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68 Year Old Male With 12.5 Hemoglobin Reading

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The effect of vitamin D supplementation on hemoglobin concentration: a systematic review and meta-analysis

  • Golnaz Ranjbar1,
  • Leila Sadat Bahrami1,
  • Mohammadreza Vafatwo &
  • Abdolreza Norouzyane

Diet Periodical volume xix, Article number:xi (2020) Cite this article

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A Correction to this article was published on 05 March 2021

This article has been updated

Abstract

Aims

The purpose of this review was to investigate the issue of vitamin D supplements on hemoglobin concentration in subjects aged 17.five–68 years old; using randomized controlled trials (RCTs).

Methods

Relevant RCT studies were identified from January 2000 to Jan 2019 past using MeSH terms in PubMed, Embase, Cochrane Library, Clinical trials, Scopus databases and gray literature. The studies were reviewed systematically, and quality assessments were evaluated by the guidelines of the Cochrane risk of bias. The upshot of vitamin D supplements (n = xiv) on hemoglobin concentration was considered as primary outcome, while its furnishings on the levels of ferritin, transferrin saturation and iron status were derived every bit secondary outcomes. In total, 1385 subjects with age range of 17.v to 68 years old were examined for iii h to 6 months; Mean (standard deviation) or median interquartile changes in the hemoglobin concentration in each handling grouping was recorded for meta-analysis.

Results

14 RCTs met the inclusion criteria. Electric current study findings propose that vitamin D supplementation leads to a non-meaning reduction in hemoglobin levels in subjects (17.5–68 years former) [std. mean deviation (SMD): 0.01; 95% CI: − 0.28, 0.29; P = 0.95], as well it has no significant effect on ferritin concentrations [std. hateful difference (SMD): -0.01; 95% CI: [− 0.xx, 0.18; P = 0.91]. However, vitamin D supplementation demonstrated positive effects on transferrin saturation [mean difference (Medico): i.54; 95% CI: 0.31, two.76; P = 0.01] and iron status [std. hateful difference (SMD): 0.24; 95% CI: − 0.09, 0.39; P = 0.002].

Conclusion

Current review concluded that supplementation with vitamin D had no pregnant outcome on hemoglobin and ferritin levels while positive effects on transferrin saturation and iron status were observed. Farther clinical studies are required to determine the bodily result of this intervention on hemoglobin levels.

Peer Review reports

Introduction

Anemia is one of the most prevalent health issues worldwide. Information technology is believed that this disease is responsible for a large portion of the fiscal burdens on communities [one, ii]. Iron deficiency is the most common grade of the illness and occurs in over 50% of patients worldwide. According to the World Health Organization (WHO), more than than one billion people are currently suffering from iron deficiency [i, 3, 4]. Several atmospheric condition, such as gastrointestinal illness, chronic center disease (CHD), chronic kidney disease (CKD), and inflammatory diseases increase the risk of anemia [5,6,seven,8,9,10,xi,12,xiii]. Information technology is believed that these conditions could decrease the quality of life equally well equally causing keen impairments in cognitive functions and increase the prevalence of fatigue and other physical dysfunctions [14,fifteen,16,17,eighteen]. As a consequence, attempts to improve the prevention and handling of anemia or the use of potential therapies can help to reduce the brunt of this disease [xix].

Vitamin D is a fat soluble vitamin that tin can be acquired from regimen (ergocalciferol from constitute sterols) and exist synthesized from direct exposure to sunlight (cholecalciferol) [20]. This vitamin is hydroxylated as 25-hydroxyvitamin D (25OHD) in the liver and and then converted to its concluding form, Calcitriol (ane, 25 (OH) 2nd), in the kidney cells [20, 21]. Vitamin D appears to be associated with the prevention of chronic disease and modulation of immunity, the regulation of cellular growth, and the differentiation and induction of erythropoiesis in bone marrow cells [22,23,24,25]. Several observational studies have indicated that there is a reverse relationship between vitamin D levels and anemia in adults [25,26,27,28]. Calcitriol (i,25-hydroxyvitamin D) could stimulate erythrocyte precursor cell receptors, which promotes the erythroid progenitor cells maturation and proliferation [29]. Information technology has also been reported that anti-inflammatory effects of vitamin D could downwards regulate mRNA expression of hepcidin levels [30]. The antimicrobial hepcidin peptides are believed to be associated with absorption and release of iron through suppression and activation of ferroportin (cellular fe exporter) [30]. Therefore, amending in iron status and prevalence of anemia are expected. According to a previous study, elevated levels of PTH may exist related to the chance of developing anemia through reduction in erythropoiesis rate, however it is suggested that vitamin D may increase the production of erythropoietin [29]. A systematic review and meta-analysis of RCTs were carried out in an attempt to summarize the show on the effects of vitamin D interventions on atomic number 26 status (ferritin, Hemoglobin, serum transferrin, transferrin saturation, serum iron and TIBC) and also evaluate the heterogeneity among said RCT results in subjects aged ≥17.5 years old.

Materials and methods

Search strategy

This review was conducted in accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Notably, PRISMA is primarily used for preparing systematic reviews of such research interventions [31, 32]. The search terms were carried out in the PubMed, Embase, Cochrane Library, and Scopus databases by two independent investigators, and relevant publications cited from Jan 2000 to Jan 2019 were identified. The post-obit search terms were used: vitamin D, 25-hydroxy vitamin D, 1, 25-hydroxy vitamin D, ergocalciferol, cholecalciferol, calcitriol, anemia, atomic number 26 deficiency, hemoglobin, ferritin, transferrin, iron regulation and iron status. Only articles in English language and simply RCTs that were chronologically limited were considered. The titles and abstracts of the scanned articles were checked, and duplicate citations were then removed. After excluding non-relevant articles, full text of the selected articles (RCTs) were retrieved.

Study choice

Inclusion criteria

A structured approach was taken to set up the research question nearly this review, using the following 5 components that are commonly known as the Participants, Interventions, Comparisons, Outcomes, and Study Design Arroyo (PICOS) [33]:

  1. 1.

    Studies reporting the effects of vitamin D interventions on atomic number 26 status as primary or secondary outcomes from single or combined vitamin D supplementation with calcium, atomic number 26 and vitamin M were considered. No restrictions were placed on the gender, historic period, race, and geographical distribution of the individuals enrolled in the report.

  2. two.

    Oral vitamin D supplements; such as Cholecalciferol, Ergocalciferol and Calcitriol.

  3. iii.

    Studies carried out in subjects with mean age of ≥17.5 years quondam.

  4. iv.

    Study design: RCTs.

Exclusion criteria

  1. 1.

    Editorials, case reports, letters to the editor, review articles, and animal studies.

  2. 2.

    RCTs without evaluating fe status as their primary or secondary outcomes; or RCT studies with no controls.

  3. 3.

    RCTs that did not study hateful (SD) or median interquartile changes in hemoglobin, ferritin levels, transferrin saturation and serum iron levels in each grouping.

Data extraction

2 researchers completed the data extraction independently (AM and LM) where qualitative and quantitative information were extracted from each study. Any disagreement between the researchers with respect to the inclusion criteria of a study was resolved by the insight of a 3rd researcher (AN). P-value of < 0.05 was considered statistically meaning for all of the included RCT studies. The information that were extracted included the name of showtime author, year of publication, land of origin, study design, sample size, subjects' age, serum vitamin D baseline levels, dose and types of vitamin D supplements, primary written report outcomes, and conclusions.

Quality and adventure of bias

The quality of each written report was evaluated independently by two researchers (AN and MV) who used bias tool method in the guidelines of Cochrane Collaboration [34]. In accordance with this method, each report was evaluated and proficient quality was obtained when the total depression chance of bias was ≥iii out of 5 items; however, if the total low risk of bias was ≤2 out of 5 items, it was considered as fair quality; and studies with ≤i low risk of bias out of 5 items were regarded every bit poor quality [34].

Statistical analysis

In the current review, all the statistical assay was performed on RevMan five.3 software (Cochrane IMS, Oxford, Great britain) with a random and fixed outcome model. Random effect model was used for random variances, when the number of studies entered was limited and in that location was a divergence between the number and characteristics of the individuals [35]. Small and large sample sizes had the aforementioned effect in the final conclusion when using this model. The stock-still issue model was used for studies with fixed parameters or non-random quantities. Nosotros extracted and accumulated continuous data from all RCTs, then analyzed the variables in guild to obtain overall weighted mean difference (WMD) with 95% confidence intervals (CIs) by the inverse variance approach. The heterogeneity by Cochrane I2 value was calculated with weighted Mantele-Haenszel method equally information technology was suggested in Cochrane handbook [36]. In trials with several elapsing of supplementations, mean and standard deviations were analysed separately. Publication bias was evaluated according to the Begg and Egger exam, by using Comprehensive Meta-Analysis (CMA) V2 software (Biostat, NJ) [37, 38]. It was considered statistically meaning if P value was less than 0.05.

Subgroup analysis

Predetermined subgroup analyses were performed according to Deeks et al. [39] study, to evaluate the potential effects of vitamin D interventions on participants with unlike health conditions. In this method, studies were explored according to the potential heterogeneity of inducer factors, thus divide statistical analyses were performed in each study subgroups. Thereafter, studies were categorized according to the health status of individuals, and then separate meta-analysis was conducted. A pregnant reduction in the extent of heterogeneity in each subgroup, confirmed the heterogeneity in the health status of individuals. We categorized subjects in RCTs to 7 groups as such: good for you adults, bloodless patients, chronic kidney disease patients, centre failure patients, hypertensive patients, critically ill patients and athletes. The levels of hemoglobin and ferritin in participants from these groups were assessed and compared when supplemented with vitamin D.

Results

PRISMA menstruation diagram in Fig. 1, illustrates the pick of included studies and screening process in this review. In total, 3510 articles were establish in the initial search, and 3496 of these articles were excluded after reading the titles and abstracts where supplementation of interest was not evaluated. Also, duplicates were removed. Finally, 14 studies met the inclusion criteria (Additional file 1: Table S1) and were suitable for quantitative synthesis [forty,41,42,43,44,45,46,47,48,49,l,51,52,53].

Fig. i
figure 1

PRISMA flow-diagram of the study selection process

Full size prototype

Study characteristics

All studies except two were parallel double blind randomized clinical trials [45, 48]. The primary characteristics of the studies are illustrated in Table 1. Studies were published online betwixt 2014 and 2019. The range of sample size was from 10 to 276 participants. Cholecalciferol was the main form of vitamin D that were supplemented in these studies. The duration of supplementation with vitamin D also varied from 3 h to 6 months [40,41,42,43,44,45,46,47,48,49,l,51,52,53].

Table one Randomized studies comparison the effect of vitamin D supplementation on iron status

Full size table

Participant characteristics

The average historic period of participants ranged from 17.5 to 68 years quondam. Males made upwards more than 50% of participant's gender distribution. Mean baseline of 25 (OH) D levels ranged between ten and thirty ng/ml, as reported in 14 studies (Table 1).

Intervention characteristics

Different types of vitamin D were used in these studies, iv studies received vitamin D fortified food with cholecalciferol [40, 46,47,48], eight studies received oral vitamin D (cholecalciferol) supplements [42, 44, 45, 49,fifty,51,52,53] and in one study subjects were supplemented with ergocalciferol and another one with calcitriol [41, 43]. The minimum vitamin D dosage was 20 IU and maximum was 500,000 IU co-ordinate to these studies (Table one).

Outcome measures

All of these xiv RCT studies reported hemoglobin levels, as their principal outcomes. While, iron markers such as levels of ferritin, serum fe, and transferrin saturation were measured as their secondary outcomes. Results are illustrated in Table 1.

Hazard of Bias cess

According to Figs. 2, 3, iv and five, the Cochrane risk of bias checklist shows the risk of bias in these randomized clinical trial studies [34]. We evaluated each variable: sequence generation (selection bias), allocating concealment (selection bias), blinding participants and personnel (operation bias), incomplete event data (compunction bias), and selective reporting (reporting bias). Each item with depression risk and appropriate information was marked equally (+), unclear risk and inadequate information marked every bit (?), high risk and unsuitable information marked as (−). Finally, we assessed the overall quality, ix RCTs had a low risk of bias rate (expert) [forty,41,42,43,44, 46, 47, 49,50,51,52,53]; two RCTs had a moderate risk of bias (fair) [45, 48].

Fig. ii
figure 2

Forest plot showing results of a meta-analysis on the effects of vitamin D supplementation on hemoglobin. Data were reported as SMDs with 95% CIs. (Toxqui study at four, 8, 12 and 16 weeks afterwards intervention, Panwar study at i, 4 and 6 weeks after supplementation)

Total size image

Fig. 3
figure 3

Woods plot showing results of a meta-analysis on the effects of vitamin D supplementation on ferritin. Information were reported as SMDs with 95% CIs. (Toxqui report at four, 8, 12 and 16 weeks after intervention, Panwar study at 1, 4 and half-dozen weeks afterwards supplementation)

Full size epitome

Fig. 4
figure 4

Forest plot showing results of a meta-assay on the furnishings of vitamin D supplementation on transferrin saturation. Information were reported as MDs with 95% CIs. (Toxqui study at 4, viii, 12 and 16 weeks after intervention, Panwar study at 1, 4 and 6 weeks after supplementation)

Full size image

Fig. 5
figure 5

Wood plot showing results of a meta-analysis on the effects of vitamin D supplementation on iron levels. Information were reported as SMDs with 95% CIs. (Toxqui study at 4, 8, 12 and sixteen weeks after intervention, Panwar study at 1, 4 and 6 weeks subsequently supplementation)

Full size paradigm

Meta-analyses

Outcomes

The remaining information from 3 studies examined differences in iron condition markers between intervention and control groups. Markers such as hemoglobin, ferritin, transferrin saturation (TS) and serum fe (SI) levels were included in the pooled analysis component.

Primary outcome

Overall effect of vitamin D on hemoglobin

Ten clinical trials (Due north = 1385) reported overall hemoglobin levels. When pooled analysis were performed, vitamin D assistants did non improve hemoglobin levels [SMD (95% CI) = 0.01 [− 0.28, 0.29]; p = 0.76; I2 = 82%; Phet < 0.00001]. Significant heterogeneity existed in the data. We categorized our information to seven groups based on participants' health condition. The subgroup analysis is demonstrated every bit pooled issue of vitamin D supplementation on hemoglobin in healthy adults 0.13 [95% CI = − 0.16, 0.42]; I2 = not applicable, bloodless patients 0.02 [95% CI = − 0.twenty, 0.24]; Iii = 30%, chronic kidney disease patients − 1.07 [95% CI = − 1.46, − 0.69]; Itwo = 0%, heart failure patients − 0.05 [95% CI = − 0.35, 0.25]; I2 = not applicable, hypertensive patients 0.00 [95% CI = − 0.29, 0.29]; I2 = not applicable, critically sick adults 3.85 [95% CI = 2.72, 4.98]; I2 = 0% and athletic subjects 0.15 [95% CI = − 0.xiii, 0.44]; I2 = 0% (Fig. 2).

Secondary effect

Overall effect of vitamin D on ferritin

In 11 of included studies (N = 1363) vitamin D supplementation did not amend ferritin concentrations in overall [SMD (95% CI) = − 0.01 [− 0.20, 0.18]; p = 0.91; I2 = 60%; Phet < 0.0010]. Significant heterogeneity existed in the information. For clarifying the bear on of vitamin D, subgroup analysis was performed in five groups. The subgroup analysis showed the pooled issue of vitamin D interventions on ferritin levels in healthy adults: -0.17 [95% CI = − 0.72, 0.39]; Itwo = 74%, anemic patients: -0.xviii [95% CI = − 0.36, 0.01]; I2 = 0%, chronic kidney affliction patients: 0.45 [95% CI = 0.06, 0.85]; Itwo = 58%, critically sick adults: -0.92 [95% CI = − 1.71, − 0.xiv]; Itwo = not applicative and athletic subjects: 0.09 [95% CI = − 0.61, 0.78]; Iii = 65% (Fig. 3).

Overall consequence of vitamin D on transferrin saturation

Pooled data of six studies (N = 1008) showed a significant difference between the case and control groups on transferrin saturation, with low heterogeneity [Dr. (95%CI): i.54 [0.31, 2.76]; p = 0.01; I2 = 21%; Phet =0.24] (Fig. four).

Overall effect of vitamin D on serum iron

The weighted results from four studies (North = 736) showed, an improving upshot of vitamin D on serum iron levels versus placebo grouping, without any existed heterogeneity [Physician (95%CI): 1.54 [0.31, 2.76]; p = 0.01; I2 = 0%; Phet =0.24] (Fig. v).

Sensitivity analysis and publication bias

Results of sensitivity analysis was conducted past using go out-one-out method, in this method removal of any of the studies from total RCTs or subgroups analysis could cause no substantial change in the impact of vitamin D supplements on hemoglobin and ferritin levels. For case, ii studies with measured hemoglobin and ferritin levels afterwards supplementation with vitamin D and a moderate quality were removed [45, 48]. Thus, the issue of vitamin D intervention did non significantly modify the overall outcome of hemoglobin levels: [SMD (95% CI) = 0.03 [− 0.27, 0.33]; p = 0.86; Iii = 84%; Phet < 0.00001], and ferritin levels: [SMD (95% CI) = 0.01 [− 0.xix, 0.21]; p = 0.92; I2 = 64%; Phet =0.0005]. Despite the weak asymmetry observed in funnel plot, electric current results showed that vitamin D supplementation effects on hemoglobin concentrations, had no evidence of publication bias (Begg'southward test, P = 0.58; Egger'south test, P = 0.92) [37, 54].

Give-and-take

The present systematic and meta-analysis study included 14 studies with 1385 participants from different countries. Vitamin D3 treatments (xx to 500,000 IU) on adults did non have a significant bear on on the levels of serum hemoglobin overall. While, pooled analysis revealed a significant consequence of vitamin D supplements on transferrin saturation and iron levels. Subgroup assay co-ordinate to the health condition of participants, propose that supplementation with vitamin D significantly increased hemoglobin levels in critically ill patients. Sensitivity analysis for studies with depression quality indicated an insignificant change on the total effect. To the extent of our cognition, this is the commencement pooled analysis which has evaluated the overall effect of vitamin D interventions on iron status in subjects with unlike health conditions. According to a cross sectional meta-analysis, there was a positive association between vitamin D deficiency and incidence of anemia [55]. This study, was performed on 5183 subjects, indicated participants who were vitamin D deficient had 64% higher risk of developing anemia compared to those who were vitamin D sufficient [55]. In some other meta-analysis by Basutkar et al. [56], .vitamin D supplementation in iron insufficient subjects did not better their clinical outcomes such as hemoglobin and ferritin levels. Similarly, the clinical trials reported in the present systematic review, showed no significant impact of unlike doses of vitamin D on hemoglobin and ferritin levels, thus, this could be due to the high heterogeneity of the combined studies [twoscore, 42,43,44,45,46, 49,l,51, 53]. Withal, it should exist noted that active form of vitamin D tin touch on erythropoiesis through stimulating the erythroid progenitor cells for proliferation and maturation, therefore calcitriol deficiency may harm erythropoiesis, and this may explain positive effect of vitamin D on iron status [57]. Our principal finding is consistent with a recent meta-analysis, where they showed vitamin D treatment had no association with improvements in patients with anemia [45, 46]. However, according to a narrative review conducted by Smith et al. [58], .cholecalciferol supplementation improved anemic condition, through modulating pro and anti-inflammatory cytokines, which leads to reduction in the levels of hepcidin and progress into anemic status [58]. Finally, vitamin D may heave erythropoiesis by increase in iron availability. Some iron inhibitor recycling agents, including the parathyroid hormone (PTH) and fibroblast growth factor 23 (FGF23) may lead to destructive effects on iron metabolism. However, iron recycling effect of vitamin D probably depends on several weather condition such as existed inflammation, loftier levels of parathyroid hormone and fibroblast growth factor 23 [29, 59]. Notably, in healthy subjects due to their balanced levels of parathyroid hormones and Fibroblast growth factor-23 (FGF-23), likewise no or low inflammation charge per unit, vitamin D could non exist effective for improving the atomic number 26 status. However, co-ordinate to the subgroup analysis, in critically ill patients with loftier inflammation rate and loftier PTH concentrations, vitamin D may meliorate their iron status through increment in erythropoietin and stimulation of erythroid progenitor formation while, PTH levels are suppressed. In this study, current outcomes suggest that vitamin D interventions significantly induce transferrin saturation and iron levels. Active vitamin D (1, 25(OH) D3) may have beneficial impacts on the levels of parathyroid hormone (PTH), through increase in the absorption rate of calcium and suppression in the release of PTH from parathyroid glands [60]. Previous studies accept proposed that depletion of PTH secretion could be related to improved erythropoiesis past inducing erythropoietin and erythroid progenitor formation also as decreased fibrosis of the os marrow [29, 61, 62]. Moreover, since fibroblast growth factor 23 is a negative modulator for iron hemostasis and erythropoiesis, vitamin D may reduce this factor thus improve the metabolism of iron, followed past an increase in the levels of iron [63, 64]. The present meta-analysis has several limitations, duration of RCTs were curt, also one of the included RCTs was not assessed in the pooled analysis since information technology lacked placebo grouping [65]. Dissimilar types of vitamin D such as ergocalciferol and calcitriol were supplemented in these trials [41, 43]. The possible reasons for the heterogeneity in data could be associated with the differences in the duration of supplementation, sex, race, geographical location, seasonal alter, mean historic period, sample size, health conditions, vitamin D dosage and co-supplementations. Therefore, we performed the random-effects model, in order to determine the heterogeneity among these studies. This study lacks bear witness regarding the mechanism of action between vitamin D and iron levels.

Conclusion

In decision, current systematic review and meta-analysis demonstrated that vitamin D supplements can meliorate hemoglobin and ferritin status in critically ill and chronic kidney disease patients' subgroups. Whereas in other subgroups (healthy adults, anemic patients, chronic kidney illness patients, center failure patients, hypertensive patients, critically ill patients and athletes) not-statistically significant difference were observed on hemoglobin and ferritin levels. The current study suggests that vitamin D supplementation on inflammatory diseases (CKD and disquisitional illness) could effectively ameliorate anemia status. Although at that place is still limited show in club to support and clarify the verbal machinery of action betwixt vitamin D and iron levels. Therefore, farther high-quality, well designed and long term RCTs in this field are extensively required.

Availability of data and materials

Please contact author for data requests.

Change history

  • 05 March 2021

    A Correction to this newspaper has been published: https://doi.org/10.1186/s12937-021-00679-iv

Abbreviations

CHD:

Chronic heart illness

CIs:

Confidence intervals

CKD:

Chronic kidney disease

EPO:

Erythropoietin

FGF23:

Fibroblast grows factor 23

Hb:

Hemoglobin concentration

MeSH:

Medical subject headings

PICOS:

The Participants, Interventions, Comparisons, Outcomes, and Study Design Approach

PRISMA:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

PTH:

Parathyroid hormone

RCTs:

Randomized controlled trials

TIBC:

Full fe binding capacity

WHO:

World Wellness System

WMD:

Weighted hateful departure

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Acknowledgements

All authors were fully responsible for the validity and reliability of the data, the assay and the writing of the manuscript.

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  1. Metabolic Syndrome Research Center, Section of Diet, Kinesthesia of Medicine, Mashhad University of Medical Sciences, Mashhad, 91179481564, Iran

    Seyed Mostafa Arabi, Golnaz Ranjbar, Leila Sadat Bahrami & Abdolreza Norouzy

  2. Section of Diet, Schoolhouse of Public Health, Iran University of Medical Sciences, Tehran, Iran

    Mohammadreza Vafa

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SMA and LSB conducted search terms on databases. AN, MV and GR assessed the quality of studies. SMA designed the manuscript. LSB revised and GR edited the manuscript. All authors read and approved the final manuscript.

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Correspondence to Abdolreza Norouzy.

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Arabi, S.M., Ranjbar, G., Bahrami, L.S. et al. The outcome of vitamin D supplementation on hemoglobin concentration: a systematic review and meta-analysis. Nutr J 19, xi (2020). https://doi.org/10.1186/s12937-020-0526-three

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Keywords

  • Anemia
  • Hemoglobin
  • Vitamin D
  • Fe status
  • RCT

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