Comparison study of oral iron preparations using a human intestinal model

Iron homeostasis in obesity and metabolic and bariatric surgery: a narrative review

Iron deficiency has been recognized as a potentially modifiable nutritional complication of metabolic and bariatric surgery (MBS) since prior to the turn of the century. Despite this, it remains the most common and clinically significant nutritional complication of this surgery with the potential to negate quality of life and the health benefits of surgical weight loss. This narrative review summarizes the current literature regarding iron deficiency as it relates to patients with severe obesity and those who undergo MBS. Advances in the clinical knowledge of iron homeostasis in severe obesity as a chronic disease, current diagnostic criteria for the diagnosis of iron deficiency in this patient population, the significance of preoperative iron deficiency, postoperative iron deficiency, and the status of supplementation and treatment will be reviewed with emphasis on gaps in knowledge and needed areas of further study.

Anemia in Breastfeeding Women and Its Impact on Offspring's Health in Indonesia: A Narrative Review

Anemia in breastfeeding women is a neglected global health issue with significant implications for maternal and child health. Despite its widespread occurrence and adverse effects, this problem remains largely unknown and overlooked on the global health agenda. Despite efforts to improve health access coverage and provide iron and folic acid supplementation, anemia persists. This underscores the need for a comprehensive approach to address the problem. Urgent action must be taken to prioritize education and awareness campaigns, ensure access to nutritious food, and enhance healthcare services. Education programs should focus on promoting iron-rich diets, dispelling cultural myths, and providing practical guidance. Improving healthcare services requires increasing availability, ensuring a consistent supply of iron supplements, and providing adequate training for healthcare providers. A successful implementation relies on a strong collaboration between the government, healthcare providers, and community. It is crucial that we acknowledge that high coverage alone is insufficient for solving the issue, emphasizing the importance of targeted interventions and a strategic implementation. By adopting a comprehensive approach and addressing the underlying causes of anemia, Indonesia can make significant progress in reducing its prevalence and improving the overall health of its population, particularly among breastfeeding women.

Preparation, characterization, antioxidant and antianemia activities of Poria cocos polysaccharide iron (III) complex

As a new natural antioxidant with high safety and non-toxic side effects, polysaccharide can also be used as a critical macromolecular carrier to form a stable iron complex with Fe³⁺. Our previous study has extracted and purified the homogeneous polysaccharide (PCP1C) from Poria cocos. In this study, the PCP1C-iron (III) complex was synthesized by co-thermal synthesis with PCP1C and ferric trichloride. The chelating capacity, iron releasing capacity, and qualitative identification of complex were evaluated. The complex was characterized by scanning electron microscope-energy dispersive spectrometer (SEM-EDS) analysis, particle size distribution, and fourier transform infrared (FTIR) spectroscopy. The antioxidant and iron supplement effects of the complex were also studied in vitro and in the iron deficiency anemia (IDA) rat model. The results showed that the iron content in the PCP1C-iron (III) complex was 28.14% with no free iron, and the iron release rate was 95.3%. The structure analysis showed that the iron core of the PCP1C-iron (III) complex existed in the form of β-FeOOH and the surface of the complex become smooth and particle size increased, which indicated the high iron content of polysaccharide iron and slow release. Furthermore, we found that the PCP1C iron (III) complex had positive scavenging effect on DPPH, ABTS, MDA, and hydroxyl radical in vitro study and significantly increased the levels of red blood cell (RBC), Hemoglobin (Hb), and red blood cell specific volume (HCT) in IDA rat model. Therefore, our results suggested that the PCP1C-iron (III) complex is expected to develop into a new comprehensive iron supplement and antioxidant.

The relationship between anemia and obesity

INTRODUCTION

Obesity is linked to a variety of unfavourable outcomes, including anaemia, which is a serious global public health problem. The prevalence of obesity along with anaemia suggests a relationship between obesity and anaemia. Recent studies have demonstrated strong associations between anaemia and obesity, chronic diseases, ageing, hepato-renal impairment, chronic infection, autoimmune diseases, and widespread malignancy. Thus, the intersection point of obesity and anaemia is an important area of attention.

AREA COVERED

This paper reviews the pathophysiology of obesity and anaemia. Then, It deliberates the relationship between obesity and different types of anaemia and other clinical forms associated with anaemia.

EXPERT OPINION

Obesity, especially obesity-related to excessive visceral fat distribution, is accompanied by several disturbances at the endothelial, hormonal, and inflammatory levels. These disturbances induce activation of several mechanisms that contribute to the anaemic state. Over-weight patients with chronic anaemias are required to maintain the related vitamins and minerals at optimum levels and appropriate BMI. In addition, a regular clinical follow-up is essential to be scheduled to reduce the risk of complications associated with anaemia in obese patients.

The Influence of Iron and Zinc Supplementation on Iron Apparent Absorption in Rats Fed Vitamins and Minerals Reduced Diets

Deficient human diet is usually reduced in many nutrients, but animal studies on iron absorption have been only carried out for rats fed well-balanced (control) and iron-deficient diets. The aim of this study was to evaluate the effect of iron or iron/zinc supplementation on iron apparent absorption (IAA) in rats fed a diet reduced in all vitamins and minerals (R). The study was conducted on 77, 6-week-old male Wistar rats in 3 stages as follows: stage I, 4-week period of adaptation to R diet (50% less vitamins and minerals compared to AIN-93M recommendations); stage II, 4-week supplementation period with iron (RSFe) or iron/zinc (RSFeZn); stage III, 2-week post-supplementation period (rats fed R diet). Feces samples to IAA determination were collected at the 20-22nd days of stage I and II and the 10-12th days of stage III. To determine the changes in IAA after introducing and discontinuation of supplementation, feces were collected for 3 days after introducing (stage II) and 5 days after the supplementation discontinuation (stage III). At the end of stage II, compared to R rats, the IAA was statistically significantly higher in RSFe and RSFeZn rats (30.3 ± 2.0% vs. 47.4 ± 1.2% and 51.0 ± 1.7%, respectively). After introducing iron or iron/zinc supplementation, the IAA stabilized fast already in the first day, while after discontinuation of the supplementation, at least 4 days was required to the stabilization. At the end of stage III, the IAA was significantly lower in RSFe (15.8 ± 6.6%) than in RSFeZn rats (43.4 ± 5.9%). In conclusion, to confirm that iron and zinc supplementation is more beneficial than iron supplementation only, especially after discontinuation of supplementation, further research among humans is necessary.

Oral Iron Supplementation—Gastrointestinal Side Effects and the Impact on the Gut Microbiota

Iron deficiency anaemia (IDA) is a worldwide healthcare problem affecting approximately 25% of the global population. The most common IDA treatment is oral iron supplementation, which has been associated with gastrointestinal (GI) side effects such as constipation and bloating. These can result in treatment non-adherence and the persistence of IDA. Intravenous iron does not cause GI side effects, which may be due to the lack of exposure to the intestinal lumen. Luminal iron can cause changes to the gut microbiota, aiding the promotion of pathogenic species and decreasing beneficial protective species. Iron is vital for methanogenic archaea, which rely on iron for growth and metabolism. Increased intestinal methane has been associated with slowing of intestinal transit, constipation, and bloating. Here we explore the literature to understand a potential link between iron and methanogenesis as a novel way to understand the mechanism of oral iron supplementation induced GI side effects.

Opportunities for plant-derived enhancers for iron, zinc, and calcium bioavailability: A review

Understanding of the mechanism of interactions between dietary elements, their salts, and complexing/binding ligands is vital to manage both deficiency and toxicity associated with essential element bioavailability. Numerous mineral ligands are found in both animal and plant foods and are known to exert bioactivity via element chelation resulting in modulation of antioxidant capacity or micobiome metabolism among other physiological outcomes. However, little is explored in the context of dietary mineral ligands and element bioavailability enhancement, particularly with respect to ligands from plant-derived food sources. This review highlights a novel perspective to consider various plant macro/micronutrients as prospective bioavailability enhancing ligands of three essential elements (Fe, Zn, and Ca). We also delineate the molecular mechanisms of the ligand-binding interactions underlying mineral bioaccessibility at the luminal level. We conclude that despite current understandings of some of the structure-activity relationships associated with strong mineral-ligand binding, the physiological links between ligands as element carriers and uptake at targeted sites throughout the gastrointestinal (GI) tract still require more research. The binding behavior of potential ligands in the human diet should be further elucidated and validated using pharmacokinetic approaches and GI models.

Refining Treatment Strategies for Iron Deficient Athletes

Iron deficiency (ID) is a prevailing nutritional concern amongst the athletic population due to the increased iron demands of this group. Athletes' ability to replenish taxed iron stores is challenging due to the low bioavailability of dietary sources, and the interaction between exercise and hepcidin, the primary iron-regulatory hormone. To date, copious research has explored the link between exercise and iron regulation, with a more recent focus on optimising iron treatment applications. Currently, oral iron supplementation is typically the first avenue of iron replacement therapy beyond nutritional intervention, for treatment of ID athletes. However, many athletes encounter associated gastrointestinal side-effects which can deter them from fulfilling a full-term oral iron treatment plan, generally resulting in sub-optimal treatment efficacy. Consequently, various strategies (e.g. dosage, composition, timing) of oral iron supplementation have been investigated with the goal of increasing fractional iron absorption, reducing gastric irritation, and ultimately improving the efficacy of oral iron therapy. This review explores the various treatment strategies pertinent to athletes and concludes a contemporary strategy of oral iron therapy entailing morning supplementation, ideally within the 30 min following morning exercise, and in athletes experiencing gut sensitivity, consumed on alternate days or at lower doses.

N-Acetylcysteine Nanocarriers Protect against Oxidative Stress in a Cellular Model of Parkinson's Disease

Oxidative stress is a key mediator in the development and progression of Parkinson's disease (PD). The antioxidant n-acetylcysteine (NAC) has generated interest as a disease-modifying therapy for PD but is limited due to poor bioavailability, a short half-life, and limited access to the brain. The aim of this study was to formulate and utilise mitochondria-targeted nanocarriers for delivery of NAC alone and in combination with the iron chelator deferoxamine (DFO), and assess their ability to protect against oxidative stress in a cellular rotenone PD model. Pluronic F68 (P68) and dequalinium (DQA) nanocarriers were prepared by a modified thin-film hydration method. An MTT assay assessed cell viability and iron status was measured using a ferrozine assay and ferritin immunoassay. For oxidative stress, a modified cellular antioxidant activity assay and the thiobarbituric acid-reactive substances assay and mitochondrial hydroxyl assay were utilised. Overall, this study demonstrates, for the first time, successful formulation of NAC and NAC + DFO into P68 + DQA nanocarriers for neuronal delivery. The results indicate that NAC and NAC + DFO nanocarriers have the potential characteristics to access the brain and that 1000 μM P68 + DQA NAC exhibited the strongest ability to protect against reduced cell viability (p = 0.0001), increased iron (p = 0.0033) and oxidative stress (p ≤ 0.0003). These NAC nanocarriers therefore demonstrate significant potential to be transitioned for further preclinical testing for PD.

Fabrication of Biopolymer Based Nanoparticles for the Entrapment of Chromium and Iron Supplements

The objective of this study was to encapsulate iron and chromium into novel nanoparticles formulated using chitosan (CS), dextran sulfate (DS) and whey protein isolate (WPI) for oral drug delivery. Empty and loaded CS-DS nanoparticles were prepared via complex coacervation whilst whey protein nanocarriers were produced by a modified thermal processing method using chitosan. The physiochemical properties of the particles were characterized to determine the effects of formulation variables, including biopolymer ratio on particle size and zeta potential. Permeability studies were also undertaken on the most stable whey protein–iron nanoparticles by measuring Caco-2 ferritin formation. A particle size analysis revealed that the majority of samples were sub-micron sized, ranging from 420–2400 nm for CS-DS particles and 220–1000 nm for WPI-CS samples. As expected, a higher chitosan concentration conferred a 17% more positive zeta potential on chromium-entrapped WPI nanoparticles, whilst a higher dextran volume decreased the size of CS-DS nanoparticles by 32%. The addition of iron also caused a significant increase in size for all samples, as seen where the loaded WPI samples were 296 nm larger than the empty particles. Caco-2 iron absorption revealed that one formulation, which had the lowest particle size (226 ± 10 nm), caused a 64% greater iron absorption compared to the ferrous sulfate standard. This study describes, for the first time, the novel design of chromium- and iron-entrapped nanoparticles, which could act as novel systems for oral drug delivery.

National Iron Plus Initiative: Current status & future strategy

Anaemia is a severe public health problem amongst all vulnerable age groups in India. The National Nutritional Anaemia Prophylaxis Programme initiated in 1970, was revised and expanded to include beneficiaries from all age groups namely children aged 6-59 months, 5-10 yr, adolescents aged 10-19 yr, pregnant and lactating women and women in reproductive age group under the National Iron Plus Initiative (NIPI) programme in 2011. The dose of iron, frequency and duration of iron supplementation and roles and responsibilities of the functionaries were described. At present, the coverage of beneficiaries with iron and folic acid has been poor at the national level. The prevalence of anaemia has continued to remain high during the last 60 years, and there has been no significant change in the scenario due to various reasons. The constraints in implementation and measures to improve the NIPI programme are discussed in the current article.

Anemia epidemiology, pathophysiology, and etiology in low- and middle-income countries

Anemia affects a third of the world's population and contributes to increased morbidity and mortality, decreased work productivity, and impaired neurological development. Understanding anemia's varied and complex etiology is crucial for developing effective interventions that address the context-specific causes of anemia and for monitoring anemia control programs. We outline definitions and classifications of anemia, describe the biological mechanisms through which anemia develops, and review the variety of conditions that contribute to anemia development. We emphasize the risk factors most prevalent in low- and middle-income countries, including nutritional deficiencies, infection/inflammation, and genetic hemoglobin disorders. Recent work has furthered our understanding of anemia's complex etiology, including the proportion of anemia caused by iron deficiency (ID) and the role of inflammation and infection. Accumulating evidence indicates that the proportion of anemia due to ID differs by population group, geographical setting, infectious disease burden, and the prevalence of other anemia causes. Further research is needed to explore the role of additional nutritional deficiencies, the contribution of infectious and chronic disease, as well as the importance of genetic hemoglobin disorders in certain populations.

Optimal Serum Ferritin Levels for Iron Deficiency Anemia during Oral Iron Therapy (OIT) in Japanese Hemodialysis Patients with Minor Inflammation and Benefit of Intravenous Iron Therapy for OIT-Nonresponders

Background: We determined optimal serum ferritin for oral iron therapy (OIT) in hemodialysis (HD) patients with iron deficiency anemia (IDA)/minor inflammation, and benefit of intravenous iron therapy (IIT) for OIT-nonresponders. Methods: Inclusion criteria were IDA (Hb <120 g/L, serum ferritin <227.4 pmol/L). Exclusion criteria were inflammation (C-reactive protein (CRP) ≥ 5 mg/L), bleeding, or cancer. IIT was withheld >3 months before the study. ΔHb ≥ 20 g/L above baseline or maintaining target Hb (tHB; 120-130 g/L) was considered responsive. Fifty-one patients received OIT (ferrous fumarate, 50 mg/day) for 3 months; this continued in OIT-responders but was switched to IIT (saccharated ferric oxide, 40 mg/week) in OIT-nonresponders for 4 months. All received continuous erythropoietin receptor activator (CERA). Hb, ferritin, hepcidin-25, and CERA dose were measured. Results: Demographics before OIT were similar between OIT-responders and OIT-nonresponders except low Hb and high triglycerides in OIT-nonresponders. Thirty-nine were OIT-responders with reduced CERA dose. Hb rose with a peak at 5 months. Ferritin and hepcidin-25 continuously increased. Hb positively correlated with ferritin in OIT-responders (r = 0.913, p = 0.03) till 5 months after OIT. The correlation equation estimated optimal ferritin of 30-40 ng/mL using tHb (120-130 g/L). Seven OIT-nonresponders were IIT-responders. Conclusions: Optimal serum ferritin for OIT is 67.4-89.9 pmol/L in HD patients with IDA/minor inflammation. IIT may be a second line of treatment for OIT-nonreponders.

Preparation and Evaluation of Taste Masking Iron Suspension: Taking Advantage of Weak Cationic Exchange Resin

The objective of this study is to use weak acid cation exchange resin to mask the taste and eliminate the teeth staining problems of ferrous sulfate liquid preparations for use in pediatrics. Amberlite IPR64 was loaded by Fe(II). Then, different suspensions of the iron-resin complex were prepared using various polymers as the suspending agents, and sorbitol as well as sucrose as sweeteners. Physical stability, rheological assessment, kinetics of Fe(II) release, and taste evaluation of suspensions were studied. The results implied that the prepared iron suspension was more stable when xanthan gum is used as the suspending agent. It was also shown that iron release in 0.7% NaCl (similar to saliva) was very negligible compared to relatively quick release in acidic medium (resembled the stomach). Overall, the volunteers confirmed that the formulations were successful in iron taste masking. The pH-dependent process of ion exchange by weak cationic resins opens an attractive approach to access a taste-masked iron suspension for infants.

Cytotoxicity, Intestinal Transport, and Bioavailability of Dispersible Iron and Zinc Supplements

Iron or zinc deficiency is one of the most important nutritional disorders which causes health problem. However, food fortification with minerals often induces unacceptable organoleptic changes during preparation process and storage, has low bioavailability and solubility, and is expensive. Nanotechnology surface modification to obtain novel characteristics can be a useful tool to overcome these problems. In this study, the efficacy and potential toxicity of dispersible Fe or Zn supplement coated in dextrin and glycerides (SunActive Fe^TM and SunActive Zn^TM) were evaluated in terms of cytotoxicity, intestinal transport, and bioavailability, as compared with each counterpart without coating, ferric pyrophosphate (FePP) and zinc oxide (ZnO) nanoparticles (NPs), respectively. The results demonstrate that the cytotoxicity of FePP was not significantly affected by surface modification (SunActive Fe^TM), while SunActive Zn^TM was more cytotoxic than ZnO-NPs. Cellular uptake and intestinal transport efficiency of SunActive Fe^TM were significantly higher than those of its counterpart material, which was in good agreement with enhanced oral absorption efficacy after a single-dose oral administration to rats. These results seem to be related to dissolution, particle dispersibility, and coating stability of materials depending on suspending media. Both SunActive^TM products and their counterpart materials were determined to be primarily transported by microfold (M) cells through the intestinal epithelium. It was, therefore, concluded that surface modification of food fortification will be a useful strategy to enhance oral absorption efficiency at safe levels.

Ascorbyl palmitate/DSPE-PEG nanocarriers for oral iron delivery: preparation, characterisation and in vitro evaluation

The objective of this study was to encapsulate iron in nanocarriers formulated with ascorbyl palmitate and 1,2-distearoyl-sn-glycero-3-phosphoethanolamine polyethylene glycol (DSPE-PEG) for oral delivery. Blank and iron (Fe) loaded nanocarriers were prepared by a modified thin film method using ascorbyl palmitate and DSPE-PEG. Surface charge of the nanocarriers was modified by the inclusion of chitosan (CHI) during the formulation process. Blank and iron loaded ascorbyl palmitate/DSPE nanocarriers were visualised by transmission electron microscopy (TEM) and physiochemical characterisations of the nanocarriers carried out to determine the mean particle size and zeta potential. Inclusion of chitosan imparted a net positive charge on the nanocarrier surface and also led to an increase in mean particle size. Iron entrapment in ascorbyl palmitate-Fe and ascorbyl palmitate-CHI-Fe nanocarriers was 67% and 76% respectively, suggesting a beneficial effect of chitosan on nanocarrier Fe entrapment. Iron absorption was estimated by measuring Caco-2 cell ferritin formation using ferrous sulphate as a reference standard. Iron absorption from ascorbyl palmitate-Fe (592.17±21.12 ng/mg cell protein) and ascorbyl palmitate-CHI-Fe (800.12±47.6 ng/mg, cell protein) nanocarriers was 1.35-fold and 1.5-fold higher than that from free ferrous sulphate, respectively (505.74±23.73 ng/mg cell protein) (n=6, p<0.05). This study demonstrates for the first time preparation and characterisation of iron loaded ascorbyl palmitate/DSPE PEG nanocarriers, and that engineering of the nanocarriers with chitosan leads to a significant augmentation of iron absorption.