Iron Deficiency Anemia:
Recommended Guidelines for the Prevention,
Detection, and Management Among U.S.
Children and Women of Childbearing Age
Committee on the Prevention, Detection, and
Management of Iron Deficiency Anemia Among
U.S. Children and Women of Childbearing Age
NATIONAL ACADEMY PRESS
Washington, D.C.
1993
National Academy Press 2101 Constitution Avenue, N.W. Washington, D.C. 20418
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.
The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine.
This study was supported under contract no. 200-92-0574 from the Division of Nutrition, Centers for Disease Control and Prevention, Public Health Service, U.S. Department of Health and Human Services.
Library of Congress Catalog Card No. 93-86771
International Standard Book Number 0-309-04987-3
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Copyright 1993 by the National Academy of Sciences. All rights reserved.
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COMMITTEE ON THE PREVENTION, DETECTION, AND MANAGEMENT OF IRON DEFICIENCY ANEMIA AMONG U.S. CHILDREN AND WOMEN OF CHILDBEARING AGE
DORIS H. CALLOWAY (Chair),*
Department of Nutrition, University of California, Berkeley, California
JOHN L. BEARD,
Nutrition Department and Department of Biobehavioral Health, College of Health and Human Development, The Pennsylvania State University, University Park, Pennsylvania
JAMES D. COOK,
Division of Hematology, University of Kansas Medical Center, Kansas City, Kansas
SAMUEL J. FOMON,
Department of Pediatrics, University of Iowa Hospitals, Iowa City, Iowa
JANET L. MITCHELL,
Department of Obstetrics and Gynecology, Harlem Hospital Center, New York, New York
DAVID RUSH,
Epidemiology Program, USDA Human Nutrition Research Center on Aging at Tufts University, Boston, Massachusetts
Consultants
GEORGE H. BEATON,
Department of Nutrition Science, University of Toronto, Toronto, Ontario, Canada
PETER R. DALLMAN, Contract Writer,
San Francisco, California
Staff
CATHERINE E. WOTEKI, Project Director
ROBERT EARL, Program Officer
MARCIA S. LEWIS, Project Assistant
MICHAEL K. HAYES, Editorial Consultant
FOOD AND NUTRITION BOARD
M.R.C. GREENWOOD (Chair),*
Office of Graduate Studies, University of California, Davis, California
EDWIN L. BIERMAN (Vice Chair),*
Division of Metabolism, Endocrinology, and Nutrition, University of Washington, Seattle, Washington
PERRY L. ADKISSON,†
Department of Entomology, Texas A&M University, College Station, Texas
LINDSAY ALLEN,
Department of Nutrition, University of California, Davis, California
DENNIS M. BIER,
Pediatric Clinical Research Center, Washington University School of Medicine, St. Louis, Missouri
HECTOR F. DeLUCA,†
Department of Biochemistry, University of Wisconsin, Madison, Wisconsin
MICHAEL P. DOYLE,
Department of Food Science and Technology, Georgia Experiment Station, University of Georgia, Griffin, Georgia
JOHANNA T. DWYER,
Frances Stern Nutrition Center, New England Medical Center Hospital, Boston, Massachusetts
JOHN W. ERDMAN, JR.,
Department of Food Science and Division of Nutritional Sciences, College of Agriculture, University of Illinois, Urbana, Illinois
CUTBERTO GARZA,
Division of Nutritional Sciences, Cornell University, Ithaca, New York
K. MICHAEL HAMBIDGE,
Department of Pediatrics, University of Colorado Medical Center, Denver, Colorado
JANET C. KING,
Department of Nutritional Sciences, University of California, Berkeley, California
JOHN E. KINSELLA (deceased),
School of Agriculture and Environmental Sciences, University of California, Davis, California
LAURENCE N. KOLONEL,
Cancer Center of Hawaii, University of Hawaii, Honolulu, Hawaii
SANFORD A. MILLER,
Graduate Studies and Biological Sciences, University of Texas Health Science Center, San Antonio, Texas
ARTHUR H. RUBENSTEIN (IOM Council Liaison),*
Department of Medicine, The University of Chicago, Chicago, Illinois
ALFRED SOMMER,*
School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Maryland
STEVE L. TAYLOR (ex officio),
Department of Food Science and Technology, University of Nebraska, Lincoln, Nebraska
VERNON R. YOUNG,†
School of Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
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Preface
Over the last decade, several expert groups have addressed the issue of iron deficiency anemia in young children and women of childbearing age. Dietary allowances have been revised, diagnostic criteria for defining anemia have been promulgated, and preventive and therapeutic measures have been developed and, for the most part, implemented. So, why another examination of the issue?
There are several reasons why a responsible agency would undertake such a reexamination. There are seemingly straightforward questions about the continued necessity for and effectiveness of existing programs. These questions are, however, complex and difficult to answer because the information base is not entirely secure. The answers to such problematic questions depend on a reasoned judgment as to the significance of new epidemiologic evidence and other scientific findings and on an ability to forecast trends. In the present instance account needs to be taken of, inter alia, trends in the consumption and composition of foods and changes in the nutritional environment more generally.
It is to be expected that committee members will not always be in perfect accord in the absence of sufficient, solid information. Members' judgments are influenced by their different experiences and disciplinary backgrounds. The present committee resolved this problem by accepting an argument that in order to set aside the recommendations of other expert groups, the contravening evidence must be as strong as the evidence that led to the others' decisions. The guidelines developed by the present committee are substantially in accord with existing recommendations. The committee did note areas of uncertainty and urges that high priority be given to developing the information needed to improve decision making. Some points are noted in the text, and an indicative list of research topics is included in the report.
The committee's work was assisted very greatly by the background documentation prepared by Dr. Peter Dallman in a consultative capacity; we
acknowledge his major contribution and appreciate the willingness with which he undertook revision as issues arose. Dr. Dallman participated in all deliberations of the committee as a member de facto. Professor George Beaton was available for consultation only at our last meeting; his ability to pose important clarifying questions was, as always, greatly appreciated. The committee owes a special debt to two of its members—to Professor John L. Beard for providing background on iron-dependent pathologies and to Dr. David Rush for a new analysis of data from the U.S. Department of Agriculture's Special Supplemental Food Program for Women, Infants, and Children and for solicitation of additional views and references relating to iron supplementation during pregnancy.
We wish particularly to thank Dr. Anne Looker and Dr. Christopher Sempos and their colleagues at the National Center for Health Statistics who prepared preliminary analyses of data from the third National Health and Nutrition Examination Survey and shared other, as yet unpublished, work.
I wish personally to thank the committee members for their diligence and patience, and for the care and concern they showed for those whom the guidelines are intended to benefit. None of the committee's tasks could have been accomplished without the leadership of Dr. Catherine Woteki and the support of her staff, especially Mr. Robert Earl and Ms. Marcia Lewis. We are grateful for their unfailing courtesy and generosity and commend the high standards reflected in their professional contributions.
DORIS HOWES CALLOWAY, CHAIR
COMMITTEE ON THE PREVENTION, DETECTION, AND MANAGEMENT OF IRON DEFICIENCY ANEMIA AMONG U.S. CHILDREN AND WOMEN OF CHILDBEARING AGE
Contents
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