HHS Public Access

Author manuscript
J Am Coll Nutr. Author manuscript; available in PMC 2018 August 13.
Author Manuscript

Published in final edited form as:

J Am Coll Nutr. 2018 ; 37(4): 342–349. doi:10.1080/07315724.2018.1427158.

A Food-Derived Dietary Supplement Containing a Low Dose of

Iron Improved Markers of Iron Status Among Nonanemic Iron-
Deficient Women
Christopher R. D’Adamo, PhDa, James S. Novick, MDb, Termeh M. Feinberg, PhD, MPHa,
Valerie J. Dawson, BSa, and Larry E. Miller, PhDc
aDepartment of Family & Community Medicine, Center for Integrative Medicine, University of
Author Manuscript

Maryland School of Medicine, Baltimore, Maryland, USA;

bCharm City Research Group, University of Maryland St. Joseph Medical Center, Towson,
Maryland, USA;
cMiller Scientific Consulting, Asheville, North Carolina, USA

Abstract
Objective: Iron deficiency is the most common nutrient deficiency in the world. While
deficiency can often be resolved through dietary supplementation with iron, adverse events are
common and frequently preclude compliance. The objective of this study was to determine
whether a food-derived dietary supplement containing a low dose of iron and nutrients that
increase iron absorption could resolve iron deficiency with fewer adverse events than reported at
Author Manuscript

higher doses.

Methods: A pilot clinical trial (NCT02683369) was conducted among premenopausal women
with nonanemic iron deficiency that was verified by blood screening. Participants consumed a
dietary supplement (Blood Builder®/Iron Response®) once daily for 8 weeks containing 26 mg of
iron, vitamin C, folate, and other food-derived nutrients. Primary outcomes were markers of iron
status (serum ferritin, hemoglobin, soluble transferrin receptor, total body iron stores) and
secondary outcomes were self-reported fatigue and energy. All outcomes were assessed at baseline
and 8 weeks. Adverse events were monitored with questionnaires, daily diaries, and contact with a
physician. Dependent samples t test and Wilcoxon signed-rank test were used to analyze
outcomes.

Results: Twenty-three participants enrolled in the study. Iron deficiency was resolved in the
Author Manuscript

sample (mean serum ferritin: baseline = 13.9 μg/L, 8 weeks = 21.1 μg/L, p < 0.001). All other
markers of iron status, fatigue, and energy also improved during the study (p < 0.04). No adverse
events were reported.

CONTACT Christopher R. D’Adamo, PhD, cdadamo@som.umaryland.edu, University of Maryland School of Medicine, Department
of Family & Community Medicine, Center for Integrative Medicine, 520 West Lombard Street, East Hall, Baltimore, MD 21201,
USA.
Disclosure
The authors have no personal financial interest in the work or with a commercial sponsor.
 D’Adamo et al. Page 2

Conclusions: While larger and controlled studies are needed to confirm these findings, a food-
Author Manuscript

derived dietary supplement with a low dose of iron and absorption-enhancing nutrients resolved
iron deficiency and improved all other markers of iron status without any adverse events.

Keywords
Iron; nonanemic iron deficiency; ferritin; hemoglobin; soluble transferrin receptor; total body iron
stores; folate; vitamin C; dietary supplement

Introduction
Iron is a mineral for which intake is required for proper human physiology. Among other
functions, iron plays a key role in energy metabolism, oxygen transport, DNA replication
and repair, and the production of neurotransmitters (1–3). Iron can be obtained in the human
Author Manuscript

diet from a variety of food sources. The more bioavailable heme form of iron is contained in
meat and poultry and the less bioavailable nonheme form of iron is found in vegetables and
legumes.

Despite the abundance of dietary sources of iron, iron deficiency is the most common
nutrient deficiency throughout the world. More than 2 billion people worldwide experience
some form of iron deficiency (4–6) and the condition is often associated with fatigue,
impaired energy metabolism, immune system dysregulation, and decreased cognition, work
performance, and overall physical function (4,5,7). Iron deficiency can occur with or without
anemia. Nonanemic iron deficiency is classified as having normal hemoglobin (Hgb) levels
(Hgb ≥ 12 g/dL) with low serum ferritin (SF) levels (SF < 20 μg/L) (4,7). While resolution
of iron deficient anemia is very well studied, not as many studies have focused on resolving
nonanemic iron deficiency.
Author Manuscript

Premenopausal women are at particularly high risk for iron deficiency. Globally, 22% of
premenopausal women are iron-deficient (8), and recent data from the National Health and
Nutrition Examination Surveys revealed that 8% of premenopausal women in the United
States were nonanemic iron-deficient (9). Symptoms of iron deficiency often become
apparent only in the more severe stages of the condition (10,11). Thus, there is substantial
public health interest in resolving nonanemic iron deficiency due to the deleterious effects
that low iron levels can have on human health and the importance of preventing the
progression to anemia.

Guidelines to resolve nonanemic iron deficiency offered by the World Health Organization
and other entities suggest that daily dietary supplementation with iron is often warranted
Author Manuscript

(6,10). Iron supplementation has consistently been shown to increase SF (12) and protect
against progression to iron-deficient anemia (13). Confounding the dietary supplementation
guidelines are the many different forms of iron supplements that are commercially available
(14). Iron is most commonly contained in dietary supplements as ferrous and ferric iron salts
such as ferrous sulfate, ferrous gluconate, ferrous citrate, or ferric sulfate (14–16). The
specific iron salts utilized in dietary supplements and their solubility affect their
bioavailability (16–19). Interactions with other nutrients can also impact the bio-availability

J Am Coll Nutr. Author manuscript; available in PMC 2018 August 13.

 D’Adamo et al. Page 3

of iron. For example, iron absorption has been shown to be synergistically increased by both
Author Manuscript

vitamin C (18) and folate (20).

Despite differences in solubility and absorption among various iron supplements, guidelines
for resolving iron deficiency do not recommend specific iron salts or formulations but rather
offer blanket recommended daily iron supplemental dosages of 60 to 120 mg for iron
deficiency (11). This is a substantial increase over both the 18-mg recommended dietary
allowance for women 19 to 50 years of age and the tolerable upper intake level (UL) of 45
mg (21). The relatively high doses of iron that are recommended to iron-deficient women
may contribute to the common incidence of adverse events that often interfere with
compliance. The most common adverse events affect the gastrointestinal system and include
constipation, nausea, and vomiting (7,12,13,21). The optimal form and dosage of iron
supplementation that successfully improves iron status while minimizing the incidence of
adverse events has not yet been established.
Author Manuscript

Accordingly, there is growing interest in determining whether lower doses of iron can
increase markers of iron status without causing the adverse events that so commonly occur.
A 2016 systematic review and meta-analysis of iron supplementation for iron-deficient
premenopausal women found an increased risk of adverse events for daily doses greater than
60 mg (13). Another systematic review concluded that weekly, as opposed to daily, doses of
60 to 120 mg may be adequate for nonanemic iron deficiency (22). Direct dose-comparison
studies in iron-deficient women have also shown that iron absorption was maximized by
providing lower doses (up to 80 mg ferrous sulfate) and avoiding twice-daily doses (23). In
addition, a 60-mg dose was shown to be as effective as an 80-mg dose in resolving iron
deficiency (7).
Author Manuscript

Nevertheless, even 60 mg of iron still falls above the UL and may contribute to the
occurrence of adverse events that commonly prevent compliance with iron supplementation.
Some (24–26) but not all (27,28) lower-dose studies with less than the UL of iron utilizing a
mean of 27 mg iron in various forms have demonstrated significant increases in SF. Given
these inconsistent results, there is a need for additional clinical research evaluating whether
iron supplementation at doses below the UL can effectively resolve iron deficiency without
causing adverse events.

The objective of this pilot clinical trial was to assess the efficacy of a low-dose iron dietary
supplement (MegaFood Blood Builder®/Innate Response Iron Response®) on raising
markers of iron status among premenopausal women with nonanemic iron deficiency. This
food-derived supplement contained just 26 mg of iron, along with vitamin C, folate, and
other elements in food that enhance iron absorption. Food-derived dietary supplements have
Author Manuscript

become increasingly popular on the premise that lower nutrient doses are required to resolve
nutrient deficiency due to synergy in food components, although clinical studies are needed
to verify this premise. Considering the suggestive evidence of efficacy of low-dose iron and
the absorption-enhancing nutrients contained in this formulation, the investigators
hypothesized that this low-dose iron supplement would increase iron levels among
premenopausal women with nonanemic iron deficiency with fewer adverse events than
typically experienced with higher doses of iron.

J Am Coll Nutr. Author manuscript; available in PMC 2018 August 13.

 D’Adamo et al. Page 4

Materials and methods

Author Manuscript

Study design
An 8-week pilot clinical trial assessing the tolerability and efficacy of a dietary supplement
containing a low dose of iron and nutrients known to increase iron absorption was conducted
among premenopausal women with nonanemic iron deficiency in Baltimore, Maryland,
from May 2016 to April 2017. The 8-week duration of the clinical trial was deemed
sufficient to detect the potential resolution of iron deficiency, in light of the many previous
clinical trials of iron supplements that were 8 weeks in duration or shorter (4,27,29–37),
without subjecting our iron-deficient study sample to a low-dose iron intervention of as yet
unknown efficacy for an unnecessarily long period of time. Similarly, a control group was
not included since the primary goal of the clinical trial was to first establish whether the low-
dose of iron with synergistic nutrients was efficacious at resolving iron deficiency prior to
Author Manuscript

conducting any comparisons to other formulations. The clinical trial received ethical
approval from both Western Institutional Review Board and the Institutional Review Board
(IRB) of the University of Maryland School of Medicine and was registered on
ClinicalTrials. gov (NCT02683369).

Participant selection
Premenopausal women in the Baltimore, Maryland, metropolitan area were recruited from
the community via flyers and social media outlets. Interested participants contacted a
research associate for an initial telephone screening of study eligibility criteria related to
demographics, health status, etc. Participants who met the initial eligibility criteria screening
were subsequently scheduled for a blood screening at an IRB-approved medical practice
located at University of Maryland St. Joseph Medical Center. Blood was collected from each
Author Manuscript

potential participant to assess her levels of Hgb (to determine anemia status) and ferritin (to
determine iron deficiency status). Participants whose results demonstrated nonanemic iron
deficiency (ferritin < 20 μg/L, Hgb ≥ 12 g/dL) were deemed eligible to participate in the
study. Those whose Hgb demonstrated anemia (< 12 g/dL) were referred to medical care.

The main inclusion criteria of the study included premenopausal females at least 18 years of
age with nonanemic iron deficiency identified during the blood screening. Eligible
participants were also required to be able to understand and write English, agreed to
continue with current diet and any dietary supplements, and voluntarily consented to
participation in the study and understanding potential risks and adverse events. Exclusion
criteria included pregnancy or breastfeeding; daily use of an iron-containing supplement
(other than multivitamin) within the past 2 weeks; known allergies to any substance in the
study product; taking medication that may interfere with the absorption of iron; history of
Author Manuscript

alcohol, drug, or medication abuse; current tobacco smoking; donation of blood in the past
month or plans to do so at any time during the study; and current diagnosis of inflammatory
bowel disease (e.g., Crohn’s disease or ulcerative colitis).

Intervention procedures
Eligible participants were scheduled for a baseline study visit at the medical practice with a
research associate. During the baseline visit, the research associate obtained informed

J Am Coll Nutr. Author manuscript; available in PMC 2018 August 13.

 D’Adamo et al. Page 5

consent and instructed the participant to take one tablet of the iron supplement per day in the
Author Manuscript

morning. The participant was also instructed not to change her diet or dietary
supplementation during the study. The research associate also administered questionnaires to
assess each of the following during the week prior to the baseline visit: consumption of iron-
containing foods (e.g., red meat, chicken, lentils, and beans) through a food frequency
questionnaire, multivitamin or other dietary supplement usage, fatigue and energy levels on
a 1-to-5 Likert scale, and the frequency and severity of gastrointestinal discomfort
(constipation, nausea, vomiting, and diarrhea). These assessments enabled the determination
of changes in these potential confounders of iron status as well as documentation of any
preexisting gastrointestinal discomfort prior to the study.

A blood draw was also performed during the baseline visit to account for any fluctuations in
iron levels that might have occurred in the time between the screening assessment and the
commencement of supplementation after the baseline visit. The baseline blood draw
Author Manuscript

analyzed an important marker of iron status, soluble transferrin receptor (sTfR), in addition
to Hgb and ferritin. The collection of sTfR also allowed for the calculation of total body iron
stores. Both of these outcomes are described in a subsequent section.

The baseline visit concluded with the research associate providing the bottle containing the
dietary supplement along with instructions to consume the supplement once per day. A daily
diary was also provided to the participant to record dietary supplement compliance, any
changes in medications, and any adverse events that occurred. Participants were instructed to
directly contact a physician co-investigator immediately if there were major adverse events.

A research associate performed telephone follow-ups with each participant after 3 and 6
weeks to obtain ongoing assessments of changes in dietary iron intake via food frequency
Author Manuscript

questionnaire, multivitamin or other dietary supplement usage, gastrointestinal adverse

events, and any other adverse events reported by the participant. At the conclusion of the 8-
week study, a follow-up visit with a research associate was conducted at the medical office.
The follow-up visit involved a blood draw for postintervention evaluation of the iron
markers as well as collection of diaries; pill count to further assess compliance with the iron
supplement regimen; and administration of questionnaires to assess the consumption of iron-
containing foods, energy levels and fatigue, and gastrointestinal discomfort or any other
adverse events during the previous week.

Study supplement
The dietary supplement under study (Blood Builder®/Iron Response®) has been
commercially available in its current form since 2005 and is commonly used by people
Author Manuscript

experiencing iron deficiency to help increase their iron levels and improve energy. Each
tablet contained 26 mg of elemental iron cultured by Saccharomyces cerevisiae. The 26-mg
dose of elemental iron was selected for this low-dose clinical trial because it was one of the
few commercially available iron dietary supplements that is dosed below the 45-mg UL and
it contains numerous nutrients known to increase iron absorption. In addition to the 26 mg of
iron, the supplement also contained 125 mg of beetroot, 15 mg of vitamin C (orange), 400
mcg of folate (broccoli), and 6 mcg of vitamin B12 (S cerevisiae).

J Am Coll Nutr. Author manuscript; available in PMC 2018 August 13.

 D’Adamo et al. Page 6

Study outcomes
Author Manuscript

Baseline and follow-up blood draws were performed and analyzed in an onsite CLIA-
certified laboratory at University of Maryland St. Joseph Medical Center. The markers of
iron status in this study were Hgb, SF, and sTfR. Hgb, assessed with Beckman Coulter LH
780 hematology analyzer (Quest Diagnostics), is a protein that carries oxygen though the
circulatory system and serves as the primary iron pool in humans. The majority of the
remaining storage iron is used to regenerate Hgb and is considered an important indicator of
iron status. Key iron storage proteins include SF and sTfR. SF, assessed with Vitros
Immunodiagnostic Products Ferritin Reagent Pack (Quest Diagnostics), is the most
commonly utilized marker of iron deficiency in clinical practice the levels of which reflect
intracellular iron stores. sTfR, assessed with nephelometry (Quest Diagnostics), reflects the
number of iron receptors expressed on cellular membranes and it increases as iron stores
become lower. All three biomarkers (Hgb, SF, and sTfR) are commonly measured in studies
Author Manuscript

assessing the effect of iron intake on iron status (4,7,13).

The final marker of iron status in this study was total body iron stores. This marker helps
detect tissue iron deficiencies by quantifying the amount of SF and sTfR and is calculated as
follows:

Total Body Iron Stores mg/kg = − log10 sTfR × 1000/SF − 2 . 8229 /0 . 1207

This method of determining total body iron using stores has been published (38), validated,
and utilized as a marker of iron status in many iron interventions (4,39–42).

In addition to the markers of iron status that served as the primary outcomes in this study,
secondary outcomes included patient-reported fatigue and energy levels. These outcomes
Author Manuscript

were scored on 1-to-5 Likert scales as follows: frequency of fatigue (1 = never fatigued, 2 =
occasionally fatigued, 3 = frequently fatigued, 4 = very fatigued, 5 = constantly fatigued),
severity of fatigue (1 = very minor or no fatigue, 2 = minor fatigue, 3 = moderate fatigue, 4
high fatigue, 5 very high fatigue) and energy (1 very low energy, 2 = low energy, 3 =
moderate energy, 4 = high energy, 5 = very high energy).

Assessment of adverse events

In light of the high incidence of adverse events in previous clinical trials of iron
supplementation, the assessment of adverse events was an area of focus in this study.
Participants were specifically asked about the frequency and severity of gastrointestinal
discomfort (constipation, nausea, vomiting, and diarrhea) during the past week at baseline, 3
weeks, 6 weeks, and follow-up concluding the 8-week study. In addition, the participant was
Author Manuscript

provided a daily diary and was instructed to record any adverse events that occurred in their
diary and to immediately contact a physician co-investigator on the research team for any
major adverse events.

Statistical methods
Continuous data were reported as mean and standard deviation or median and interquartile
range, depending on normality assumptions. Categorical data were reported as counts and

J Am Coll Nutr. Author manuscript; available in PMC 2018 August 13.

 D’Adamo et al. Page 7

percentages. Changes in Hgb, SF, total body iron stores, fatigue, and energy over the 8-week
Author Manuscript

treatment period were assessed by dependent samples t test. Values for sTfR were
nonnormally distributed and were analyzed using Wilcoxon signed-rank test. Statistical
significance was defined as p < 0.05. Statistical analyses were performed using Predictive
Analytics Software (v. 22; IBM, Inc.).

Results
As revealed in Figure 1, a total of 67 premenopausal women participated in blood screening
to enable determination of non-anemic iron deficiency eligibility status. Twenty-nine of
those screened were not iron-deficient (SF > 20 μg/L), and 15 were anemic (Hgb < 12 g/dL)
and referred to medical care. The remaining 23 eligible participants provided informed
consented, completed a baseline study visit, and were allocated to the dietary supplement
intervention. Of the 23 participants who enrolled, 22 participants (95.6%) completed the
Author Manuscript

study. The sole dropout in the study moved from the area to return to university and was
unable to travel to the follow-up visit.

Table 1 characterizes the study population at baseline. In brief, the study sample was
approximately 30 years of age, normal weight (mean body mass index D 24.4 kg/m2),
racially diverse (52% white, 48% black or other), and highly educated (87% had at least a
college degree).

The changes in the markers of status from baseline to the conclusion of the study are
provided in Table 2. All markers of iron status showed statistically significant improvements
from baseline to the 8-week follow-up visit (p < 0.04). Most notably, the sample experienced
a mean increase of 7.2 μg/L in SF. This increase represented resolution of iron deficiency
back to normal range (mean baseline SF = 13.9 μg/L, mean follow-up SF = 21.1 μg/L, p <
Author Manuscript

0.001). Similar improvements were also noted for Hgb, sTfR, and total body iron stores (p <
0.04).

The changes in fatigue and energy levels from baseline to the conclusion of the study are
provided in Table 3. There were modest but statistically significant reductions (p < 0.001) in
fatigue frequency, fatigue severity, and composite fatigue score (frequency × severity).
Energy also increased (p < 0.001) among the study sample.

While there was a slight decrease in red meat intake from the week before the baseline visit
(mean = 1.3 servings) to the week before the 8-week follow-up visit (mean = 0.9 servings),
this decrease was not significant (p = 0.1) and there were no changes in intake of any other
foods containing high amounts of iron during the study. Only three participants were
Author Manuscript

consuming a multivitamin at baseline, and there were no changes in multivitamin or other

dietary supplement usage (neither beginning nor stopping) among any participants during
the study.

There were no changes in frequency, severity, or composite score (frequency × severity) of

any of the symptoms of gastro intestinal distress (constipation, nausea, vomiting, and
diarrhea) from baseline to the conclusion of the study (p > 0.3). Moreover, there were no
adverse events of any sort reported during the course of the study.

J Am Coll Nutr. Author manuscript; available in PMC 2018 August 13.

 D’Adamo et al. Page 8

Discussion
Author Manuscript

The dietary supplement under study (Blood Builder®/Iron Response®) restored mean SF
levels among a sample of nonanemic iron-deficient women back into normal range during
this 8-week pilot clinical trial. All other markers of iron status (Hgb, sTfR, total body iron
stores) also demonstrated improvements from baseline to the conclusion of this brief study
(p < 0.04). Alongside the improvements noted in all of the markers of iron status, there were
modest increases noted in energy and reductions in fatigue (p < 0.001).

The improvements in the markers of iron status among this iron-deficient study sample are
particularly noteworthy in light of both the very low dose of iron (26 mg) contained in the
dietary supplement and the complete absence of adverse events reported during this study.
The investigators believe that the absence of adverse events may have been due largely to the
much lower dose of iron in this dietary supplement compared to doses that have typically
Author Manuscript

been studied. While some recent studies have shown that 60 mg of iron may ameliorate iron
deficiency as efficaciously as higher doses of between 80 and 120 mg, adverse events
associated with iron supplementation are still quite common even at 60-mg doses. In fact,
the mean incidence of adverse events in previous clinical trials of iron supplementation
among other samples of iron-deficient premenopausal women is approximately 34%
(7,13,30,32,33,43–45). The relatively high incidence of adverse events noted previously is
not terribly surprising, as most of these studies utilized doses above the tolerable UL of 45
mg of iron. Consequently, the investigators conducted a rigorous assessment of adverse
events, including probing by a research associate throughout the study for gastrointestinal
(constipation, nausea, vomiting, and diarrhea) and any other types of distress, which makes
the lack of adverse events in this study compelling.
Author Manuscript

The investigators offer several hypotheses as to how this dietary supplement was able to
restore iron levels at such a low dose. The inclusion of synergistic nutrients in this dietary
supplement along with the iron—most notably folate and vitamin C, which have been
previously shown to increase iron absorption (18,20)—may have resulted in its efficacy at a
low dose. While less is currently known about the impact of beetroot and vitamin B12 on
iron absorption, our findings suggest that they might merit future study as adjuvant
ingredients in iron supplements. However, the addition of novel dietary ingredients to iron
formulas must be selected and studied carefully, as some dietary polyphenols have been
shown to decrease iron absorption (46,47).

In addition to the synergistic nutrients included in this supplement, the food-derived process
through which the iron was obtained might have also contributed to its efficacy at a low
dose. The form of iron and binding salts contained in dietary supplements have previously
Author Manuscript

been shown to impact the solubility and bioavailability in humans. For instance, ferrous iron
has been shown to be more soluble and with higher bioavailability than ferric iron (16,18). It
is possible that the iron attained from S cerevisiae culturing of whole-food sources may have
resulted in a more soluble and bioavailable form of iron that ultimately lent itself to
enhanced efficacy in our study sample. Comparative studies of the solubility and
bioavailability of this food-derived form of iron versus other forms would allow for a more
conclusive determination of this potential mechanism. Food-derived dietary supplements in

J Am Coll Nutr. Author manuscript; available in PMC 2018 August 13.

 D’Adamo et al. Page 9

general have become increasingly popular in recent years and more studies are needed to
Author Manuscript

determine whether there is indeed additional synergy among nutrients in these types of
supplements as compared to synthetic versions.

The accompanying synergistic nutrients and food-derived form of iron in this dietary
supplement might have also contributed to the absence of adverse events noted in this study.
Clinical trials of iron supplementation with co-administration of vitamin C or citrus juice
containing high levels of vitamin C have reported markedly lower rates of adverse events as
compared to iron supplementation alone (25,34,44). Thus, the vitamin C and other
accompanying dietary ingredients in this supplement might have provided some protection
against the incidence of adverse events in this study. Adverse events have also varied by the
form of the iron supplement in previous studies, with the highest mean incidence of adverse
events approximately 91% for carbonyl iron (33) and the lowest mean incidence of adverse
events of approximately 17% for both ferrous gluconate (48,49) and ferrous sulfate
Author Manuscript

(4,7,28,30,32,45,49–51). Future studies would be needed to elucidate the specific

mechanisms underlying the lack of adverse events for the dietary supplement utilized in this
study.

While the findings in this study are promising, there were several notable limitations that are
worthy of consideration. As an uncontrolled pilot trial aimed at assessing the tolerability and
preliminary efficacy of this low-dose iron-containing dietary supplement, the inference is
limited until larger, randomized, and placebo-controlled studies can be conducted. As there
is no endogenous production of iron in human beings, very little placebo effect was believed
to have occurred with respect to the improvements noted across the comprehensive set of
blood-based biomarkers of iron status that served as the primary outcomes in this study.
However, while the increases in energy and reductions in fatigue are notable in light of the
Author Manuscript

limited room for improvement from baseline (participants were neither markedly low in
energy nor fatigued at baseline), these participant-reported outcomes are far more prone to
the placebo effect and inference should be viewed in that limited context. Controlled studies
comparing this efficacious dietary supplement to equal doses of other forms of iron in two-
arm clinical trials, as well as to equal doses of food-derived iron without synergistic
nutrients in three-arm clinical trials, appear warranted to establish the comparative efficacy
of this unique iron formulation.

Another related limitation was the lack of standardized diets provided to participants to
control for any changes in dietary iron intake during the study. A standardized diet was
viewed as infeasible for the participants in this community-based study and, to the authors’
knowledge, has never been implemented in previous clinical studies of this nature. In order
Author Manuscript

to control for potential confounding introduced by changes in iron-containing foods during

the study, the investigators administered food frequency questionnaires including intake of a
variety of iron-containing foods at all time points in the study (baseline, 3 weeks, 6 weeks,
and 8-week follow-up) and there were no statistically significant changes in dietary intake
noted over the course of the study (p ≥ 0.1). The only dimension of dietary intake that even
trended toward a change throughout the study was red meat, which decreased from 1.3
servings in the week prior to the baseline visit to 0.9 servings per week in the week prior to
the 8-week visit (p = 0.1). Red meat is one of the richest sources of bioavailable heme iron

J Am Coll Nutr. Author manuscript; available in PMC 2018 August 13.

 D’Adamo et al. Page 10

in the diet and, as such, the improvements in the markers of iron status noted in this study
Author Manuscript

might have been slightly underestimated by the slight decrease in mean red meat intake that
occurred during the study. There were also no changes reported in multivitamin usage or any
other forms of dietary supplementation during the study. Nevertheless, dietary intake
assessment is imperfect and it is possible that unreported changes in iron intake during the
study might have influenced the observed efficacy of the dietary supplement on improving
markers of iron status.

Menstruation can also impact markers of iron status. While the study sample was limited to
premenopausal women on this basis to reduce the potential for confounding within a mixed
pre- and postmenopausal sample, the timing of menstrual cycles during the study was not
assessed and this might have had an impact on some participants. Last, while data are
conflicting, inflammation may also impact some markers of iron status (52) and changes in
inflammation were not assessed in this study. In order to more directly account for the
Author Manuscript

potential impact of inflammation on the iron status of our sample, the investigators included
sTfR among the markers of iron status assessed in this study as it is robust to changes in
inflammation (53). The improvements in sTfR among our sample suggest that inflammation
did not have an influence on the resolution of iron deficiency in this study, although future
studies might include markers of inflammation alongside sTfR to allow for direct and
indirect assessment of the potential impact of inflammation on iron status. Larger and
controlled trials in the future would help overcome the primary limitations of this pilot study.

The findings in this study raise intriguing possibilities regarding the potential for nutrient
synergy in iron dietary supplement formulation, which may enable lower doses of iron than
are typically recommended to resolve iron deficiency while simultaneously reducing the
high incidence of adverse events that often interfere with compliance at higher doses.
Author Manuscript

Nutrient synergy is common in calcium dietary supplements, which often contain vitamin D
and other nutrients known to increase calcium absorption, and most commercially available
iron dietary supplements have not yet espoused this approach. While the findings in this
pilot study are promising, larger and controlled studies are needed to more conclusively
determine the efficacy of the approach of low-dose iron with synergistic nutrients to resolve
iron deficiency.

Conclusion
The resolution of iron deficiency and improvements in all other markers of iron status with
just 26 mg of supplemental iron in this iron-deficient study sample, without the occurrence
of any adverse events, is highly encouraging. Future mechanistic and clinical studies
comparing this low-dose iron supplement with synergistic food-derived nutrients to
Author Manuscript

synthetically isolated and higher-dosage iron supplements known to have high rates of
adverse events appear warranted.

Acknowledgments
Funding

J Am Coll Nutr. Author manuscript; available in PMC 2018 August 13.

 D’Adamo et al. Page 11

Support for this research was provided by FoodState, Inc. and the National Institute of Diabetes and Digestive and
Kidney Diseases grant number T35 DK095737.
Author Manuscript

References
1. Huebers H Iron metabolism: iron transport and cellular uptake mechanisms In: Lonnerdal B , editor.
Iron metabolism in infants. Boca Raton (FL): CRC Press; 1989 p. 163.
2. Anderson G , Vulpe C . The cellular physiology of iron In: Yehuda S , Mostofsky DI editors. Iron
deficiency and overload: from basic biology to clinical medicine. Totowa, NJ: Humana Press; 2010
p. 3–29.
3. Kim J , Wessling-Resnick M . Iron and mechanisms of emotional behavior. J Nutr Biochem.
2014;25:1101–1107. doi:10.1016/j.jnutbio.2014.07.003. PMID:.25154570
4. DellaValle DM , Haas JD . Iron supplementation improves energetic efficiency in iron-depleted
female rowers. Med Sci Sports Exerc. 2014;46:1204–1215. doi:10.1249/MSS.0000000000000208.
PMID:.24195864
5. Looker AC , Dallman PR , Carroll MD , Gunter EW , Johnson CL . Prevalence of iron deficiency in
Author Manuscript

the United States. JAMA. 1997;277:973–976. doi:10.1001/jama.1997.03540360041028. PMID:.

9091669
6. Stoltzfus RJ , Dreyfuss ML . Guidelines for the use of iron supplements to prevent and treat iron
deficiency anemia. Washington (DC): ILSI Press; 1998.
7. Leonard AJ , Chalmers KA , Collins CE , Patterson AJ . Comparison of two doses of elemental iron
in the treatment of latent iron deficiency: efficacy, side effects and blinding capabilities. Nutrients.
2014;6:1394–1405. doi:10.3390/nu6041394. PMID:.24714351
8. Galan P , Yoon HC , Preziosi P , Viteri F , Valeix P , Fieux B , Briancon S , Malvy D , Roussel AM ,
Favier A , Hercberg S . Determining factors in the iron status of adult women in the SU.VI.MAX
study. Eur J Clin Nutr. 1998;52:383–388. doi:10.1038/sj.ejcn.1600561. PMID:9683388.9683388
9. Sekhar DL , Murray-Kolb LE , Kunselman AR , Weisman CS , Paul IM . Association between
menarche and iron deficiency in non-anemic young women. PLoS One. 2017;12:e0177183. doi:
10.1371/journal.pone.0177183. PMID:.28486542
10. World Health Organization. Iron deficiency anaemia: Assessment, prevention and control A guide
for programme managers. Geneva (Switzerland): World Health Organization; 2001.
Author Manuscript

11. Centers for Disease Control and Prevention. Recommendations to prevent and control iron
deficiency in the United States. MMWR Recomm Rep. 1998;47:1–29.
12. Smith GA , Fisher SA , Doree C , Di Angelantonio E , Roberts DJ . Oral or parenteral iron
supplementation to reduce deferral, iron deficiency and/or anaemia in blood donors. Cochrane
Database Syst Rev. 2014;7 (Jul): 1–153.
13. Low MS , Speedy J , Styles CE , De-Regil LM , Pasricha SR . Daily iron supplementation for
improving anaemia, iron status and health in menstruating women. Cochrane Database Syst Rev.
2016;4(Apr): 1–225. PMID:.27087396
14. National Institutes of Health, Office of Dietary Supplements: Iron: dietary supplement fact sheet
[Internet]. Available from: https://ods.od.nih.gov/factsheets/Iron-HealthProfessional/#en5.
15. Manoguerra AS , Erdman AR , Booze LL , Christianson G , Wax PM , Scharman EJ , Woolf AD ,
Chyka PA , Keyes DC , Olson KR , Caravati EM , Troutman WG . Iron ingestion: an evidence-
based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2005;43:553–
570. doi:10.1081/CLT-200068842. PMID:.16255338
Author Manuscript

16. Murray-Kolbe LE , Beard J . Iron, 2nd edition New York: Informa Healthcare; 2010.
17. Yetley EA . Multivitamin and multimineral dietary supplements: definitions, characterization,
bioavailability, and drug interactions. Am J Clin Nutr. 2007;85:269S–276S. PMID:.17209208
18. Hurrell R , Egli I . Iron bioavailability and dietary reference values. Am J Clin Nutr.
2010;91:1461S–1467S. doi:10.3945/ajcn.2010.28674F. PMID:.20200263
19. Bueno L , Pizzo JC , Marchini JS , Dutra-de-Oliveira JE , Dos Santos JE , Barbosa Junior F . Iron
(FeSo4) bioavailability in obese subjects submitted to bariatric surgery. Nutr Hosp. 2013;28:100–
104. PMID:.23808436

J Am Coll Nutr. Author manuscript; available in PMC 2018 August 13.

 D’Adamo et al. Page 12

20. Christian P , Shrestha J , LeClerq SC , Khatry SK , Jiang T , Wagner T , Katz J , West KP .

Supplementation with micronutrients in addition to iron and folic acid does not further improve the
Author Manuscript

hematologic status of pregnant women in rural Nepal. J Nutr. 2003;133:3492–3498. PMID:.

14608063
21. Institute of Medicine. Dietary reference intakes for vitamin A, vitamin K, arsenic, boron,
chromium, copper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and zinc.
Washington (DC): The National Academies Press; 2001.
22. Cogswell ME , Looker AC , Pfeiffer CM , Cook JD , Lacher DA , Beard JL , Lynch SR ,
Grummer-Strawn LM . Intermittent iron supplementation for reducing anaemia in US preschool
children and nonpregnant females of childbearing age: National health and nutrition examination
survey 2003–2006. Am J Clin Nutr. 2009;89:1334–1342. doi:10.3945/ajcn.2008.27151. PMID:.
19357218
23. Moretti D , Goede JS , Zeder C , Jiskra M , Chatzinakou V , Tjalsma H , Melse-Boonstra A ,
Brittenham G , Swinkels DW , Zimmermann MB . Oral iron supplements increase hepcidin and
decrease iron absorption from daily or twice-daily doses in iron-depleted young women. Blood.
2015;126:1981–1989. doi:10.1182/blood-2015-05-642223. PMID:.26289639
Author Manuscript

24. Hoppe M , Brun B , Larsson MP , Moraeus L , Hulthen L . Heme iron-based dietary intervention
for improvement of iron status in young women. Nutrition. 2013;29:89–95. doi:10.1016/j.nut.
2012.04.013. PMID:.22951158
25. Taniguchi M , Imamura H , Shirota T , Okamatsu H , Fujii Y , Toba M , Hashimoto F .
Improvement in iron deficiency anemia through therapy with ferric ammonium citrate and vitamin
C and the effects of aerobic exercise. J Nutr Sci Vitaminol (Tokyo). 1991;37:161–171. doi:
10.3177/jnsv.37.161. PMID:.1919803
26. Fogelholm M , Suominen M , Rita H . Effects of low-dose iron supplementation in women with
low serum ferritin concentration. Eur J Clin Nutr. 1994;48:753–756. PMID:.7835330
27. Marks DC , Speedy J , Robinson KL , Brama T , Capper HR , Mondy P , Keller AJ . An 8-week
course of 45 mg of carbonyl iron daily reduces iron deficiency in female whole blood donors aged
18 to 45 years: Results of a prospective randomized controlled trial. Transfusion. 2014;54:780–
788. doi:10.1111/trf.12464. PMID:.24660763
28. Mujica-Coopman MF , Borja A , Pizarro F , Olivares M . Effect of daily supplementation with iron
and zinc on iron status of childbearing age women. Biol Trace Elem Res. 2015;165:10–17. doi:
Author Manuscript

10.1007/s12011-014-0226-y. PMID:.25582309
29. Ballin A , Berar M , Rubinstein U , Kleter Y , Hershkovitz A , Meytes D . Iron state in female
adolescents. Am J Dis Child. 1992;146:803–805. PMID:.1496946
30. Maghsudlu M , Nasizadeh S , Toogeh GR , Zandieh T , Parandoush S , Rezayani M . Short-term
ferrous sulfate supplementation in female blood donors. Transfusion. 2008;48:1192–1197. doi:
10.1111/j.1537-2995.2007.01671.x. PMID:.18363581
31. Pereira DI , Couto Irving SS , Lomer MC , Powell JJ . A rapid, simple questionnaire to assess
gastrointestinal symptoms after oral ferrous sulphate supplementation. BMC Gastroenterol.
2014;14:103. doi:10.1186/1471-230X-14-103. PMID:.24899360
32. Waldvogel S , Pedrazzini B , Vaucher P , Bize R , Cornuz J , Tissot JD , Favrat B . Clinical
evaluation of iron treatment efficiency among non-anemic but iron-deficient female blood donors:
A randomized controlled trial. BMC Med. 2012;10:8. doi:10.1186/1741-7015-10-8. PMID:.
22272750
33. Gordeuk VR , Brittenham GM , Hughes MA , Keating LJ . Carbonyl iron for short-term
Author Manuscript

supplementation in female blood donors. Trans-fusion. 1987;27:80–85. doi:10.1046/j.

1537-2995.1987.27187121482.x. PMID:.3810831
34. Zhu YI , Haas JD . Response of serum transferrin receptor to iron supplementation in iron-
depleted, nonanemic women. Am J Clin Nutr. 1998;67:271–275. doi:10.1093/ajcn/67.2.271.
PMID:.9459375
35. Brownlie Tt , Utermohlen V , Hinton PS , Haas JD . Tissue iron deficiency without anemia impairs
adaptation in endurance capacity after aerobic training in previously untrained women. Am J Clin
Nutr. 2004;79:437–443. PMID:.14985219

J Am Coll Nutr. Author manuscript; available in PMC 2018 August 13.

 D’Adamo et al. Page 13

36. Binkoski AE , Kris-Etherton PM , Beard JL . Iron supplementation does not affect the
susceptibility of LDL to oxidative modification in women with low iron status. J Nutr.
Author Manuscript

2004;134:99–103. PMID:.14704300
37. Hinton PS , Giordano C , Brownlie T , Haas JD . Iron supplementation improves endurance after
training in iron-depleted, nonanemic women. J Appl Physiol. 2000;88:1103–1111, Online
publication. doi:10.1152/jappl.2000.88.3.1103. PMID:.10710409
38. Cook J , Flowers CF , Skikne B . The quantitative assessment of body iron. Blood. 2003;101:3359–
3364. doi:10.1182/blood-2002-10-3071. PMID:.12521995
39. Biebinger R , Zimmermann MB , Al-Hooti SN , Al-Hamed N , Al-Salem E , Zafar T , Kabir Y ,
Al-Obaid I , Petry N , Hurrell RF . Efficacy of wheat-based biscuits fortified with microcapsules
containing ferrous sulfate and potassium iodate or a new hydrogen-reduced elemental iron: a
randomised, double-blind, controlled trial in Kuwaiti women. Br J Nutr. 2009;102:1362–1369. doi:
10.1017/S0007114509990353. PMID:.19653920
40. Haas JD , Beard JL , Murray-Kolb LE , del Mundo AM , Felix A , Gregorio GB . Iron-biofortified
rice improves the iron stores of nonanemic Filipino women. J Nutr. 2005;135:2823–2830. PMID:.
16317127
Author Manuscript

41. Murray-Kolb LE , Beard JL . Iron treatment normalizes cognitive functioning in young women.
Am J Clin Nutr. 2007;85:778–787. PMID:.17344500
42. Zimmermann MB , Winichagoon P , Gowachirapant S , Hess SY , Harrington M , Chavasit V ,
Lynch SR , Hurrell RF . Comparison of the efficacy of wheat-based snacks fortified with ferrous
sulfate, electrolytic iron, or hydrogen-reduced elemental iron: Randomized, double-blind,
controlled trial in Thai women. Am J Clin Nutr. 2005;82:1276–1282. PMID:.16332661
43. Rybo E , Bengtsson C , Hallberg L , Oden A . Effect of iron supplementation to women with iron
deficiency. Scand J Haematol Suppl. 1985;43:103–114. PMID:.3863237
44. Bryson D . Iron and anaemia in adolescent girls. A double-blind trial. The Practitioner.
1968;200:694–697. PMID:.4870203
45. Flink H , Tegelberg A , Thorn M , Lagerlof F . Effect of oral iron supplementation on unstimulated
salivary flow rate: A randomized, double-blind, placebo-controlled trial. J Oral Pathol Med.
2006;35:540–547. doi:10.1111/j.1600-0714.2006.00450.x. PMID:.16968234
46. Rutzke CJ , Glahn RP , Rutzke MA , Welch RM , Langhans RW , Albright LD , Combs GF ,
Wheeler RM . Bioavailability of iron from spinach using an in vitro/human Caco-2 cell bioassay
Author Manuscript

model. Habitation (Elmsford). 2004;10:7–14. doi:10.3727/154296604774808900. PMID: .

15880905
47. Gillooly M , Bothwell TH , Torrance JD , MacPhail AP , Derman DP , Bezwoda WR , Mills W ,
Charlton RW , Mayet F . The effects of organic acids, phytates and polyphenols on the absorption
of iron from vegetables. Br J Nutr. 1983;49:331–342. doi:10.1079/BJN19830042. PMID:.6860621
48. Kiss JE , Brambilla D , Glynn SA , Mast AE , Spencer BR , Stone M , Klein-man SH , Cable RG ,
for the National Heart L, Blood Institute Recipient Epidemiology and Donor Evaluation Study-III.
Oral iron supplementation after blood donation: a randomized clinical trial. JAMA. 2015;313:575–
583. doi:10.1001/jama.2015.119. PMID:.25668261
49. Cancelo-Hidalgo MJ , Castelo-Branco C , Palacios S , Haya-Palazuelos J , Ciria-Recasens M ,
Manasanch J , Perez-Edo L . Tolerability of different oral iron supplements: A systematic review.
Curr Med Res Opin. 2013;29:291–303. doi:10.1185/03007995.2012.761599. PMID:.23252877
50. Pulani L , Sunethra A , Geethanjali dS , Swarnamali S , Lakshmi D . Evaluation of nutrition
education for improving iron status in combination with daily iron supplementation. Food Nutr
Author Manuscript

Bull. 2000;21:259–269. doi:10.1177/156482650002100302.

51. Viteri FE , Ali F , Tujague J . Long-term weekly iron supplementation improves and sustains
nonpregnant women’s iron status as well or better than currently recommended short-term daily
supplementation. J Nutr. 1999;129:2013–2020. PMID:.10539778
52. Ross AC . Impact of chronic and acute inflammation on extra- and intracellular iron homeostasis.
Am J Clin Nutr. 2017;106(Suppl 6):1581S–1587S. doi:10.3945/ajcn.117.155838.29070546
53. Al-Saqladi AWM , Bin-Gadeem HA , Brabin BJ . Utility of plasma transferrin receptor, ferritin and
inflammatory markers in children with sickle cell disease. Paediatr Int Child Health. 2012;32:27–
34. doi:10.1179/2046905511Y.0000000009. PMID:.22525445

J Am Coll Nutr. Author manuscript; available in PMC 2018 August 13.

 D’Adamo et al. Page 14
Author Manuscript
Author Manuscript

Figure 1.
Author Manuscript

Patient flow diagram.

Author Manuscript

J Am Coll Nutr. Author manuscript; available in PMC 2018 August 13.

 D’Adamo et al. Page 15

Table 1.

Baseline Participant Characteristics (n = 23).

Author Manuscript

Variable Value*
Age (years) 29.7 (7.9)
BMI (kg/m2) 24.4 (6.9)
Race
White 52% (12/23)
Black 44% (10/23)
Other 4% (1/23)
Highest education level
Associate, trade, or technical degree 13% (3/23)
College degree 35% (8/23)
Graduate/professional degree 52% (12/23)
Author Manuscript

Note.
*
Values are mean (SD) or % (n/N).

BMI = body mass index.

Author Manuscript
Author Manuscript

J Am Coll Nutr. Author manuscript; available in PMC 2018 August 13.

 D’Adamo et al. Page 16

Table 2.

Markers of Iron Status.

Author Manuscript

Variable Value p value

Hemoglobin (g/dL)*
Week 0 12.8 (0.8)
Week 8 13.2 (0.7) 0.004

Serum ferritin (μg/L)*

Week 0 13.9 (5.0)
Week 8 21.1 (9.0) < 0.001

Soluble transferrin receptor (mg/L)**

Week 0 1.31 (0.97, 1.50)
Week 8 1.23 (1.04, 1.37) 0.04

Total body iron stores (mg/kg)*

Author Manuscript

Week 0 6.77 (2.30)

Week 8 8.57 (1.93) < 0.001

Note.
*
Values are mean (SD) with p values determined by dependent samples t test.
**
Values are median (interquartile range) with p values determined by Wilcoxon signed-rank test due to nonnormally distributed data.
Author Manuscript
Author Manuscript

J Am Coll Nutr. Author manuscript; available in PMC 2018 August 13.

 D’Adamo et al. Page 17

Table 3.

Fatigue and Energy During the Previous Week.

Author Manuscript

Variable Value p value

Fatigue severity*
Week 0 2.6 (0.8)
Week 8 1.9 (0.6) < 0.001

Fatigue frequency*
Week 0 2.8 (0.9)
Week 8 1.8 (0.4) < 0.001

Fatigue composite**
Week 0 7.6 (4.2)
Week 8 3.5 (1.6) < 0.001

Energy*
Author Manuscript

Week 0 2.7 (0.6)

Week 8 3.3 (0.6) < 0.001

Note.
*
Values are mean (SD) on a 1–5 Likert scale with p values determined by dependent samples t test.
**
Values are mean (SD) on a 1–25 Likert scale (fatigue severity × fatigue frequency) with p values determined by dependent samples t test.
Author Manuscript
Author Manuscript

J Am Coll Nutr. Author manuscript; available in PMC 2018 August 13.