Iron supplementation--is it necessary for healthy pregnancy?Abstract Iron is an important mineral during pregnancy for both mother and fetus. Although the food supply provides numerous sources of iron, many women of child-bearing age in New Zealand New Zealand (zē`lənd), island country (2005 est. pop. 4,035,000), 104,454 sq mi (270,534 sq km), in the S Pacific Ocean, over 1,000 mi (1,600 km) SE of Australia. The capital is Wellington; the largest city and leading port is Auckland. consume intakes below what is recommended. The beneficial effects of iron supplementation in pregnancy on birth outcomes are controversial however maternal benefits have been clearly identified. The recommended dose for iron supplementation in pregnancy is generally accepted to be between 30-100 mg/day. Even when the women is aware of the importance of obtaining adequate dietary iron and are encouraged by midwives to follow healthy eating practices, iron supplementation may be indicated in some situations. Midwives should therefore assess women based on their iron status and history and provide appropriate advice regarding diet and supplementation to support healthy pregnancy. Introduction Iron deficiency iron deficiency A relative or absolute deficiency of iron which may be due to chelation in the GI tract, loss due to acute or chronic hemorrhage or dietary insufficiency Sources Meat, poultry, eggs, vegetables, cereals, especially if fortified with iron; per the is the number one micronutrient mi·cro·nu·tri·ent n. A substance, such as a vitamin or mineral, that is essential in minute amounts for the proper growth and metabolism of a living organism. deficiency worldwide with estimates of over two billion people affected. Iron deficiency is more common in women than men and its prevalence increases during pregnancy (Stoltzfus, 2001). Iron deficiency or iron depletion occurs when levels of stored iron in the body (ferritin ferritin /fer·ri·tin/ (-i-tin) the iron-apoferritin complex, one of the chief forms in which iron is stored in the body. fer·ri·tin n. ) fall below normal levels (Table 1). As ferritin levels fall, the amount of iron transported in the blood also decreases resulting in a reduction in the amount of iron transported in the blood (transferrin saturation Transferrin saturation, measured as a percentage, is a medical laboratory value. It is the ratio of serum iron and total iron-binding capacity, multiplied by 100. For an explanation of some clinical situations in which this ratio is important, see Total iron-binding capacity. ) and eventually a reduction in functional iron (haemoglobin haemoglobin or US hemoglobin Noun a protein in red blood cells that carries oxygen from the lungs to the tissues [Greek haima blood + Latin globus ball] Noun 1. ). The reduction in haemoglobin indicates the presence of iron deficiency anaemia Noun 1. iron deficiency anaemia - a form of anemia due to lack of iron in the diet or to iron loss as a result of chronic bleeding iron deficiency anemia . Prophylactic iron supplementation during pregnancy is recommended in some countries (Danish National Board of Health, 1992; American College of Obstetricians and Gynecologists The American College of Obstetricians and Gynecologists (ACOG) is a professional association of medical doctors specializing in obstetrics and gynecology in the United States. It has a membership of over 49,000[1] and represents 90 percent of U.S. , 1993). In New Zealand routine iron supplementation for pregnancy is not recommended, instead supplementation is based on individual need. The following article provides an overview of iron in pregnancy and explores strategies for attaining adequate iron status focusing on iron supplementation for at-risk groups. The role of iron in pregnancy Maternal effects Iron is a component of haemoglobin, which is required during pregnancy to supply maternal and fetal tissues with oxygen. In pregnancy additional haemoglobin is required for the increase in maternal red cell mass and to allow for normal blood losses at delivery. An insufficient haemoglobin concentration may cause fatigue, reduced immune function Immune function The state in which the body recognizes foreign materials and is able to neutralize them before they can do any harm. Mentioned in: Herbalism, Traditional Chinese, Stress Reduction , deficits in concentration and mood, and impaired work performance (Bodnar, Cogswell & McDonald, 2005). Further, a reduction in haemoglobin during pregnancy has been associated with increased risk for post-partum haemorrhage and overall maternal morbidity (Allen & Casterline-Sabel, 2000). Fetal and infant effects Low maternal haemoglobin has been associated with an increased risk of pre-term birth, low birth weight and perinatal mortality Perinatal mortality (PNM), also perinatal death, refers to the death of a fetus or neonate and is the basis to calculate the perinatal mortality rate. Variations in the precise definition of the perinatal mortality exist specifically concerning the issue of inclusion particularly in developing countries where rates of anaemia anaemia see anemia. are high and other factors such as general hygiene and nutrition are sub-optimal (Rasmussen, 2001; Yip, 2000). Infants born to iron-deficient or anaemic a·nae·mic adj. Variant of anemic. anaemic or US anemic Adjective 1. having anaemia 2. pale and sickly-looking 3. lacking vitality Adj. mothers are at greater risk of being iron-deficient or anaemic (Haram For the municipality of Haram, see . For the technical Islamic legal meaning, see . The Arabic term ḥaram has a meaning of "sanctuary" or "holy site" in Islam. , Nilsen & Ulvik, 2001). However, in a group of New Zealand infants this relationship was not evident (Emery & Barry, 2004). Iron-deficiency and iron-deficiency anaemia in infancy has also been linked to poor cognition and reduced immunity (Booth & Aukett, 1997). Assessment of iron status There is controversy with respect to the appropriate cut-off values for defining iron deficiency and iron-deficiency anaemia particularly for pregnancy. The World Health Organisation defines anaemia as haemoglobin levels below 110 g/L in the first and third trimester Noun 1. third trimester - time period extending from the 28th week of gestation until delivery trimester - a period of three months; especially one of the three three-month periods into which human pregnancy is divided and below 105 g/L in second trimester Noun 1. second trimester - time period extending from the 13th to the 27th week of gestation trimester - a period of three months; especially one of the three three-month periods into which human pregnancy is divided . Milman, Bergholt, Eriksen, Byg, Graudal, Pedersen & Hertz (2005) suggest similar cut-offs but also include that ferritin levels below 12 micrograms/ L is indicative of iron-deficiency anaemia. The Australian Iron Advisory Panel (no date [n.d.]) recommends using haemoglobin and ferritin along with a variety of risk factors including a history of iron deficiency, post-partum haemorrhage, recent blood donation, poor socioeconomic status socioeconomic status, n the position of an individual on a socio-economic scale that measures such factors as education, income, type of occupation, place of residence, and in some populations, ethnicity and religion. and heavy menses menses /men·ses/ (men´sez) the monthly flow of blood from the female genital tract. men·ses n. , to assess a woman's risk of iron deficiency and iron deficiency anaemia in pregnancy. They suggest that woman in the first trimester of pregnancy with haemoglobin levels between 105-115 g/L and one or more risk factors are at risk of developing iron deficiency in pregnancy whereas women with haemoglobin less than 105 g/L are considered anaemic. Iron recommendations for pregnancy The New Zealand recommendation for iron intake during pregnancy is 27 mg/day for both adolescents (14-18 years) and women (>18 years) (Australian Government National Health and Medical Research Council The National Health and Medical Research Council (NHMRC) is Australia's peak funding body for medical research, with a budget of nearly A$500M a year . The Council was established to develop and maintain health standards and is responsible for implementing the , 2005). Little is known about the iron intake and iron status of pregnant New Zealand women. However according to the 1997 National Nutrition Survey, non-pregnant women aged 25-44 had mean iron intakes of only 10.5 mg/day (Russell, Parnell & Wilson, 1999). Although women in this survey had low intakes of iron, the prevalence of iron deficiency anaemia in this population was low (2%). There is no evidence to suggest that dietary intakes of pregnant women are significantly different than non-pregnant women therefore it is likely that pregnant New Zealand women also have low intakes of dietary iron, well below the recommendations. Iron absorption, however is enhanced in pregnancy; the mechanism by which this occurs is not known (Fairbanks, 1999). Despite enhanced iron absorption in pregnancy, women with low dietary iron intakes prior to and during pregnancy, are at increased risk for iron deficiency or iron deficiency anaemia in pregnancy. How to ensure adequate iron status Diet Iron has many oxidation states, however only the ferric ferric (fĕr`ĭk), iron in the +3 valence state. See ferrous. and ferrous states exist in food. When describing the iron present in food the terms haem haem see heme. and non-haem are used. Both haem and non-haem iron are present in animal products, whereas plant sources such as whole grains, nuts, beans and legumes Legumes A family of plants that bear edible seeds in pods, including beans and peas. Mentioned in: Cholesterol, High legumes (l contain only non-haem iron. Haem iron is present as ferrous iron, bound within haemoglobin and myoglobin myoglobin (mī'əglō`bĭn), protein molecule isolated from the cells of vertebrate skeletal muscle that is both a structural and functional relative of hemoglobin, the oxygen-transport protein of the blood of higher animals. in animal flesh. Non-haem iron is found in foods as ferric and ferrous iron (Groff & Gropper, 2000). Some foods in New Zealand are also fortified fortified (fôrt  ´fīd),adj containing additives more potent than the principal ingredient. with non-haem iron including breakfast cereals, sweet biscuits and some milks. Only a small proportion of dietary iron is absorbed in the gut and therefore, not all dietary iron consumed is available for use by the body. This is referred to as the bioavailability bioavailability /bio·avail·a·bil·i·ty/ (bi?o-ah-val?ah-bil´i-te) the degree to which a drug or other substance becomes available to the target tissue after administration. bi·o·a·vail·a·bil·i·ty n. of iron. Haem iron is readily absorbed by the body whereas non-haem iron is less soluble in the gut and therefore less is absorbed. Up to one-third of haem iron and 220% of non-haem iron is considered bioavailable (Hurrell, 1997). To enhance the bioavailability of non-haem iron the following strategies can be employed: * Consumption of vitamin C vitamin C or ascorbic acid Water-soluble organic compound important in animal metabolism. Most animals produce it in their bodies, but humans, other primates, and guinea pigs need it in the diet to prevent scurvy. rich food with meals or snacks containing iron (examples of vitamin C rich foods include tomatoes, capsicums, strawberries). Vitamin C increases the bioavailability of iron by forming a chelate chelate Any of a class of coordination or complex compounds consisting of a central atom of a metal (usually a transition element) attached to a large molecule (ligand). with iron converting ferric iron into ferrous iron, a more soluble and absorbable form of iron (Cook, 2001). * Consuming small portions of meat, poultry and fish with foods containing non-haem iron (examples might include bean chilli with small portions of mince beef, vegetable and nut stir-fry with small quantities of chicken, beef or pork). Certain amino acids present in high concentrations in animal flesh enable the conversion of ferric iron to the ferrous form (Hurrell, 1997). * Consuming black types of tea (oolong oo·long n. A dark Chinese tea that has been partially fermented before drying. [Chinese (Mandarin) w , Ceylon) one to two hours before or after a meal rather than with a meal. Tannins tannins, n.pl polyphenolic phytochemicals whose name derives from their use in tanning animal skins. Used as astringents, antioxidants, and styptics; treats burns, relieves diarrhea. , polyphenolic co pounds present in tea, bind to iron in the gut thereby inhibiting the absorption of iron (ibid). Furthermore, zinc and calcium can interfere with iron absorption thereby reducing iron bioavailability. Zinc, calcium and iron compete for absorption into the intestinal mucosa; however this interaction appears to occur only when these minerals are given in high doses such as those found in supplements. Calcium and zinc present within food do not appear to have similar inhibitory effects on iron absorption (Minihane & Fairweather-Tait, 1998; Groff & Gropper, 2000). Supplements In addition to food, iron supplements can also be used to meet dietary iron requirements. There are many types of iron supplements available in New Zealand (Table 2). Iron supplements come as either tablets or liquid, and are available in various doses ranging from tonics with negligible amounts (<10mg), to low-dose (20-60mg), slow-release and high-dose (>60mg). Iron supplements contain ferrous iron and are combined with other compounds such as fumurate, gluconate, lactate Lactate A salt or ester of lactic acid (CH3CHOHCOOH). In lactates, the acidic hydrogen of the carboxyl group has been replaced by a metal or an organic radical. Lactates are optically active, with a chiral center at carbon 2. or sulphate to increase its stability. The term 'elemental iron' is used to indicate the amount of iron present within these compounds, and therefore represents the amount of iron available for absorption. The need for iron supplementation is greatest for women who enter pregnancy with poor iron status. Poor iron status may be attributed to a variety of factors including a poor diet with low intake of iron-rich foods, history of iron-deficiency or iron-deficiency anaemia, recent pregnancy, previous post-partum haemorrhage and low socioeconomic status (Australian Iron Advisory Panel, n.d.). In addition, women with high menstrual loss are also at risk for iron deficiency and iron deficiency anaemia (Lynch, 2000). Adolescents, who often have sub-optimal intakes of iron and low blood ferritin concentrations, are also at increased risk for developing iron-deficiency anaemia in pregnancy (ibid). Non-pregnant New Zealand adolescents aged 15-18 years, have iron intakes of 10.4 mg/day (Russell et al, 1999) well below the recommended intakes of 15 mg/day (Australian Government National Health and Medical Research Council, 2005). Although dietary strategies should be encouraged to improve iron status, increasing dietary iron intake alone does not always result in increased haematological Adj. 1. haematological - of or relating to or involved in hematology hematologic, hematological values in the short term. A study of non-pregnant New Zealand women with mild iron deficiency who had made significant dietary changes over four months achieved minimal increases in iron status, compared to those supplemented daily with 50 mg elemental iron (Heath, Skeaff, O'Brien, Williams & Gibson, 2001). Therefore in some situations, particularly in at-risk groups as described, iron supplementation is warranted. Low-dose iron supplementation in pregnant women with haemoglobin levels of 110-120 g/L has been found to be effective in preventing iron deficiency and iron-deficiency anaemia. Supplementation with 20 mg elemental iron/day 20 weeks gestation until delivery prevented iron deficiency and iron-deficiency anaemia in a group of Australian women (Makrides, Crowther, Gibson, Gibson & Skeaff, 2003). Milman et al (2005) also found that daily supplementation of 40 mg elemental iron early in pregnancy (18 weeks gestation) was as effective as 60 or 80 mg elemental iron/day in preventing iron deficiency and iron deficiency anaemia in women with an initial mean haemoglobin of 117 g/L. Similarly, daily supplementation of 50 mg elemental iron from 21-26 weeks gestation for three months resulted in a mean rise in haemoglobin, from 112 g/L to 123 g/L (Ekstrom, Kavishe, Habicht, Frongillo, Rassmussen & Hemed, 1996). Cogswell, Parvanta, Ickes, Yip & Brittenham (2003) however, found that daily supplementation of 30 mg elemental iron from 10 weeks gestation until 28 weeks gestation did not result in a lower prevalence of iron-deficiency anaemia compared to placebo in a group of iron replete, non-anaemic women. It is possible however, that if supplementation continued throughout pregnancy a lower prevalence of iron-deficiency anaemia may have been found. These studies demonstrate that low-dose iron supplementation (<60 mg/day) can help prevent iron deficiency anaemia in women with haemoglobin values at the lower end of normal when given from approximately 20 weeks gestation until birth. Although low-dose iron supplementation can be effective in preventing iron-deficiency and iron-deficiency anaemia, higher levels are necessary for treatment. A meta-analyses of data from randomized controlled trials between 1966 and 1998 found that >90 mg iron/day was needed to improve haematological indices in pregnant, anaemic women (Sloan, Jordan & Winikoff, 2002). Some of the issues regarding iron supplementation are tolerance and compliance. Gastro-intestinal side effects Side effects Effects of a proposed project on other parts of the firm. such as nausea, vomiting, epigastric epigastric adjective Referring to the body region between the costal margins and the subcostal plane pain and constipation are associated with iron supplementation. However, the results of many studies, including a large (n=427) randomised Adj. 1. randomised - set up or distributed in a deliberately random way randomized irregular - contrary to rule or accepted order or general practice; "irregular hiring practices" controlled trial controlled trial Clinical research A clinical study in which one group of participants receives an experimental drug while the other receives either a placebo or an approved–'gold standard' therapy. See Blinding, Double-blinded. , found that gastro-intestinal side effects associated with iron supplementation did not differ between women supplemented daily with 20, 40, 60 or 80 mg elemental iron in the form of ferrous fumarate fumarate /fu·ma·rate/ (fu´mah-rat) a salt of fumaric acid. fumarate a salt of fumaric acid. (Milman, Byg, Bergholt & Erikson, 2006). Higher doses of elemental iron (>100 mg) however, have been reported to increase side effects and therefore are associated with lower compliance than lower doses (Ekstrom et al, 1996). There is limited evidence to support the use of one type of iron supplement over another due to tolerance; however larger doses irrespective of type tend to be less tolerable than low dose supplements. When using supplements, toxicity issues should always be addressed. With iron however, toxicity is generally not a concern as the body regulates iron absorption based on stored levels (ferritin). Therefore individuals with poor stores have a greater absorptive ability than those with normal stores. There are some women for whom iron supplementation is contraindicated. Women with the condition haemochromatosis Haemochromatosis, also spelt hemochromatosis, is a hereditary disease characterized by improper dietary iron metabolism (making it an iron overload disorder), which causes the accumulation of iron in a number of body tissues. , a condition most common in individuals of Northern European descent, have an enhanced ability to absorb and store iron in the body. The increase in body iron, if not treated, results in iron overload Iron overload A side effect of frequent blood transfusions in which the body accumulates abnormally high levels of iron. Iron deposits can form in organs, particularly the heart, and cause life-threatening damage. and leads to tissue damage, specifically in the liver and heart (Groff & Gropper, 2000). Conclusion Despite the controversy surrounding the benefits of iron supplementation for birth outcome, benefits to maternal haematological values and general well-being are well established. It is important for pregnant women to maintain healthy iron levels for both themselves and their offspring. It is essential therefore, that iron status be monitored throughout pregnancy, and that midwives provide necessary recommendations regarding diet and supplementation. Even when supplementation is warranted, strategies to increase a woman's dietary iron intake are paramount for developing good eating habits that will continue throughout pregnancy and beyond. Accepted for publication: March 2007. References Allen, H. L., & Casterline-Sabel, J. (2000). Prevalence and causes of nutritional anaemia. In U. Ramakrishnan (Ed.). Nutritional anemias. Florida: CRC (Cyclical Redundancy Checking) An error checking technique used to ensure the accuracy of transmitting digital data. The transmitted messages are divided into predetermined lengths which, used as dividends, are divided by a fixed divisor. Press. American College of Obstetricians and Gynecologists (1993). Nutrition during pregnancy: ACOG ACOG American College of Obstetricians and Gynecologists. ACOG American College of Obstetricians & Gynecologists Technical Bulletin No. 179. Washington DC: ACOG. Australian Government National Health and Medical Research Council. (2005). Nutrient Reference Values ref·er·ence values pl.n. A set of laboratory test values obtained from an individual or from a group in a defined state of health. for Australia and New Zealand including Recommended Dietary Intakes. Australia: National Health and Medical Research Council. Australian Iron Advisory Panel (n.d.). Iron and pregnancy recommended guidelines. Accessed September 1, 2006, from http://www.ironpanel.org.au/AIS/AISdocs/pregdocs/ pregtitle.html Bodnar, L. M., Cogswell, M. E., & McDonald, T. (2005). Have we forgotten the significance of postpartum iron deficiency? American Journal of Obstetrics and Gynecology obstetrics and gynecology Medical and surgical specialty concerned with the management of pregnancy and childbirth and with the health of the female reproductive system. 193, 36-44. Booth, J. W., & Aukett, M. A. (1997). Iron deficiency anaemia in infancy and early childhood. Archives of Diseases in Children 76, 549-554. Cogswell, M. E., Parvanta, I., Ickes, L., Yip, R., & Brittenham, G. M. (2003). Iron supplementation during pregnancy, anemia, and birth weight: a randomized ran·dom·ize tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es To make random in arrangement, especially in order to control the variables in an experiment. control trial. American Journal of Clinical Nutrition Clinical nutrition The use of diet and nutritional supplements as a way to enhance health prevent disease. Mentioned in: Naturopathic Medicine 78, 773-781. Cook, J. D., & Reddy, M. B. (2001). Effect of ascorbic acid intake on nonheme-iron absorption from a complete diet. American Journal of Clinical Nutrition 73, 93-98. Danish National Board of Health. (1992). Recommendations about iron supplementation during pregnancy Ugeskr Laeger 154, 3445. Ekstrom, E. M., Kavishe, F. P., Habicht, J., Frongillo, E. A., Rusmussen, K. M., & Hemed, L. (1996). Adherence to iron supplementation during pregnancy in Tanzania: determinants and hematologic hematological, hematologic pertaining to or emanating from blood cells. hematological tests total and differential white cell counts, hematocrit estimation, erythrocyte count. consequences. American Journal of Clinical Nutrition 64, 368-74. Emery, D., & Barry, D. (2004). Comparison of Maori and non-Maori maternal and fetal iron parameters. The New Zealand Medical Journal 117, 909-913. Fairbanks, V. F. (1999). Iron in medicine and nutrition. In M. E. Shils, J. A. Olson, M. Shike, & A. C. Ross (Eds.) Modern nutrition and disease (9th ed.). Baltimore: Williams & Wilkins. Groff, J. L., & Gropper, S. S. (2000). Advanced nutrition and human metabolism (3rd ed.). Belmont, California: Wadsworth Thomson Learning. Haram, K., Nilsen, S. T., & Ulvik, R. J. (2001). Iron supplementation in pregnancy--evidence and controversies. Acta Obstetricia et Gynecologica Scandinavica 80, 683-688. Heath, A., Skeaff, C. M., O'Brien, S. M., Williams, S. M., & Gibson, R. S. (2001). Can dietary treatment of non-anemic iron deficiency improve iron status? Journal of the American College of Nutrition The American College of Nutrition (ACN) was established in 1959, to encourage the scientific investigation of nutrition. The ACN publishes, bi-monthly, the "Journal of the American College of Nutrition. 20, 477-484. Hurrell, R. F. (1997). Bioavailability of iron. European Journal of Clinical Nutrition 51, S1-S4. Lynch, S. R. (2000). The potential impact of iron supplementation during adolescence on iron status in pregnancy. The Journal of Nutrition 130, 448S-451S. Makrides, M., Crowther, C. A., Gibson, R. A., Gibson, R. S., & Skeaff, C. M. (2003). Efficacy and tolerability of low-dose iron supplements during pregnancy: a randomized controlled trial. American Journal of Clinical Nutrition 78, 145-153. Milman, N., Bergholt, T., Eriksen, L., Byg, K. E., Graudal, N., Pedersen, P., & Hertz J. (2005). Iron prophylaxis prophylaxis (prō'fĭlăk`sĭs), measures designed to prevent the occurrence of disease or its dissemination. Some examples of prophylaxis are immunization against serious diseases such as smallpox or diphtheria; quarantine to confine during pregnancy--how much iron is needed? A randomized dose-response study of 20-80mg ferrous iron daily in pregnant women. Acta Obstetricia et Gynecologica Scandinavica 84, 238-247. Milman, N., Byg, K. E., Bergholt, T., & Eriksen, L. (2006). Side effects of oral iron prophylaxis in pregnancy--myth or reality? Acta Haematologica 115, 53-57. Minihane, A. M., & Fairweather-Tait, S. J. (1998). Effect of calcium supplementation calcium supplementation Metabolism The addition of Ca2+ to the diet, usually in the form of calcium carbonate on daily nonheme-iron absorption and long-term iron status. American Journal of Clinical Nutrition 68, 96-102. Rasmussen, K. M. (2001). Is there a causal relationship between iron deficiency or iron-deficiency anemia iron-deficiency anemia Most common type of anemia, which may develop in times of high iron loss and depletion of iron stores (e.g., rapid growth, pregnancy, menstruation) or in settings of low dietary iron intake or inefficient iron uptake (e.g. and weight at birth, length of gestation and perinatal mortality? Journal of Nutrition 131, 590S-603S. Russell, D., Parnell, W., & Wilson, N. (1999). NZ Food: NZ People, Key results of the 1997 National Nutrition Survey. Wellington: Ministry of Health. Sloan, N. L., Jordan, E., & Winikoff, B. (2002). Effects of iron supplementation on maternal hematologic status in pregnancy. American Journal of Public Health The American Journal of Public Health (AJPH) is a peer reviewed monthly journal of the American Public Health Association (APHA). The Journal also regularly publishes authoritative editorials and commentaries and serves as a forum for the analysis of health policy. 92, 288-293. Stoltzfus, R. (2001). Defining iron-deficiency anemia in public health terms: a time for reflection. Journal of Nutrition 131, 565S-567S. Yip, R. (2000). Significance of an abnormally low or high hemoglobin concentration during pregnancy: special consideration of iron nutrition. America Journal of Clinical Nutrition 72S, 272S-279S. Strategies to ensure optimal iron status for pregnancy * Consume iron rich foods on a daily basis * Increase the bioavailability of iron in foods by ** Consuming foods rich in vitamin C ** Consuming small portions of meat, poultry and fish with foods containing non-haem iron ** Avoiding black types of tea (oolong, Ceylon) with meals * Consider the use of iron supplements (40-60 mg elemental iron/day) for women with poor iron status and take at separate times of day than calcium or zinc supplements. Sandra Elias is a Senior Lecturer in the School of Midwifery midwifery (mĭd`wī'fərē), art of assisting at childbirth. The term midwife for centuries referred to a woman who was an overseer during the process of delivery. In ancient Greece and Rome, these women had some formal training. , Otago Polytechnic in Dunedin. She completed an MSc in the area of Maternal Nutrition from the University of British Columbia Locations Vancouver The Vancouver campus is located at Point Grey, a twenty-minute drive from downtown Vancouver. It is near several beaches and has views of the North Shore mountains. The 7. , Canada. Contact for correspondence: Email: sandrae@tekotago.ac.nz
Table 1. Parameters of iron status used in iron assessment
Iron status stored iron Transport iron
(ferritin) (transferrin)
Iron-deficiency anemia Low Low
Iron depletion Low Normal
Normal iron status Normal Normal
Iron overload High High
Iron status Functional iron
(haemoglobin)
Iron-deficiency anemia Low
Iron depletion Normal
Normal iron status Normal
Iron overload Normal
Table 2. Iron supplements available in New Zealand
Supplement name Preparation
Bayer Elevit ferrous fumurate
Blackmore Pregnancy
and Breastfeeding ferrous fumurate
Ferrit Ferroforce ferrous lactate
Abbott Ferro-gradumet ferrous sulphate
Abbott Ferrograd-folic ferrous sulphate
Healtleries Iron
with Vitamin C ferrous gluconate
Healtheries Iron Fizz
with Vitamin C iron oxide
Red Seal Floravital tonic ferrous gluconate
Solgar Gentle Iron iron bisglycinate
(chelated iron)
Solgar Prenatal Nutrients iron bisglycinate
(chelated iron)
Thompsons Liquid Iron ferrous gluconate
Thompsons Organic
Iron Complete ferrous fumurate
Thompsons Prenagcare ferrous fumurate
Supplement name Daily Amount of Subsidised
DOse elemental by
iron per Pharma
daily dose
(mg)
Bayer Elevit 1 tablet 60 No
Blackmore Pregnancy
and Breastfeeding 2 tablets 5 No
Ferrit Ferroforce 15 ml 15 No
Abbott Ferro-gradumet 1 tablet 105 Partsubshfy
Abbott Ferrograd-folic 1 tablet 105 Partsubsicy
Healtleries Iron
with Vitamin C 1 tablet 20 Yes
Healtheries Iron Fizz
with Vitamin C 2 tablets 12 No
Red Seal Floravital tonic 20 mls 19 No
Solgar Gentle Iron 1 tablet 25 No
Solgar Prenatal Nutrients 1 tablets 27 No
Thompsons Liquid Iron 10 mls 20 No
Thompsons Organic
Iron Complete 1 tablet 24 No
Thompsons Pregnacare 2 tablets 10 No
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