CORRECTION OF ANEMIA AND IRON DEFICIENCY IN VEGETARIANS BY ADMINISTRATION OF ASCORBIC ACID - controlled study

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CORRECTION OF ANEMIA AND IRON DEFICIENCY IN VEGETARIANS BY ADMINISTRATION OF

ASCORBIC ACIDDINESH C. SHARMA* AND RATI MATHUR*Corresponding AuthorDepartment of

Biochemistry S M S Medical College, Jaipur - 302 004

(Received on December 8, 1994)

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macol-1995-v39-n4-p403.htm

 

 

 

Abstract: Twenty-eight strict vegetarians were given 500 mg ascorbic acid twice

daily after lunch and dinner for two months. Hemoglobin and certain iron status

parameters were measured before and after the treatment. Ascorbate treatment

increased mean hemoglobin by 8%, serum iron by 17% and transferrin saturation by

23% and decreased total iron binding capacity by 7%. All these changes were

statistically significant. The rise in serum ferritin was 12%. The serum protein

or copper level did not indicate their dietary deficiency, while initial serum

ascorbate level were low which rose by 60% on therapy. It is concluded that

ascorbate supplementation is a better method of improving hematologic and iron

status than iron salt administration.

 

Key words: ascorbic acid, iron deficiency, anemia, vegetarians, hemoglobin,

iron, ferritin

 

 

INTRODUCTION

Anemia is the second most common affliction in the world and iron deficiency is

the most common cause of it (1). The incidence of iron deficiency anemia is much

greater in India than western countries, despite the fact that daily iron intake

of Indians is twice that of westerners (2, 3). This apparent paradox is

attributed to consumption of predominantly cereal based diet, rich in phytate,

oxalates, phosphates, fiber and other inhibitors of iron absorption, by the

majority of Indians who practice vegetarianism on account of religion or poverty

(4, 5). So we had found significantly lower serum iron in healthy vegetarians as

compared to healthy non-vegetarians (6). Similarly vegetarian parturient women

had significantly lower hemoglobin, serum iron and transferrin saturation in

comparison to their non-vegetarian counterparts (7). Recently in a closely

matched study all the parameters (hemoglobin, serum iron, transferrin saturation

and ferritin) were significantly lower in vegetarian

women and their newborns, respectively, despite having received supplemental

iron (Ferrous sulphate=60 mg Fe) for about six months during antenatal period

(5). The absence of expected response in hemoglobin regeneration was perhaps due

to the fact the vegetarian diet was not deficient in iron but some other

nutrient. The dietary survey of vegetarian mothers revealed that their diet was

lacking in ascorbic acid as the consumption of fruits and citrus fruits was

meagre (5).

 

The present study was, therefore, undertaken to see the effect of administration

of ascorbic acid on hemoglobin and iron status of strictly vegetarian people.

 

 

METHODS

The subjects of this study were taken from the staff of the Department of

Biochemistry, medical and nursing students, neighbours etc. who volunteered for

the study and were vegetarians. All person were known to be healthy so that the

drug compliance could be checked frequently and follow up was easy. They were

selected on the basis of their dietary habit (vegetarianism) rather than initial

hemoglobin level. All the subjects were free from infection and inflammation

which are known to affect serum iron, total iron binding capacity and ferritin

values (3).

 

The study started with 36 persons but ended with 28; eight persons discontinued

vitamin tablets or were erratic in taking them. All the subjects were asked to

take a 500 mg ascorbic acid tablet (Celin, Glaxo) within half an hour after

lunch and dinner regularly for two months. Then each person received 1 gm

ascorbic acid daily and a total of 60 gm during the study. The dose was not

large enough to cause any harmful effect. No one had complained of any side

effect. The subjects were not allowed to take any hematinic during this study.

 

The blood was collected before and after the drug trial. The following

estimations were performed on both the samples immediately after the collection

- blood hemoglobin (Hb) (cyanmethemoglobin method), serum iron (8), total iron

binding capacity (TIBC) (8), percent saturation (PS), (by calculation), serum

ferritin (9), serum copper (10), total proteins (11) and ascorbic acid (12).

 

An oral questionnaire method was used to find out the details of the diet intake

and dietary habits of all the subjects studied.

 

The results were statistically analyzed by the paired ‘t’ test (13). The

critical level of significance was 5 percent (probability, 0.05).

 

 

RESULTS

Out of 28 subjects of this study, 10 were male, 18 were female, and 28 had

initial Hb level below the WHO normal range. Their age ranged between 18-50

years. All were vegetarians and had regularly taken vitamin C tablets. This is

confirmed by a rise in ascorbic acid of about 60% in two months time (Table I)

 

The pre- and post-treatment values are shown in Table I. There was a

statistically significant rise in blood hemoglobin, highly significant rise in

serum iron and a significant fall in total iron binding capacity. The rise in

transferrin saturation of plasma was highly significant. Interestingly, the

response to therapy was better in those who were iron deficient/anemic. Serum

ferritin level also showed a rise but statistically insignificant. It may be

because (i) the normal range of serum ferritin is very wide, (ii) increased iron

was preferentially utilized for hemoglobin regeneration rather than storage, and

(iii) ferritin reflects storage iron which was not expected to rise appreciably

in such a short time.

 

TABLE I. : Hematalogic and iron status of vegetarians before and after ascorbate

treatment

 

Parameter

 

Pre-treatment level

 

Post-treatment level

 

“t”

(paired)

 

“P”

 

Percent

rise

Hemoglobin (g/dl)10.10 ± 01.8010.90 ± 01.405.81<0.00107.90Iron (µg/dl)63.70 ±

13.7074.50 ± 13.006.36<0.00116.90Total Iron Binding Capacity (µg/dl)325.30 ±

49.60301.70 ±55.40-3.62<0.010-07.20Percent Saturation (%)19.90 ± 05.4024.40 ±

04.904.32<0.00122.60Ferritin (ng/ml)39.90 ± 39.3044.70 ±

40.801.23NS12.00Ascorbic Acid (mg/dl)00.47 ± 00.1000.75 ±

00.207.03<0.00159.50Total Proteins (g/dl)08.33 ± 00.4706.42 ±

00.430.09NS01.40Copper (µg/dl )80.90 ± 18.0081.40 ± 19.300.53NS00.60

 

All values are Mean ± SD; NS-Indicates Not Significant

 

 

DISCUSSION

The improvement in iron status and correction of anemia in vegetarians by giving

only ascorbic acid is a very important finding. Such studies were also conducted

in the past but the results were not conclusive (14), because the studies were

multifactorial (14).

 

The role of ascorbic acid in iron metabolism is manyfold. It reduces ferric iron

to ferrous form which is then absorbed, lowers the pH which is conducive to iron

absorption, reverses the inhibitory effect of phytate, oxalate, phosphate etc.,

and also forms chelate with iron for absorption (15).

 

As dietary proteins and copper also affect iron absorption and utilization, so

in this study total serum proteins and serum copper were also estimated. Their

levels were within normal range (16) suggesting nutritional adequacy of these

nutrients. On the other hand ascorbate level in serum was low or on the lower

side of normal (16) indicating inadequate vitamin C nutrition. This confirms our

contention of Vitamin C nutritional inadequacy in vegetarian population on

account of meagre intake of fruits, especially citrus fruits (5). The intake of

fruits by subjects of present study was also very bow, as revealed by diet

survey during oral questionnaire.

 

The control of nutritional anemia is one of the national health programme of

Government of India (17) and pregnant women are advised to take ferrous sulphate

tablets. As iron preparations did not give desired response in our previous

study (5) and are not well tolerated by many persons we instead suggest vitamin

C tablets (500 mg) to be given twice daily after every major meal. This will

improve iron status and correct anemia as shown in this study. In contrast to

iron preparations ascorbic acid is well tolerated, quite palatable and harmless.

The risk of forming oxalate stones was reported with only megadoses of vitamin C

(18), and even this was not confirmed in experimental animals (19). In addition,

the daily consumption of vitamin C may confer following benefits (20) - prevent

common cold and other viral infections, retard atherosclerosis, decrease risk of

cancer, slow down ageing and reduce toxicity of metals.

 

It is hoped that this study will stimulate further work in this field and that

physicians will see the need for prescribing vitamin ‘C’ tablets instead of iron

tablets for amelioration of anemia or iron deficiency, especially because men

and women need to absorb only 1.14 to 2.38 mg of iron per day (21) while the

actual intake iron vegetarian diet in this region is calculated to range from

22.0 to 37.0 mg per day (22).

 

 

ACKNOWLEDGEMENTS

This work was supported by a Research Grant from S.M.S. Medical College, Jaipur

for which we are thankful to the Principal, Dr. P. L. Nawalakha.

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From Indian Journal of Physiology and Pharmacology, October 1995, Volume 39,

Number 4, pp. 403-406

 

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