Iron in your prenatal vitamin - likely helpful or possibly harmful?

Many women take prenatal vitamins before, during and after a pregnancy, often on the advice of their OB-GYN. Some doctors will write a prescription for one, others suggest over-the-counter brands. Both of these types will contain iron, some as much as 45 mg in a single tablet or capsule. Not surprising since the CDC and the American College of Obstetricians and Gynecologists recommend universal consumption of prenatal supplements containing iron to meet pregnancy needs and to prevent anemia. 

A woman has an increased need for iron during pregnancy as her blood volume expands and the demands of her growing baby and placenta increase. According to, she needs 27 mg per day during pregnancy, and 9 during lactation; this mirrors the Institute of Medicine recommendations. 

A large percentage of women have iron deficiency during their reproductive years. What about during pregnancy? Iron deficiency prevalence during pregnancy increases with each trimester, 7% of women in the first, 14% in the second, and 30% in the third trimester test positive for it (1). So it would seem to make good sense to take a vitamin supplement with iron during pregnancy. But let's take a closer look. 

What are the risks of iron deficiency during pregnancy? According to the National Library of Medicine at NIH:

"There are more than 60 studies on the use of iron supplements in pregnancy. A total of more than 30,000 women took part in the studies. The results show that, if women have normal blood values, taking 30 mg of iron per day as a precautionary measure does not have any noticeable health benefits for them or for their children. Although iron supplements were found to lower the risk of anemia, they did not influence the number of preterm births or infections in pregnant women." (2)

For some women, however, iron supplementation for all three trimesters may not always be the best course of action. Iron seems to be one of those "Goldilocks" nutrients - you don't want too much, or too little, just about right is ideal. 

Beyond the more immediate side effects of higher doses of supplemental iron to a woman: constipation, nausea, and even vomiting in excess of what is normal during pregnancy, high body stores of iron (as measured by higher serum ferritin levels) appear to be linked to an increase in the risk for gestational diabetes. A blood test for ferritin can be good indicator of body stores of iron, but the test is affected by the body's level of inflammation. Pregnancy is considered an "inflammatory state", so measuring serum ferritin during pregnancy may or may not reflect the actual body stores of iron for a given woman (3).

My recommendation would be to get your serum ferritin checked prior to conception, along with a marker of inflammation such as hsCRP. Your doctor can then evaluate your need for iron supplementation well before or at the onset of your pregnancy, and monitor you throughout your gestation to see if and how your status changes.

You might want to consider those two tests (serum ferritin and hsCRP) at least 6 months prior to an anticipated pregnancy, so you can increase your dietary intake of iron-rich foods such as red meat, dark chicken, liver, and/or supplement with a high quality, easy-on-the stomach formula such as Feosol, as needed. Follow this with another check just before you "start trying" to conceive. 

It is possible that the same metabolic problems that lead to gestational diabetes are contributing to a rise in ferritin in some women. If your ferritin is elevated as evaluated by your doctor (or for example above 150-200 ng/mL and no substantial elevation in hsCRP) you may want to consider monitoring your own blood glucose (see a previous post here on "Gestational Pre-diabetes", especially if you or anyone in your family has a history of GDM.

Finally, please be aware that what may look like iron deficiency anemia could have other contributing factors, nutritionally speaking: vitamins A, B6, folate, B12, and the minerals zinc and copper play roles in the formation of red blood cells. Vitamin A and B6 are particularly difficult for many women to obtain from their diet - see my articles published in the Wise Traditions Journal for reasons behind that and what to do diet-wise (4,5). Zinc can also be problematic especially if a women has been on oral contraceptives for a number of years. 

 1. 2. 3.                                                

4. Vitamin A:                                                                                                

5. Vitamin B6:

PCOS - Another Dietary Change that can Help

PCOS – Lowering Insulin Levels with Diet

You may be expecting me to discuss lowering your carb intake – and thinking, so tell me something I don’t know.

Please keep reading on, this is not the same old advice. 

While excess refined carbs are clearly a problem, most women with PCOS will reduce “white” foods and sugar as their first dietary change; and many see results, especially with modest weight loss.

But is there more you can do?  Yes, and you may find it an easy change to make.  It is simply cooking your food at lower temperatures with plenty of moisture. 

I advise most of my patients not to grill, and if they do so, to limit how dark they cook their food, and ideally marinating with acid-marinade for at least a few hours before grilling.  Ditto for eating fried foods – I recommend they be eaten minimally if at all, especially considering the highly-damaged fats they are fried in. This is to limit the consumption of chemical by-products when protein and/or carbohydrates are heated to temperatures in excess of 400 degrees.

Now we are learning that any type of dry, heat cooking – even sauté – is associated with increased fasting insulin levels in healthy adults. In fact, after a year of modifying their diets to a low “AGE”, or advanced glycation product containing diet, the individuals who used low-temp cooking techniques had more than a one-third reduction in fasting insulin levels compared to those who used high-temp cooking methods. 

You may know that increased insulin levels are linked to an increased output of testosterone from the ovaries in women with PCOS.  So while the participants in this study did not have PCOS, it is a fair assumption that a low AGE, or low-temp cooked diet, could be helpful to you if you have been diagnosed with PCOS.  Another benefit is the reduction of markers of inflammation, such as hsCRP, which are often elevated in PCOS. 

While boiled or poached food may not be as tasty, the use of spices and low-sugar sauces can help you adjust to the change.  Some suggestions would be to eat soft or hard-boiled eggs instead of fried, beef stew instead of grilled steak, poached fish instead of grilled, baked meatballs instead of fried (keep oven around 300 degrees and don’t overbrown), raw versus roasted nuts, and raw milk cheese instead of cheese made with pasteurized milk. Vegetables can be lightly steamed and will maintain a good crunch such as with a stir-fry. Sorry, you will have to forgo toasting your bread, even your whole grain bread; similarly, most dry cereals are moderately high in AGEs, stick to oatmeal. And baked potatoes in the skin are clearly better than oven-roasted potatoes even when using healthy oils like ghee or olive oil.

The key is to keep food from getting darker in color as you cook it.

If you are looking for more advice on how to manage your PCOS, please give me a call and take advantage of my free 10-minute consult to see if I am a good fit for your needs. There are many nutritional options including some very helpful supplements your doctor may not be aware of.  I have seen good results in women of all ages - less unwanted hair, less acne, weight loss, and restoration of regular cycles - by following some relatively simple changes.

Diabetologia. 2016 Oct;59(10):2181-92.

Vitamin A - avoid or embrace during pregnancy?

Disclaimer:  The following is meant for use as general nutrition educational content only. A woman, pregnant, breastfeeding, or trying to conceive, is strongly advised to discuss her need for vitamin A, or any specific nutrient, with her obstetrical/gynecological care provider. This is not meant to replace the advice of an individual’s qualified healthcare provider.

I recently wrote an article about the inclusion of vitamin A from food and/or vitamins during pregnancy. I discussed the role of vitamin A in reproduction and development, the current recommendations from "authoritative" bodies, and what type of foods can supply an adequate amount. While it is somewhat lengthy, I would encourage all women (and men) anticipating a pregnancy or currently expecting to read it in its entirety. You can find it here: 

More on Gestational "Pre-diabetes"

A recently published study pointed to an increased risk of worse outcomes when a women has an elevated glucose response, even when it does not meet the diagnostic criteria for outright gestational diabetes. I have spoken about this in the past on the late Dr. Su's podcast (no longer available unfortunately).

According to the study's author: "there isn't a cutoff number for [gestational diabetes mellitus] testing that determined 'at risk' from 'not at risk,' there is likely a benefit to diet modification and exercise 'treatment', but this suggests that we need to do further studies to assess the best thresholds, or whether thresholds are not helpful at all."

Currently, women are diagnosed with gestational diabetes if two or more blood glucose measurements are above a "threshold" number during a 3-hour oral glucose tolerance test (95 mg/dL during fasting, 180 after hour one, 155 after hour two, and/or 140 after hour three). But research continues to suggest that glucose management is important for pregnant women even if they don't cross these threshold numbers.

According to Dr. Loralei Thornburg: "The biggest thing this study adds to existing research is that glucose intolerance isn't a 'yes-no' of having or not having diabetes. So, even with what is typically considered high normal testing (no gestational diabetes) patients were at higher risk for poor outcomes than someone with lower testing."

This is not meant to alarm but to inform you - if you think you could benefit from some guidance in understanding your own blood glucose numbers, please consider discussing with a licensed dietitian.





How can parents motivate teenagers to eat better?

I have a lot of first hand experience "motivating" my three teenage (now adult) children to eat better. As I have discussed in previous posts on this blog, it is a challenge that is at times very frustrating, but well worth the effort. Compromises will be needed in most cases, but in any case, dietary perfection is not the goal.

A recent study spoke to me, both on a personal and professional level. The study demonstrated how teenagers would respond best to appeals to vanity and other short term outcomes including increased optimism. I have witnessed this firsthand in my practice as teenagers often want to achieve a more "ideal" physique. However,  I am reluctant to encourage better eating as way to become more "attractive." That can become a slippery slope to disordered eating.

This study used daily text messages to prompt two groups of Italian students 14 to 19 years of age on the benefits of eating fruit and vegetables; one group was reminded about the appearance and attitude benefits; the other about the health benefits. The first group increased consumption of f&v to 5.5 servings/day, the second to 5.1; statistically meaningful differences as small as they seem. Long term health benefits provide little incentive for the majority of teens and certainly almost all children in the tweens or younger.  

Nothing wrong with encouraging more f&v. But if you really want to help your teen (or anyone) achieve optimal appearance and attitude, other foods could actually exert stronger positive effects. Foods rich in protein, collagen, vitamin A, zinc, biotin, choline, iron, and vitamins B6 & B12 can help increase muscle mass, improve skin and reduce acne, help hair and nails grow shiny and strong, improve neurotransmitter balance in the brain - leading to a more positive outlook, and even enhance athletic performance if a teen is deficient or has marginal intakes. These foods would be mostly animal foods: whole eggs, red meat, full fat dairy, chicken with skin!, and the all important liver.

Yeah - I know - your daughter wants to become a vegetarian or even a vegan, your son doesn't have time for breakfast so forget the eggs, and who eats liver anyway? I can help you overcome these challenges and help your teen understand how they can live up to their full potential, physically, mentally, and emotionally, by eating a diet that contains the full range of essential nutrients. 

You may be surprised that making liver tasty is actually not that hard. Take liver (I get mine at Standard Foods in Raleigh), "marinate" overnight in buttermilk. When ready to cook, drain and dredge in seasoned flour (can be gluten free baking mix also).  Cook 2 slices of bacon (I like Trader Joe's) per 4 oz serving of liver, remove from pan - pouring off and saving some of the bacon fat; then brown 1/2 medium sliced onion per serving and again remove from pan leaving some bacon fat behind. Cook liver at medium heat for 5-7 minutes per side, don't overcook or it will get tough. Serve topped with onions, bacon on the side, and lots of ketchup if needed!

You can also finely chop the liver (still half-frozen) and add about 1/4 lb to each 1 lb of ground meat in your meatloaf recipe, again with other seasonings to "disguise." Many moms have been "disguising" vegetables in recipes since Jessica Seinfeld popularized this technique. I preferred non-disclosure of egg yolks and liver when I could, and it usually was accepted. Whatever you do, just make sure if you have guests over that you let them know in case of food allergies.

Reporting on the study published in the British Journal of Health Psychology:  Ann Lukits, Wall Street Journal, Tuesday August 16, 2016.