Written by Grace Delany, Dietetic Student
Reviewed by Elena Usdenski, RD
As of September 9th, 2024, Ontario has implemented updated guidelines for iron deficiency assessment. These changes could significantly impact how patients are diagnosed and treated, particularly in fertility and prenatal health, where iron plays a crucial role. A major improvement in these guidelines is the emphasis on earlier detection and treatment. Many individuals who were previously told their iron levels were “normal” despite experiencing symptoms may now be diagnosed and treated. Previously, ferritin thresholds varied by lab, ranging from under 10 to under 15 micrograms per liter (mcg/L). With the new guidelines, the threshold has at least doubled, allowing for earlier intervention and better health outcomes.
What is Iron and Why is it Important?
Iron is an essential mineral that supports numerous physiological processes that are critical to our health and well-being, including:
- Oxygen Transport: A key component of hemoglobin, the protein in red blood cells that delivers oxygen from the lungs to tissues throughout the body.
- Energy Production: Involved in enzymatic reactions that help generate energy at the cellular level.
- Immune Function: Supports the body’s defence against infections by aiding the immune system.
- Cell Health: Fundamental for the growth and maintenance of healthy cells, as it supports their metabolic functions and energy production.
- Muscle Health: Plays a role in forming myoglobin, a protein that supplies oxygen to muscle cells, enabling proper muscle function and endurance.
- Brain Development: Crucial for neurological development, particularly during pregnancy and early childhood.
Cells with high metabolic demands, like muscle cells and those involved in growth and development, require more iron to function properly. Without enough iron, the body cannot produce sufficient healthy red blood cells, leading to iron deficiency anemia and symptoms like fatigue, weakness, and impaired concentration.
What Are the New Guidelines?
The recent updates focus on ferritin test reports, replacing traditional reference intervals with clinical decision limits to identify iron deficiency more effectively. Key changes include:
- Iron Deficiency Detection Thresholds:
- Adults: Ferritin levels below 30 µg/L now indicate iron deficiency.
- Children: Ferritin levels below 20 µg/L indicate iron deficiency.
- High Ferritin Flags:
- Results ≥600 µg/L will be flagged as high.
This shift enables earlier detection of iron deficiency, meaning individuals previously considered to have “normal” iron levels may now be diagnosed and treated sooner.
The Role of Iron in Pregnancy
- Increased Iron Requirements
- Maternal Blood Volume Expansion: Pregnancy causes a significant increase in blood volume to support the growing fetus, requiring more iron to produce hemoglobin.
- Fetal Growth and Development: Iron is crucial for brain development and oxygen delivery to the fetus.
- Placental Development: Iron supports the formation and function of the placenta, which facilitates nutrient and oxygen transfer to the fetus.
- Iron Deficiency in Pregnancy
- Prevalence: Iron deficiency is one of the most common nutrient deficiencies during pregnancy affecting more than one-half of pregnancies
- Risks: Untreated deficiency is linked to adverse outcomes such as low birth weight, preterm delivery, and impaired cognitive development in infants.
- Low ferritin stores, which indicate depleted iron reserves, have been associated with an increased risk of miscarriage.
- Mechanisms of Iron Deficiency
- High Metabolic Demand: Cells with high metabolic rates, such as those in the placenta and developing tissues, are particularly vulnerable to dysfunction during iron deficiency.
- Adaptive Changes: During pregnancy, the body increases iron absorption from the diet; however, this adaptation may not fully meet the increased demand, particularly in individuals with low iron stores at the start of pregnancy. Therefore, ensuring optimal iron stores prior to conception is critical, especially since pregnancy symptoms like food aversions, nausea, and vomiting can make eating well difficult.
- Progressive Decline: Iron stores will continue to drop as the pregnancy progresses due to increased demands, making strong iron levels before conception essential.
Iron and Fertility
While iron is commonly associated with pregnancy, it also plays a vital role in fertility for both men and women.
Male Fertility: Iron is essential for sperm health and motility, with deficiencies potentially impacting reproductive outcomes.
How Much Iron Do Pregnant Women Need?
- The Recommended Dietary Allowance (RDA) for iron during pregnancy is 27 mg per day, accounting for:
- Normal iron losses
- Iron used by the fetus and related tissues
- Increased hemoglobin mass
- Approximately 25% of dietary iron is absorbed during the second and third trimesters.
Should You Take a Prenatal Multivitamin with Iron?
Yes, taking a prenatal vitamin with 16-20 mg of iron per dose is a good start. Ideally, women should begin taking a prenatal vitamin at least three months before conception. However, since 50% of pregnancies are unplanned, it is recommended that all women of childbearing age take a prenatal vitamin. It is also important to have your ferritin levels tested, as iron deficiency can occur even with a seemingly adequate diet due to factors like malabsorption, increased needs, genetics, and more.
Dietary Iron Sources
Iron comes in two forms:
- Heme iron: Found in meat, poultry, and fish. It is more bioavailable and better absorbed.
- Non-heme iron: Found in plant foods like vegetables, whole grains, nuts, seeds, and legumes.
It should also be noted that vegetarians require 1.8 times more iron than individuals who consume meat. This is because heme iron from meat is more bioavailable than nonheme iron from plant-based foods, and meat, poultry, and seafood increase the absorption of nonheme iron.
How to Enhance Iron Absorption
- Pair iron-rich foods with vitamin C-rich foods (e.g., citrus fruits, bell peppers, strawberries) to increase iron absorption.
- Avoid consuming iron with calcium-rich foods or beverages (e.g., dairy) at the same meal, as calcium can inhibit absorption.
- Cooking with cast-iron cookware can increase iron intake, particularly for acidic foods.
Takeaways for Fertility and Prenatal Care
Understanding increased iron demands during pregnancy and the risks associated with deficiency, highlights the importance of early detection and intervention. The updated Ontario guidelines will likely lead to better maternal and fetal health outcomes by enabling earlier and more precise diagnosis and treatment of iron deficiency.
By raising awareness of iron deficiency and implementing these new guidelines, we can take a proactive approach to supporting fertility and prenatal health through early diagnosis, proper supplementation, and dietary improvements.
References
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Harrison, L. (2024, September 10). Ontario’s new iron deficiency guidelines a ‘life changer’ for patients, doctors say. CBC. https://www.cbc.ca/news/canada/toronto/iron-deficiency-bloodwork-testing-ontario-1.7314795
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Prenatal Nutrition Guidelines for Health Professionals: Iron Contributes to a Healthy Pregnancy. (n.d.). Canada.ca. Retrieved from https://www.canada.ca/content/dam/hc-sc/migration/hc-sc/fn-an/alt_formats/hpfb-dgpsa/pdf/pubs/iron-fer-eng.pdf