Strategies to reduce the phytates and tannins in the staple foods can be used to modestly improve absorption of iron from these foods. Soaking beans and maize flour (discarding the soaking water), fermentation, and germination have been used. The inclusion of liver from chickens has also been successful in participatory interventions.

Have you checked for genetic factors that inhibit iron absorption as well?

It is understandable that many people have a hard time changing their diets significantly, but try helping her eat one iron-rich meal per day with no iron-absorption inhibitors within two hours either side, and with a vitamin-C source in the meal. If you can get a list of 15 foods that might be part of that meal — the 10 highest vegetables in iron in that area, plus five foods with a high vitamin-C content — these could combine with any animal protein and a serving of beans to give her quite a lot of iron.

I agree with Nance's suggestions above but you may also wish to find out how she takes the iron tablets-does she take the supplement with tea,coffee, milk or beverages that contain chelating agents (that could inhibit absorption)? Could she try taking the supplements with plain water and during a meal that contains some animal protein. Many uninformed pregnant women take fruits which could be their major source of ascorbic acid as a snack outside meal times. Your client may need to undergo a full counselling session with a dietitian who must take a proper food intake history and help her plan her diet based on her resources to maximize iron absorption. You may also prescribe ascorbic acid as part of her supplements and it should be taken along with the iron tablets. She has to be advised not to take her calcium supplements together with the iron tablets. She should take it between meals. Have you also checked her stool for worm infestation?

Ask her to take vitamin c rich foods along with iron supplementsand iron rich foods for better absorption. avoid tea,coffee after a meal.

did she have bariatric surgery? parasites? bariatric patients have poor absorption ferro.you can supplement with vitamin B12 too.

A small amount of meat added to the current mixed meals will improve absorption of both iron and B12 from the meal. Low hemoglobin is not specific to iron deficiency but can also represent low B12 or folate status. A low ferritin may indeed indicate parasites, excess blood loss, or inadequate iron intake or absorption. Check the eosinophil count. If high, there is a high index of suspicion for parasites. Check the red blood cell count. If low, there is a high index of suspicion for B12 deficiency and/or excess blood loss. If intake is low, the University of Guelph has recently funded the development of a small cast iron fish figurine which can be added to cooking pots during cooking and which has had significant positive impact on iron deficiency among vulnerable communities in the South Americas.

It's indicated that she has persistent iron deficiency with normal lab tests. Is she anemic too?

What does a normal velue mean? and when? sometimes, having a Hb level of 12 g/dL is not actually normal and she is in marginal status.

In terms of dietary approach, what kind of inhibitors are found in her diet? Phytates, oxalates, phosphates, hi-fiber foods in large amounts?

It's recommended to have more detailed look on her diet. Adding 25-75 mg ascorbic acid will increase non-heme iron by 2-3 times. Moreover, adding some organic acids in fruits has enhacing effect too.

If oxalates are abundant in her diet, consuming milk or yogurt will yield more Ca-oxalate rather than fe-oxalate, so iron would be more available in the gut.

--------------------------------

Reza Amani (PhD, R Nutr)

Nutritionist

Jondi-Shapour University

Iran

What do the ferritin and transferrin levels look like?

It is normally vitamin B6 or pyridoxine deficiency that causes unresponsive anemia.

If the lady is caucasian they can be missing the MTHFR1 gene and may need extra folate which is still best from foods.

Folic acid in supplement form uses up some B12 to methylate it.

Iron supplements can interfere with copper absorption too and cause copper deficiency anemia.

Ascorbate, Folate, B12, B6 and copper are the main factors.

I'd suspect B6, it always gets missed.

Google 'pyridoxine iron anemia' studies old and new, it's like a lot of studies were done pre 1960's and forgotten.

Cooking acidic foods, such as tomato based products, in cast iron utensils will help put additional available iron into the cooked food.

Nutritional anemia can be caused by the deficiency of iron, folic acid, pyrydoxine, cyanocobalamin and copper. So there is need to identify the type of anemia in order to plan for effective treatment. The use of supplements for treatment becomes handy to reverse clinical manifestations. For long term healthy living and prevention, it is advisable to use diets that are rich in the nutrients listed above which is mainly animal foods. Considering the low economic status of most clients, a nutritionist must identify locally-available low cost animal foods to be able to help the client in planning food combinations that will beneficial. Checking for parasites and other hidden haeemorhagic losses will be helpful.

I agree with most of the answers: we must investigate the etiology of anemia (and supplement with the nutrients required), increase consumption of foods rich in these nutrients and eliminate dietary factors that can inhibit proper absorption of these nutrients . I would add only the findings of a Cochrane meta-analysis to minimize potential adverse effects of iron supplementation during pregnancy:

Intermittent oral iron supplementation during pregnancy:

The findings suggest that intermittent iron+folic acid regimens produce similar maternal and infant outcomes at birth as daily supplementation but are associated with fewer side effects. Women receiving daily supplements had increased risk of developing high levels of Hb in mid and late pregnancy but were less likely to present mild anaemia near term. Although the evidence is limited and the quality of the trials was low or very low, intermittent may be a feasible alternative to daily iron supplementation among those pregnant women who are not anaemic and have adequate antenatal care.

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009997/pdf

It will also be important to monitor the iron status of the newborn during lactation.

For a proper diagnosis,get her Hemograme, S. Iron, TIBC (Total Iron binding Capacity, % Transferin Saturation, S. Ferritin, Folic acid , and Vit. B12 tests done.

Why not adding Vitamin C rich fruits (to enhance the absorption of Iron) plus some alternative foods like river shrimps or fish added to the diet? Should not be more complicated than that. What is her HIV status?

Strategies to reduce the phytates and tannins in the staple foods can be used to modestly improve absorption of iron from these foods. Soaking beans and maize flour (discarding the soaking water), fermentation, and germination have been used. The inclusion of liver from chickens has also been successful in participatory interventions.

Ahmad Faqih University of Jordan (Retired)

I agree with most of what was written above. I would like to add that vitamin A deficiency should be considred. There is in literature what is called vitamin A resposive anemia(?) ,wherein iron deficiency anemia will not respond to Fe treatment unless vitamin A deficiency is corrected. The work was published by Amine E and other(s), Hegsted(?) if I am not mistaken. It can be chechked easily. the work was publshed in the 60`s(?)..Sorry, I am not now close to my library.

Taking Vitamin C / ascorbic acid along with iron supplement having higher bioavailability can improve the situation.

Milk and milk prdoucts, vitamin C rich foods and carotene/vitamin A rich food along with iron supplements can improve the bioavailability of dietary iron. Avoid foods rich in tannins and, phytate.

There seems to be a great reliance on vitamin C to enhance iron absorption in the answers above. But vitamin C only helps absorption of non-haem iron from vegetable sources. Haem iron, on the other hand, is easily absorbed without the need vitamin C.

Haem iron is found only in foods of animal origin, preferentially in organ meats such as liver and kidneys which we in US and UK tend to discard. In countries which don't have anywhere near as many health problems as we do, such organs are eaten freely.

While I agree that foods containing high levels of phytates and tannins (invariably plant foods) should be avoided, we should also include those most nutritious parts of animals which at present we stupidly throw away.

We, in our community-based studies, have seen high levels of Homocysteine among women of child-bearing age in Pakistani mothers and in mothers of other south asian countries. This indicates that they are less likely to respond to any amount of folic acid that you give during the antenatal period (where we supplement all the expectant mothers with iron and folic acid). All that they need as supplement added is Vitamin B12. javascript:;

Again, Shakila,basing meals on foods of animal origin would solve the problem. Not just vitamin B12, but all the B vitamins.

Sure, but the shortest and more easy method for supplementation in most of these underpriveleged areas is supplementation. I agree that it should be all the B vitamins. We tried some community-based interventions by feeding the mothers different sources of vitamins and minerals in food and prepared foods and supplements through iron-folic acid and vitamin in the form of tablets. The later was the easier method and worked sufficiently. The availability of foods of animal origin was the most difficult to measure.

Might want to check for any intestinal parasitic infections. In case there is - WHO recommends deworming after the 1st trimester. Can the IFA doze be increased. If food patterns are difficult to change - a) changes in food preparation might help and b) IFA tablet should be taken with food that would increase iron absorption.

Molasses contains less only 4.7mg of iron per 100g. And that iron is non-haem, which is not very bio-available - absorption around 10%..

Add to that the fact that molasses is practically nothing but sugar and you have a very unhealthy and inefficient solution to the problem

Barry I partially agree with you but deviate from your points based on the following:

The iron content of mollases depend upon sources it derived, It also depends upon soil in which that source is grown. The nutritionally availability of iron is also dependent on Grade of mollases.

Please check the following publication: The American Journal of Digestive Diseases

July 1939, Volume 6, Issue 7, pp 459-462

The nutritional availability of iron in molasses

Robert S. Harris, L. Malcolm Mosher, John W. M. Bunker

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Grape mollases also have potential to be used in this case:

Please check a comparitive study on that:

Absorption of iron from grape-molasses and ferrous sulfate: a comparative study in normal subjects and subjects with iron deficiency anemia. Aslan Y, Erduran E, Mocan H, Gedik Y, Okten A, Soylu H, Değer O

Department of Pediatrics, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey.

The Turkish Journal of Pediatrics [1997, 39(4):465-471]

(PMID:9433148)

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In developing countries including third world countries, animal meat is an expensive commodity, some countries do not use animal meat due to religious belief (Hindu in India). So their intake for haeme iron is low. They have to rely on plant sources for iron.

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following link will be useful for composition of mollases. Although it may vary from source to source:

http://www.whfoods.com/genpage.php?dbid=118&tname=foodspice

Asif

I agree that, as with all minerals, the composition in the soil is all important. Nevertheless, I still don't see any real benefit from eating molasses.

The whole 1939 paper you mentioned was not available to me, but the little I was able to read related to a rat study (my experience has taught me that, when it comes to diet, different species are very different. I don't place much reliance on rat studies).

The Turkish study finds that absorption from molasses is less that half as good as that from FeSO4 (27mcg/dl vs 60mcg/dl respectively). And FeSO4 is already not a very good supplier of iron.

The whfoods link says that 13.8g of molasses contains 13.2% of daily requirements. But it doesn't factor in bioavailability. Using 10%, which is the norm for non-haem iron, that reduces to 1.32%. This means you would need to eat 75.757 times as much to meet your daily target!

Sorry, but animal foods are the only real answer. If, for religious reasons pork or cattle are unacceptable, then shellfish are a very good source.

If the anaemic person is vegan and won't eat anything from these sources, then I see that as a self-inflicted problem they will have to live with, and have little sympathy. There is too much nutritional inadequacy in the world already without having to cater for unnatural fad diets.

nice thinking GROVES. Good luck

I still believe that vitamin A status should be checked out.

this is based on the work reported in chapter 5,pp.150-162 entitled, "Anemia and Iron Metabolism" in Vitamin A Deficiency: Health, Survival, and Vision" by Alfred Sommer and Keith P. West,Jr, Oxford: Oxford Univ. Press.

thi

I am sorrry there were unavoidable interruptions by the internet.

In addition to possible vitamin A deficiency as I said before, Zn and other micronutrient deficiencies ( vitamins) needed for hematopoeisis should be considered.and checked out..Zn deficiecy could be caused by intake of excessive fiber with phytate and phenolic compounds, or alternately by excessive copper(Cu) intake that might come from cooking utensils or wter pipes and joints. Cu is antagonist to Zn and itself is a hematopoeitic nutrient.

Furthermore, high exposure to Pb can precipitate IDA.

Caution: in a tropical country, if there is malaria infestation, the method of iron supplentation is of vital importance because malaria flourishes on Fe and its supplementarion may be fatal.

Ahmad, your last point is a very good one. Where malaria flourishes a slight Fe deficiency might be safer than Fe sufficiency.

Thank you Barry. I believe that parasites other than malari such as helminths should be cheked out as suggested by Nisha Malhorta. In adition, the suggestions stated by Collen Walton are valid and to the point

Iron status is related to other nutrients. Dietary zinc, copper, retinol, calcium, magnesium and possibly other divalent cations can affect the iron absorption. Especially, when dietary iron is mostly in the form of non-heme iron, as generally happens, the effect of other nutrients is more prominent.

Some non-nutrient ingredients in dietary pattern such as tannins, phytates, oxalates and phosphate compounds (in cola drinks) can also impact on its gut absorption. 

Firstly, we need to assess the dietary pattern, preferably using FFQ, to find out the main habits and food groups consumed. Drinking heavy tea frequently could be a great concern as well. 

Secondly, other diseases such as malabsorption, GI bleeding or parasitic issues should also be checked.

Thirdly, taking any medications should be evaluated. Calcium supplements are of concern as well.

- Has serum ferritin been evaluated pre- and post-supplementation? 

The World Health Organization (http://apps.who.int/iris/bitstream/10665/75335/1/9789241502016_eng.pdf), based in a Cochrane Review (find here the updated version in 2015: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009997.pub2/full), established the recommendation as follow:

"Intermittent use of iron and folic acid supplements by non-anaemic pregnant women is recommended to prevent anaemia and improve gestational outcomes" (strong recommendation). Suggested schem in table 1 (page 9).

The Cochrane's updated review compared the intermittent use of iron  supplements alone, or in combination with folic acid or other micronutrients, with no intervention or placebo, and with the same supplements given on a daily basis to pregnant women living in a variety of settings, including malaria-endemic areas. 

http://apps.who.int/iris/bitstream/10665/75335/1/9789241502016_eng.pdf

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009997.pub2/full