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Iron Deficiency Anemia: Nutritional Considerations

Dietary iron is available in 2 forms: heme and nonheme. Heme iron is found in animal muscle and blood, whereas nonheme iron is found both in animal products and in a variety of plant-based foods.

Heme iron in the diet is absorbed at a relatively constant rate of about 23%, independent of other dietary factors. On the other hand, nonheme iron absorption varies, depending on other dietary factors, as described below. As body stores of iron decrease, the percentage of nonheme iron absorbed increases significantly.

Iron deficiency is common in developing countries (30% to 70%).4 In industrialized countries, the prevalence of iron deficiency is much lower-roughly 20%-due partly to iron fortification of grain products.4 However, only one third to one half of iron-deficient individuals actually have iron deficiency anemia.5

Healthful sources of iron include greens and legumes. Although the myth persists that meat is a preferred iron source, a balanced vegetarian diet that includes legumes, fortified grains, and green vegetables easily provides adequate iron. Studies have shown that the incidence of iron deficiency anemia is not greater among individuals consuming a healthy vegetarian diet than among omnivores.6

Dairy products and eggs decrease iron absorption. Caseins from milk and certain forms of calcium inhibit iron absorption.7 In addition, infants who are allergic to cow's milk may be particularly susceptible to intestinal blood losses due to the irritating effect of dairy products.5 Iron status measured as serum ferritin is inversely associated with greater consumption of dairy products in toddlers, particularly when they displace foods that contain iron or that facilitate iron absorption.8 Eggs (especially yolks) also appear to inhibit iron absorption.9,10

Fruits and vegetables aid the absorption of nonheme iron. Fruits and vegetables contain vitamin C and organic acids (eg, citric acid) that keep iron in a reduced form, allowing for better absorption of nonheme iron. Vitamin A and carotenoids also appear to enhance iron absorption, by overcoming the inhibiting effect of iron on absorption caused by the polyphenols and phytates in whole- grain foods. Adding vitamin A to an iron supplement regimen has also been shown to result in greater anemia reduction than iron alone produces.7

Tea, coffee, and cocoa should not be consumed with meals if poor iron status is suspected. Polyphenols in these beverages inhibit the absorption of nonheme iron. Black tea appears to be the most potent in this regard.7

Taking in adequate iron before pregnancy can help prevent anemia in both mothers and infants. Iron deficiency is more common in women of child-bearing age, especially during pregnancy.5 The physiologic need for iron increases almost 10-fold during pregnancy and lactation, and iron deficiency in the first trimester results in significantly poorer indicators of fetal growth, neural development, and behavior in offspring, compared with what happens when mothers have adequate iron status.11 In mothers with iron deficiency, exclusive breast-feeding often results in iron deficiency in infants.12 Without adequate iron stores prior to conception, iron supplementation may be necessary during pregnancy (see below).

Breast milk contains significant iron. Human milk and cow's milk contain similar equal concentrations of iron (0.5 mg/100 ml, although breast-feeding is preferable for many reasons (see Healthy Diets at All Stages of Life chapter). Unfortified infant formula contains about 20% of the iron found in breast milk, whereas fortified formula has over twice the iron concentration. Despite this higher level, iron in breast milk is more absorbable than that in soy- or dairy-based formulas.

Iron supplementation should be individualized. The CDC recommends that iron supplementation be individualized based on hemoglobin screening of at-risk individuals.13 Iron supplementation should be avoided in cases lacking documented need, because excess iron stores are associated with greater risks for colon cancer, coronary heart disease, and insulin resistance.14,15

Alcohol intake enhances iron absorption, but should not be used as a means of regulating iron status. Consumption of any amount of alcohol is associated with a 40% reduction in the risk of iron deficiency anemia. However, the prevalence of markers of iron overload, which may be more harmful than mild reductions in iron status, was found to be significantly elevated among individuals who consumed > 2 alcoholic drinks per day.16 Increasing alcohol consumption is obviously not a recommended treatment for improving a person's iron status.


See Basic Diet Orders chapter.

Avoid tea, coffee, and cocoa with meals.

What to Tell the Family

Iron deficiency anemia is usually preventable and highly treatable. A diet of fortified grains, legumes, nuts and seeds, and fruits and vegetables can provide for healthy iron balance. During times of increased iron requirements or when an iron deficiency has been diagnosed, iron supplementation may be needed. Simple blood tests can accurately assess a person's iron status.


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