy vegetables, peas, turnips and asparagus. It can also be found in dried beans and some citrus fruits like papaya and oranges. Folate contributes to the formation of new cells in the body.*
Likewise, vitamin B12 is needed for a healthy metabolism and optimal function of the nervous system. B vitamins in general are water soluble and cannot be stored in the body. B12 is one exception as the liver does store it in substantial amounts. Also known as cobalamin, B12 is derived from animal sources, such as fish, meat, dairy and milk. Patients who do not consume animal products may find it difficult to get enough B12 in their diet. Along with folate, B12 contributes to keeping homocysteine levels in the body in check.* B12 and folate have been associated with healthy cardiovascular function among their many other supportive roles.9* Both of these vitamins are linked to iron because they form the red blood cells that carry oxygen around the body. Along with Vitamin C, both B12 and folate serve as cofactors for iron assisting with its digestibility and bioavailability in the body.*
5. MacKensie EL et al. Intracellular Iron Transport and Storage from molecular mechanisms to health implications. Antiox Redox Signal 2008 Jun; 10(6):997-1030. DOI: 10.1089/ars.2007.1893. 6. Ibid. American Society of Nutritional Sciences, 2000 7. WHO/UNICEF/UNU. Micronutrients. http://www.who.int/nutrition/topics/micronutrients/en/ 8. Hallberg L, Brune M, Rossander L., The role of vitamin C in iron absorption. Int J Vitam Nutr Res Suppl. 1989;30:103-8. 9. Ibid. JAMA 1993
*These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease. 5 | CHAPTER 2
Health implications of Iron, B12 and Folate Deficiencies
A deficiency of Iron, B12 or folate, threatens these processes and can be detrimental to optimal health. For example, deficiency of any one of these nutrients can lead to anemia. There are more than 400 types of anemia, but the most common is iron deficiency anemia.
Iron deficiency anemia
According to the World Health Organization, iron deficiency anemia (IDA) is the most common nutrient deficiency in the world.10 It is also common in the United States, affecting two percent of adult men, 9 to 12 percent of non-Hispanic white women and nearly 20 percent of black and Mexican American women.11 This means that on average one in 10 Americans and as many as one in five women are affected by this deficiency--and this may only be part of the picture. Because IDA is widely underdiagnosed due to mild symptoms or being attributed to other issues ranging from hypothyroidism to depression to side effects from medication, it could be even more prevalent.12
Bone marrow, which is found at the center of the bone, needs iron to make hemoglobin. The hemoglobin carries oxygen to the body’s organs to support their function. Without enough iron the body cannot produce enough hemoglobin for the blood cells resulting in IDA. Development of IDA is caused by either inadequate intake of iron or a loss of blood -- which can be attributed to a variety factors. Symptoms, such as fatigue, lightheadedness, hair loss, depression and constipation have all been associated with IDA.13
Certain gastrointestinal problems can cause poor absorption of iron and lead to anemia. Symptoms regarding constipation or diarrhea may be a red flag for iron, folate and B12 deficiency14 as well as anemia. Patients who have an increased need for iron, such as women who experience heavy menstrual cycles, those who have experienced blood loss from an accident and anyone who frequently donates blood, may be at risk of low iron in the blood. As noted in the previous chapter, patients who have an iron-poor diet, including infants, children and teens as well as vegetarians and vegans, may also have trouble getting enough iron in their diet. Consumption of excess caffeinated beverages, whole grains or dairy can also lead to poor iron absorption.
Nutritional deficiency anemia
Vitamin B12 and folate are required to make red blood cells. If these two cofactors are not present in adequate amounts, the body cannot make enough red blood cells to carry the oxygen. A deficiency of either or both can also lead to different types of anemia. If a patient is both B12 and folate deficient, it can lead to megaloblastic anemia, a condition in which the red blood cells are either too large or too small to carry the oxygen effectively. With this type of anemia, it is important to distinguish whether the condition is caused by low levels of B12 or folate. If low B12 is the problem and it is not addressed, this can lead to permanent neurological damage.15
10. Bruno de Benoist 9ed) et al. Worldwide Prevalence of Anemia, 1993-2005, World health Organization website; http://www.who. int/nutrition/publications/micronutrients/anemia_iron_deficicency/9789241596657/en/ 11. Shersten Killip, MD, MPH et al. Iron Deficiency AnemiaAM Fam Physician. 2007 Mar 1;75(5):671-678. 12. Friedman AJ et al. Iron deficiency anemia in women: a practical guide to detection. diagnosis and treatment. Obstet Gynecol Surv. 2015 May:70(5):342-53. 13. ibid 14. ibid Am Fam Physician 2007. 15. Castle WB. Megaloblastic anemia. Post Grad Med 1978. Oct;64(4) 117-22. 6 | CHAPTER 2
Poor B12 absorption alone can be caused by certain gastrointestinal problems and lead to pernicious anemia. A poor diet or other conditions, such as pregnancy, gastrointestinal problems, use of certain medications or alcohol abuse also may cause deficiencies of either folate or B12, although, in general, these deficiencies tend to be more common among patients who are 75 years or older.16
While much is still being discovered about the role of these nutrients in supporting health, a 2008 article in the journal Medicine concluded that deficiencies in iron, B12 and folate can result in widespread effects in various organ systems and may precede the appearance of haematological abnormalities. The authors wrote:
“Investigation of suspected iron, B12 or folate deficiency should be directed at establishing that the deficiency state exists, as well as determining its cause and should always include a detailed history and physical examination as well as relevant laboratory tests. Correcting the deficiency with supplements is usually straightforward, provided adherence to treatment is ensured. The underlying cause of the nutritional deficiency should also be treated where possible.”17
16. Kraft SA. What is nutritional deficiency anemia? Medical News Today. http://www.medicalnewstoday.com/articles/188770.php 17. Ibid. J Medicine 2009 Baker RD, et al. Pediatrics. 2010;126(5):1040–1050. 7 | CHAPTER 3
Supplementation - Capitalizing on the synergy
Taking oral iron supplements is almost always effective for correcting an iron deficiency or IDA, but it may also be advisable to help certain at risk patients maintain optimal levels.* However, not all iron supplements are created equally. Look for high quality iron supplements that contain iron glycinate, iron picolinate or iron citrate, which enhance absorption by the body.
In addition, iron supplementation can also be optimized when performed properly. The following tips from Tieraona Low Dog, M.D., Clinical Associate Professor of Medicine at the University of Arizona Health Sciences Center, may help assist patients in optimizing their iron absorption.
Take iron supplements:
• on an empty stomach or with a meal containing meat
• with vitamin C, foods containing vitamin C, or acidic foods
• Zinc, vitamin A and riboflavin are also important
• do not take iron supplements with dairy products, coffee or tea
“Iron pills should be taken two hours before or after other medications,” explained Dr. Low Dog. “Iron can inhibit the effectiveness of thyroid medications, antibiotics and some antidepressant drugs. Foods and substances that can interfere with the absorption of iron include calcium, tannins, which are found in coffee, tea, grapes, red wine, purple or red rice, and bran fiber or chocolate. Iron supplementation is best taken two hours after consuming these substances.”
Adequate stomach acid is also essential for proper iron absorption, noted Dr. Low Dog. “Pure iron is dissolved in sulfuric or HCl acid. Then a negatively charged counter ion (sulfate, gluconate, fumarate) is added. As pH is adjusted towards neutrality, it binds to the ion and drops out of solution. This is then dehydrated and the remaining dry matter is iron salt. This is why a patient must have stomach acid to dissolve the iron salt. If the patient is taking PPI or has atrophic gastritis, iron is much more difficult to absorb.”
In addition, oral iron supplements can cause undesirable gastrointestinal symptoms, such as diarrhea, constipation, nausea and darkly colored stools in about 10% to 20% of patients.
*These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease. 8 | CHAPTER 3
Dosing of iron, B12 and folate
Every patient may have specific needs, but dosing of iron supplements for IDA is generally recommend at 120 mg/d elemental iron x 3 months in adults, 3 mg/kg/d, up to 60 mg per day in kids.18 However, studies have shown that lower doses (60-100 mg) taken once per day or even every other day actually increases absorption and is more easily tolerated.19*
A balanced diet rich in meat and dark green leafy vegetables is a good start for maintenance of healthy B12 and folate levels, but for patients needing extra help these nutrient levels can also be managed with with nutritional supplementation. According to the Office of Dietary Supplements, the recommended dietary allowance of B12 for teens and age 14 and older as well as healthy adults is 2.4 mcg. Pregnant women are advised to take 2.6 mcg and lactating women are advised to take 2.8 mcg. The recommended daily intake of folic acid is 400 mcg for healthy patients 14 years or older. Again, the recommended daily intake for pregnant and lactating women is slightly higher at 600 mcg and 500 mcg respectively.
18. Baker RD et al. Pediatrics. 2010;126(5):1040-1050. 19.Moretti D, et al. Blood. 2015 Oct 22. 126 (17):1981-9
*These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease.