Iron status in 268 Danish women aged 18-30 years: influence of menstruation, contraceptive method, and iron supplementation

Diagnosing anemia: Challenges selecting methods, addressing underlying causes, and implementing actions at the public health level

Accurate and affordable tools for diagnosing anemia and its main determinants are essential for understanding the magnitude and distribution of the problem and the appropriate interventions needed for its timely prevention and treatment. The objective of this review is to address methods, equipment, and sample-related and quality control aspects of hemoglobin measurement for anemia diagnosis. Also, other iron-, infectious-, and genetic-related causes of anemia are addressed in individuals and populations. The best practice for hemoglobin determination is the use of venous blood, analyzed on automated hematology analyzers, with high-quality control measures in place. The importance of a correct anemia diagnosis is highlighted by the cost of a misdiagnosis. A false-negative diagnosis may result in missing out and not treating anemia, its causes, and its adverse effects. On the other hand, a false-positive diagnosis may result in the provision of unneeded treatment or referral for expensive laboratory tests to determine a cause of anemia, wasting valuable resources and risking causing harm. At the individual level, clinicians must understand the causes of absolute and functional anemia to diagnose and treat anemia at the clinical level. Actions toward anemia diagnosis and control at public health levels require global, regional, and country actions that should cover general and context-specific characteristics.

Iron-Containing Oral Contraceptives and Their Effect on Hemoglobin and Biomarkers of Iron Status: A Narrative Review

Oral contraceptive use has been associated with decreased menstrual blood losses; thus, can independently reduce the risk of anemia and iron deficiency in women. Manufacturers have recently started to include supplemental iron in the non-hormonal placebo tablets of some contraceptives. The aims of this narrative review are: (i) to describe the relationship between oral contraceptive use and both anemia and iron status in women; (ii) to describe the current formulations of iron-containing oral contraceptives (ICOC) available on the market; and (iii) to systematically review the existing literature on the effect of ICOC on biomarkers of anemia and iron status in women. We discovered 21 brands of ICOC, most commonly including 25 mg elemental iron as ferrous fumarate, for seven days, per monthly tablet package. Our search identified one randomized trial evaluating the effectiveness of ICOC use compared to two non-ICOC on increasing hemoglobin (Hb) and iron status biomarker concentrations in women; whereafter 12 months of contraception use, there were no significant differences in Hb concentration nor markers of iron status between the groups. ICOC has the potential to be a cost-effective solution to address both family planning needs and iron deficiency anemia. Yet, more rigorous trials evaluating the effectiveness of ICOC on improving markers of anemia and iron deficiency, as well as investigating the safety of its consumption among iron-replete populations, are warranted.

Iron status in mid-pregnancy and associations with interpregnancy interval, hormonal contraceptives, dietary factors and supplement use

Adequate iron supply in pregnancy is important for both the woman and the fetus, but iron status is often assessed late in first trimester, if assessed at all. Therefore, identification of factors associated with iron status is important to target vulnerable groups with increased risk of deficiency. Our objectives were to (1) describe iron status in mid-pregnancy and (2) identify sociodemographic and lifestyle predictors of pregnancy iron status. This cross-sectional study uses data from The Norwegian Mother, Father and Child Cohort Study (collected 2002-2008) and The Medical Birth Registry of Norway. Iron status was measured as non-fasting plasma ferritin (P-Fe) and transferrin in gestational week (GW) 18 (n 2990), and by lowest reported Hb in GW 0-30 (n 39 322). We explored predictors of iron status with elastic net, linear and log-binomial regression models. Median P-Fe was 33 μg/l, and 14 % had depleted iron stores (P-Fe <15 μg/l). P-Fe below 30 μg/l was associated with reduced Hb. We identified eleven predictors, with interpregnancy interval (IPI) and parity among the most important. Depleted iron stores was more common among women with IPI < 6 months (56 %) and 6-11 months (33 %) than among those with IPI 24-59 months (19 %) and among nulliparous women (5 %). Positively associated factors with iron status included hormonal contraceptives, age, BMI, smoking, meat consumption and multi-supplement use. Our results highlight the importance of ferritin measurements in women of childbearing age, especially among women not using hormonal contraceptives and women with previous and recent childbirths.

Iron Therapeutics in Women's Health: Past, Present, and Future

Iron plays a unique physiological role in the maintenance of homeostasis and the pathological outcomes of the female reproductive tract. The dual nature of elemental iron has created an evolutionary need to tightly regulate its biological concentration. The female reproductive tract is particularly unique due to the constant cycle of endometrial growth and shedding, in addition to the potential need for iron transfer to a developing fetus. Here, iron regulation is explored in a number of physiologic states including the endometrial lining and placenta. While iron dysregulation is a common characteristic in many women's health pathologies there is currently a lack of targeted therapeutic options. Traditional iron therapies, including iron replacement and chelation, are common treatment options for gynecological diseases but pose long term negative health consequences; therefore, more targeted interventions directed towards iron regulation have been proposed. Recent findings show potential benefits in a therapeutic focus on ferritin-hepcidin regulation, modulation of reactive oxygen species (ROS), and iron mediated cell death (ferroptosis). These novel therapeutics are the direct result of previous research in iron's complex signaling pathway and show promise for improved therapy, diagnosis, and prognosis in women's health.

Haemoglobin, iron status and lung function of adolescents participating in organised sports in the Finnish Health Promoting Sports Club Study

Objectives

To compare laboratory test results and lung function of adolescent organised sports participants (SP) with non-participants (NP).

Methods

In this cross-sectional study, laboratory tests (haemoglobin, iron status), and flow-volume spirometry were performed on SP youths (199 boys, 203 girls) and their NP peers (62 boys, 114 girls) aged 14–17.

Results

Haemoglobin concentration <120/130 g/L was found in 5.8% of SP and 5.1% NP (OR 1.20, 95% CI 0.54 to 2.68). Ferritin concentration below 15 µg/L was found in 22.7% of both SP and NP girls. Among boys ferritin <30 µg/L was found in 26.5% of SP and 30.2% of NP (OR 0.76, 95% CI 0.40 to 1.47). Among SP iron supplement use was reported by 3.5% of girls and 1.5% of boys. In flow-volume spirometry with bronchodilation test, 7.0% of SP and 6.4% of NP had asthma-like findings (OR 1.17, 95% CI 0.54 to 2.54); those using asthma medication, that is, 9.8% of SP and 5.2% of NP were excluded from the analysis.

Conclusions

Screening for iron deficiency is recommended for symptomatic persons and persons engaging in sports. Lung function testing is recommended for symptomatic persons and persons participating in sports in which asthma is more prevalent.

Anemia epidemiology, pathophysiology, and etiology in low- and middle-income countries

Anemia affects a third of the world's population and contributes to increased morbidity and mortality, decreased work productivity, and impaired neurological development. Understanding anemia's varied and complex etiology is crucial for developing effective interventions that address the context-specific causes of anemia and for monitoring anemia control programs. We outline definitions and classifications of anemia, describe the biological mechanisms through which anemia develops, and review the variety of conditions that contribute to anemia development. We emphasize the risk factors most prevalent in low- and middle-income countries, including nutritional deficiencies, infection/inflammation, and genetic hemoglobin disorders. Recent work has furthered our understanding of anemia's complex etiology, including the proportion of anemia caused by iron deficiency (ID) and the role of inflammation and infection. Accumulating evidence indicates that the proportion of anemia due to ID differs by population group, geographical setting, infectious disease burden, and the prevalence of other anemia causes. Further research is needed to explore the role of additional nutritional deficiencies, the contribution of infectious and chronic disease, as well as the importance of genetic hemoglobin disorders in certain populations.

Role of Gender in Regulation of Redox Homeostasis in Pulmonary Arterial Hypertension

Pulmonary arterial hypertension (PAH) is one of the diseases with a well-established gender dimorphism. The prevalence of PAH is increased in females with a ratio of 4:1, while poor survival prognosis is associated with the male gender. Nevertheless, the specific contribution of gender in disease development and progression is unclear due to the complex nature of the PAH. Oxidative and nitrosative stresses are important contributors in PAH pathogenesis; however, the role of gender in redox homeostasis has been understudied. This review is aimed to overview the possible sex-specific mechanisms responsible for the regulation of the balance between oxidants and antioxidants in relation to PAH pathobiology.

Duplicate portion sampling gives the most accurate iron intake estimate: Implications for iron status of female students

Iron deficiency (ID) is one of the most common nutritional problems in the developing world, affecting primarily women of childbearing age. Poor dietary iron intake is a major reason of ID. Accurate measurement of iron intake is of crucial importance to combat the problem. The daily dietary iron intake of 67 female students aged between 20-30 years (a mean BMI of 21.8±3.4 kg/m²) was evaluated using three assessment methods: atomic absorption spectrometry of 3-day food duplicate samples, and food composition tables (FCTs) in combination with either food frequency questionnaire (FFQ) or dietary records. Iron status was examined using hematological and biochemical tests. The dietary iron intake determined by duplicate portion sampling (DPS; 4.12±1.84 mg/day) was significantly lower than the FCT-based estimates (P<0.001), and it was less than ¼ of the recommended dietary allowance of 18 mg/day. No significant correlation was found between DPS technique and FCT-based assessment methods. Fifty percent of the participants had small or depleted iron stores (serum ferritin< 30 ng/mL), but only 4.5% had ID anemia (serum ferritin< 12 ng/mL and hemoglobin<12 g/dL). Dietary iron intakes and FFQ-based intakes of vitamin C were not significantly correlated with all the investigated hematological parameters. In order to take some steps toward more practical approaches to combat this health problem, development of an accurate iron intake assessment seems to be the first priority. In this regard, improvement and validation of national FCTs would be a promising solution.

Iron status at opposite ends of the menstrual function spectrum

OBJECTIVES

Although exercising women are at high risk of poor iron status, it is unknown how non-pathological, physiological menstrual function affects iron status. As such, this study investigates the association between menstrual function and iron status in exercising women with amenorrhea and exercising women with ovulatory, eumenorrheic menstrual cycles.

DESIGN

Cross-sectional analysis of iron depletion prevalence, iron status indices, exercise parameters, and diet composition.

METHODS

Women aged 18-35 years performing at least 2 h per week of aerobic exercise were recruited. Women with amenorrhea (AMEN) were defined by the absence of menses for at least 90 days or less than 6 menses in the past 12 months (n = 82). Women with ovulatory, eumenorrheic menstrual cycles (OvEU) were defined by the presence of ovulatory cycles of 26-35 days in length for the past 6 months (n = 109). Group differences in serum ferritin (Ft), soluble transferrin receptor (sTfR), total body iron (TBI), hemoglobin (Hb), hematocrit (Hct), iron depletion prevalence (Ft <15 μg/L), peak oxygen consumption (VO_2peak), exercise minutes per week, and diet logs were assessed.

RESULTS

The prevalence of iron depletion was greater in OvEU when compared to AMEN (26% vs. 15%, p = 0.04). No significant differences were observed between AMEN and OvEU in Ft (30.2 ± 2.2 vs. 24.9 ± 2.6 μg/L; p = 0.62), sTfR (5.2 ± 1.4 vs. 4.9 ± 1.5 mg/L; p = 0.95), TBI (5.3 ± 2.7 vs. 4.8 ± 3.7 mg/kg; p = 0.42), Hb (13.2 ± 0.4 vs. 13.4 ± 0.6 g/dL; p = 0.80), Hct (39.5 ± 0.8% vs. 39.8 ± 4.1%; p = 0.93), or exercise parameters. AMEN consumed more vitamin C than OvEU (269 ± 180 vs. 129 ± 141 mg/day, p < 0.001), but all other dietary factors were similar between AMEN and OvEU.

CONCLUSION

Exercising women with ovulatory, eumenorrheic cycles are at a greater risk of iron depletion than exercising, amenorrheic women. Thus, menstrual function must be considered when screening for poor iron status in exercising women.

Reference values for serum ferritin and percentage of transferrin saturation in Korean children and adolescents

Background

Ferritin reference values vary by age, gender, and ethnicity. We aimed to determine reference values of serum ferritin (SF) and the percentage of transferrin saturation (TSAT) for Korean children and adolescents.

Methods

We analyzed data from 2,487 participants (1,311 males and 1,176 females) aged 10-20 years from the Korea National Health and Nutrition Examination Survey (2010-2012). We calculated age- and gender-stratified means and percentile values for SF and TSAT.

Results

We first plotted mean SF and TSAT by gender and according to age. In males, mean SF tended to be relatively constant among participants aged 10 to 14 years, with an upward trend thereafter. Mean SF trended downward among female participants until the age of 15 years and remained constant thereafter. Thus, significant gender differences in ferritin exist from the age of 14 years. High levels of SF were associated with obesity, and lower SF levels were associated with anemia and menarche status.

Conclusion

We established reference values of SF and TSAT according to age and gender. The reference values for SF calculated in this study can be used to test the association between SF values and other defined diseases in Korean children and adolescents.

Association between Haem and Non-Haem Iron Intake and Serum Ferritin in Healthy Young Women

Iron is an essential micronutrient for human health and inadequate intake may result in iron deficiency (ID) or iron deficiency anaemia (IDA). Unlike other recent studies investigating iron status in young women, this cross-sectional study analysed dietary intake and biochemical data from healthy young (18-35 years) women (n = 299) to determine the association between both haem iron (HI) and non-haem iron (NHI) intakes and serum ferritin (SF). Dietary restraint and possible inflammation secondary to obesity were also measured and accounted for, and energy intake was adjusted for using the residuals method. Independent samples t-tests and chi-squared tests were performed, and factors found to be significantly different between iron replete (IR) and ID/IDA participants were analysed using general linear modelling. ID/IDA participants consumed significantly lower total energy than iron replete (IR) (p = 0.003). Lower energy intake was also associated with higher levels of dietary restraint (p = 0.001). Both HI and NHI were positively associated with SF with HI was found to be a stronger predictor (β = 0.128, p = 0.009) than NHI (β = 0.037, p = 0.028). The study demonstrates that intake of both HI and NHI, as well as adequate dietary energy, are associated with normal iron status levels in young women, and that restrained eaters may be at greater risk of low iron status.

Effect of oral contraception on anemia in 12 low- and middle-income countries

CONTEXT

In low- and middle-income countries, anemia is a major public health issue in women of reproductive age for a series of factors including iron deficiency.

OBJECTIVE

To estimate prevalence of anemia and to assess the association of low level of hemoglobin versus duration of use of oral contraceptives (OC).

METHODS

Demographic and Health Surveys of 12 countries, conducted between 2005 and 2012, were analyzed. The status of anemia was separately evaluated for nonpregnant women using OC for at least 6 months, 1 year and 2 years, and for women using no method of contraception and/or using nonhormonal contraception.

RESULTS

The total study population comprised 201,720 women, with 40% diagnosed with anemia; around 1 out of 25 women was using oral contraception. The current and continuous use of oral contraception was of benefit against anemia, with the risk for anemia decreasing from odds ratio (OR) 0.68 [95% confidence interval (CI) 0.64-0.73] for use of at least 6 months to OR 0.56 (95% CI 0.52-0.61) for use of at least 1 year and to OR 0.50 (95% CI 0.46-0.54) for use of at least 2 years.

CONCLUSIONS

Findings reinforce evidence of the noncontraceptive benefit of long-term use of OC and provide valuable information for policy makers, family planning staff and clinicians working in low- and middle-income countries in efforts to control anemia.

Interaction of iron status with single nucleotide polymorphisms on incidence of type 2 diabetes

The objective of this study is to find single nucleotide polymorphisms (SNPs) associated with a risk of Type 2 diabetes (T2D) in Korean adults and to investigate the longitudinal association between these SNPs and T2D and the interaction effects of iron intake and average hemoglobin level. Data from the KoGES_Ansan and Ansung Study were used. Gene-iron interaction analysis was conducted using a two-step approach. To select candidate SNPs associated with T2D, a total of 7,935 adults at baseline were included in genome-wide association analysis (step one). After excluding T2D prevalent cases, prospective analyses were conducted with 7,024 adults aged 40–69 (step two). The association of selected SNPs and iron status with T2D and their interaction were determined using a Cox proportional hazard model. A total of 3 SNPs [rs9465871 (CDKAL1), rs10761745 (JMJD1C), and rs163177 (KCNQ1)] were selected as candidate SNPs related to T2D. Among them, rs10761745 (JMJD1C) and rs163177 (KCNQ1) were prospectively associated with T2D. High iron intake was also prospectively associated with the risk of T2D after adjusting for covariates. Average hemoglobin level was positively associated with T2D after adjusting for covariates in women. We also found significant interaction effects between rs10761745 (JMJD1C) and average hemoglobin levels on the risk of T2D among women with normal inflammation and without anemia at baseline. In conclusion, KCNQ1 and JMJD1C may prospectively contribute to the risk of T2D incidence among adults over the age of 40 and JMJD1C, but CDKAL1 may not, and iron status may interactively contribute to T2D incidence in women.

The reproductive ecology of iron in women

Reproductive ecology focuses on the sensitivity of human reproduction to environmental variation. While reproductive ecology has historically focused on the relationship between energy status and reproductive outcomes, iron status is equally critical to women's reproductive health, given the wide-ranging detrimental effects of iron-deficiency anemia on maternal and infant well-being. This review interprets the vast literature on iron status and women's reproduction through an evolutionary framework. First, it will critique the evidence for iron deficiency caused by blood loss during menstruation, reinterpreting the available data as ecological variation in menses within and between populations of women. Second, it will highlight the scant but growing evidence that iron status is implicated in fertility, a relationship that has deep evolutionary roots. Third, this review proposes a new hypothesis for the transfer of iron from mother to infant via pregnancy and breastfeeding: reproductive iron withholding. In this hypothesis, mothers transfer iron to infants in a manner that helps infants avoid iron-mediated infection and oxidative stress, but trades off with potential risk of maternal and infant iron deficiency. Finally, this review explores two main factors that can modify the relationship between iron status and the gestation-lactation cycle: (1) the relationship between long-term reproductive effort (parity) and iron status and (2) supplementation schemes before and during pregnancy. The review concludes by suggesting continued research into iron homeostasis in women using evolutionary, ecological, and biocultural frameworks.

Maternal Iron Status in Pregnancy and Long-Term Health Outcomes in the Offspring

Iron is an essential micronutrient and is important not only in carrying oxygen but also to the catalytic activity of a variety of enzymes. In the fetus, it is vital to the synthesis of hemoglobin and in brain development. Iron deficiency (ID) anemia in pregnancy is a common problem, even in high-income country settings. Around 50% of pregnant women worldwide are anemic, with at least half of this burden due to ID. Iron supplements are widely recommended and used during pregnancy globally. However, the evidence on the extent of benefit they contribute to the offspring's health is not well established, and their routine use has its side effects and drawbacks. Dietary iron intake is difficult to assess accurately and it is unlikely to be sufficient to meet the demands of pregnancy if women start with inadequate body iron stores at conception. Evidence from experimental animal models suggests that maternal ID during pregnancy is associated with fetal growth restriction, as well as offspring obesity and high blood pressure later in life. The possible biological mechanisms for this observed association may be due to ID-induced changes in placental structure and function, enzyme expression, nutrient absorption, and fetal organ development. However, such evidence is limited in human studies. Prenatal ID in experimental animal models also adversely affected the developing brain structures, neurotransmitter systems, and myelination resulting in acute brain dysfunction during the period of deficiency and persistence of various postnatal neurobehavioral abnormalities as well as persistent dysregulation of some genes into adult life after iron repletion pointing to the possibility of gene expression changes. The evidence from human population studies is limited and heterogeneous and more research is needed in the future, investigating the effects of ID in pregnancy on future offspring health outcomes.

Extended and Continuous Use of Hormonal Contraceptives to Reduce Menstruation

During the use of long-cycle regimens of monophasic oral contraceptives, the total number of bleeding and cycle-dependent complaints is considerably lower than during conventional treatment with oral contraceptives. Despite an initially higher rate of irregular bleeding, the majority of women prefer the long-cycle treatment since it may improve quality of life. As this regimen provides an enhanced ovarian suppression, it may prevent pregnancies, especially in noncompliant women or patients who are concomitantly treated with drugs that may impair the efficacy of oral contraceptives. Postponement or suppression of withdrawal bleeding also reduces menses-associated disorders such as menorrhagia and dysmenorrhea, and has beneficial effects in patients with hemorrhagic diathesis, endometriosis, uterine leiomyomas and polycystic ovary syndrome. Long-term studies are necessary to assess the impact of long-term use of extended regimens of oral contraceptives on safety, for example, the risk of cancer and cardiovascular disease, and on fertility after discontinuation of treatment.

Fertility Cycle Patterns in Motives for Sexual Behavior

Three studies examined the relationship between fertility, as indexed by day in cycle or salivary estradiol levels, and reported motives for sexual intercourse. Data from university and community samples in both cross-sectional and repeated-measures designs showed that sex-for-intimacy motives are endorsed significantly less by women who are relatively more fertile or show higher salivary estrogen levels. Sex for enhancement, self-affirmation, and partner approval also declined, although the data were less consistent. The remaining motives (coping and power) showed no consistent patterns across fertility status. Results suggest that sexual motives are rooted partly in woman's biology and are discussed in terms of plausible evolutionary mechanisms that might promote female “choosiness” at midcycle.

Joint Model of Iron and Hepcidin During the Menstrual Cycle in Healthy Women

Hepcidin regulates serum iron levels, and its dosage is used in differential diagnostic of iron-related pathologies. We used the data collected in the HEPMEN (named after HEPcidin during MENses) study to investigate the joint dynamics of serum hepcidin and iron during the menstrual cycle in healthy women. Ninety menstruating women were recruited after a screening visit. Six fasting blood samples for determination of iron-status variables were taken in the morning throughout the cycle, starting on the second day of the period. Non-linear mixed effect models were used to describe the evolution of iron and hepcidin. Demographic and medical covariates were tested for their effect on model parameters. Parameter estimation was performed using the SAEM algorithm implemented in the Monolix software. A general pattern was observed for both hepcidin and iron, consisting of an initial decrease during menstruation, followed by a rebound and stabilising during the second half of the cycle. We developed a joint model including a menstruation-induced decrease of both molecules at the beginning of the menses and a rebound effect after menses. Iron stimulated the release of hepcidin. Several covariates, including contraception, amount of blood loss and ferritin, were found to influence the parameters. The joint model of iron and hepcidin was able to describe the fluctuations induced by blood loss from menstruation in healthy non-menopausal women and the subsequent regulation. The HEPMEN study showed fluctuations of iron-status variables during the menstrual cycle, which should be considered when using hepcidin measurements for diagnostic purposes in women of child-bearing potential.

Changes in the choroidal thickness in reproductive-aged women with iron-deficiency anemia

BACKGROUND

The aim of this study was to investigate the potential significance of the central macular thickness (foveal thickness-FT) and choroidal thickness (CT) in the eyes of patients with iron-deficiency anemia, the most common form of the anemia, via enhanced-depth imaging optical coherence tomography (EDI-OCT). We also investigated whether such changes might serve as an early indicator of underlying hematological disease.

METHODS

This prospective clinical study compared 96 female patients with iron-deficiency anemia and 60 healthy female control subjects. The macular and choroidal thicknesses in the temporal and nasal subfoveal areas were measured using enhanced-depth imaging optical coherence tomography (EDI-OCT) at 500 and 1500 microns and in five different regions (FCT, T1500, T500, N500, and N1500).

RESULTS

The mean ages of the patients and healthy controls were 34.08 ± 10.39 years and 32.29 ± 8.28 years, respectively (P =0.232). There were no significant changes in macular thickness between the groups (225.58 ± 19.76 vs. 222.45 ± 13.51, P =0.2). The choroidal thickness was significantly reduced in the patient group relative to the controls at all measured points (foveal choroidal thickness, P = 0.042; nasal-500 microns, P = 0.033; temporal-500 microns, P = 0.033; and temporal-1500 microns, P = 0.019). At some points, the choroidal thickness findings correlated with the hemoglobin values (temporal-500 microns, r = -0.287, P = 0.001; nasal-500 microns, r = -0.287, P = 0.005; nasal-1500 microns, r = -0.245, P = 0.016; and temporal-1500 microns, r = -0.280, P = 0.06).

CONCLUSIONS

Patients with iron-deficiency anemia had a significantly reduced choroidal thickness.

Hemisphere, gender and age-related effects on iron deposition in deep gray matter revealed by quantitative susceptibility mapping

The purpose of this work was to investigate the effects of hemispheric location, gender and age on susceptibility value, as well as the association between susceptibility value and diffusional metrics, in deep gray matter. Iron content was estimated in vivo using quantitative susceptibility mapping. Microstructure was probed using diffusional kurtosis imaging. Regional susceptibility and diffusional metrics were measured for the putamen, caudate nucleus, globus pallidus, thalamus, substantia nigra and red nucleus in 42 healthy adults (age range 25-78 years). Susceptibility value was significantly higher in the left than the right side of the caudate nucleus (P = 0.043) and substantia nigra (P < 0.001). Women exhibited lower susceptibility values than men in the thalamus (P < 0.001) and red nucleus (P = 0.032). Significant age-related increases of susceptibility were observed in the putamen (P < 0.001), red nucleus (P < 0.001), substantia nigra (P = 0.004), caudate nucleus (P < 0.001) and globus pallidus (P = 0.017). The putamen exhibited the highest rate of iron accumulation with aging (slope of linear regression = 0.73 × 10(-3) ppm/year), which was nearly twice those in substantia nigra (slope = 0.40 × 10(-3) ppm/year) and caudate nucleus (slope = 0.39 × 10(-3) ppm/year). Significant positive correlations between the susceptibility value and diffusion measurements were observed for fractional anisotropy (P = 0.045) and mean kurtosis (P = 0.048) in the putamen without controlling for age. Neither correlation was significant after controlling for age. Hemisphere, gender and age-related differences in iron measurements were observed in deep gray matter. Notably, the putamen exhibited the highest rate of increase in susceptibility with aging. Correlations between susceptibility value and microstructural measurements were inconclusive. These findings could provide new clues for unveiling mechanisms underlying iron-related neurodegenerative diseases.

Association between oral contraceptive use and markers of iron deficiency in a cross-sectional study of Tanzanian women

OBJECTIVE

To analyze the associations between oral contraceptive (OC) use and markers of iron deficiency, objectively measured using hemoglobin and soluble transferrin receptor.

METHODS

A secondary data analysis was performed of a population-based cross-sectional study using data from the 2010 Tanzania Demographic and Health Survey. Weighted percentages were calculated. Multivariable logistic regression was used to examine the associations between OC use and iron deficiency, anemia, and iron deficiency anemia.

RESULTS

Of the 4336 participants, only 7.3% reported a history of OC use. The prevalence rates of iron deficiency, anemia, and iron deficiency anemia were 30.3%, 40.9%, and 15.1%, respectively. Use of OCs was negatively associated with anemia and iron deficiency anemia, independent of potential confounders. Compared with OC nonusers, the multivariable-adjusted odds ratio among OC users was 0.44 (95% confidence interval 0.32-0.59; P<0.001) for anemia and 0.43 (95% confidence interval 0.27-0.68; P<0.001) for iron deficiency anemia. A longer duration of OC use was negatively associated with iron deficiency (P=0.003 for trend), anemia (P<0.001 for trend), and iron deficiency anemia (P<0.001 for trend).

CONCLUSION

The significant association between OC use and iron status has important implications for educating healthcare providers and women about additional nutritional benefits of the use of OCs.

Risk factors for deferral due to low hematocrit and iron depletion among prospective blood donors in a Brazilian center

Objective

Deferral of blood donors due to low hematocrit and iron depletion is commonly reported in blood banks worldwide. This study evaluated the risk factors for low hematocrit and iron depletion among prospective blood donors in a large Brazilian blood center.

Method

A case–control study of 400 deferred donors due to low hematocrit and 456 eligible whole blood donors was conducted between 2009 and 2011. Participants were interviewed about selected risk factors for anemia, and additional laboratory tests, including serum ferritin, were performed. Bivariate and multivariate analyses were performed to assess the association between predictors and deferral due to low hematocrit in the studied population and iron depletion in women.

Results

Donors taking aspirins or iron supplementation, those who reported stomachache, black tarry stools or hematochezia, and women having more than one menstrual period/month were more likely to be deferred. Risk factors for iron depletion were repeat donation and being deferred at the hematocrit screening. Smoking and lack of menstruation were protective against iron depletion.

Conclusion

This study found some unusual risk factors related to gastrointestinal losses that were associated with deferral of donors due to low hematocrit. Knowledge of the risk factors can help blood banks design algorithms to improve donor notification and referral.

Iron status and reproduction in US women: National Health and Nutrition Examination Survey, 1999-2006

Women experience significant changes in iron status throughout their reproductive lifespans. While this is evident in regions with high rates of malnutrition and infectious disease, the extent of reproductive-related changes is less well known in countries with low rates of iron deficiency anemia, such as the United States. The goal of this study is determine the relationship between women's reproductive variables (pregnancy, parity, currently breastfeeding, regular menstruation, hormonal contraceptive use, and age at menarche) and iron status (hemoglobin, ferritin, transferrin receptor, and % transferrin saturation) using an anthropological framework for interpreting the results. Data from women aged 18-49 were taken from the 1999-2006 US NHANES, a nationally representative cross-sectional sample of US women. Using multiple imputation and complex survey statistics, women's reproductive variables were regressed against indicators of iron status. Pregnant women had significantly poorer iron status, by most indicators, than non-pregnant women. All biomarkers demonstrated significantly lower iron levels with increasing parity. Women who were having regular periods had iron indicators that suggested decreased iron levels, while women who used hormonal contraceptives had iron indicators that suggested increased iron levels. Despite relatively good iron status and widespread availability of iron-rich foods in the US, women still exhibit patterns of iron depletion across several reproductive variables of interest. These results contribute to an ecological approach to iron status that seeks to understand variation in iron status, with the hopes that appropriate, population-specific recommendations can be developed to improve women's health.

A simple and feasible questionnaire to estimate menstrual blood loss: relationship with hematological and gynecological parameters in young women

Background

Menstrual blood loss (MBL) has been shown to be an important determinant in iron status, work performance and well-being. Several methods have been developed to estimate MBL, the standard quantitative method however has limited application in clinical practice as it is expensive and requires women to collect, store and submit their sanitary products for analysis. We therefore aimed to develop a MBL-score based on a questionnaire, and to validate it by several hematological and biochemical parameters in women of childbearing age.

Methods

A total of 165 healthy young women were recruited. Hematological (hematocrit, hemoglobin, erythrocyte, leucocyte and platelet counts) and iron status (serum iron, serum ferritin, serum transferrin, and total iron binding capacity) parameters were analyzed at baseline. Women were asked to fulfill two gynecological questionnaires: a general questionnaire, to inform about the volunteer’s general menstrual characteristics; and a MBL questionnaire, to provide details of the duration of menstruation, number of heavy blood loss days, and number and type of pads and/or tampons used during the heaviest bleeding day, for all consecutive menstrual periods during 16 weeks. A MBL-score was calculated for each period and women, and its reliability determined by the Cronbach’s alpha coefficient. Pearson’s linear correlation tests were performed between blood parameters and the MBL-score. Two clusters were formed according the MBL-score (cluster 1: low MBL and cluster 2: high MBL).

Results

Significant higher MBL-score was observed in women who reported having a history of anemia (p = 0.015), staining the bed at night during menstruation (p < 0.001) and suffering inter-menstrual blood loss (p = 0.044), compared to those who did not. Women who used hormonal contraceptives presented lower MBL-scores than the others (p = 0.004). The MBL-score was negatively associated with log-ferritin (p = 0.006) and platelet count (p = 0.011). Women in cluster 1 presented higher ferritin (p = 0.043) than women in cluster 2.

Conclusions

We developed an easy and practical method for estimating menstrual blood loss based on a score calculated from a questionnaire in healthy women at childbearing age. The MBL-score is highly reliable and reflects menstrual blood loss validated by hematological and biochemical parameters.

Impact of a new levonorgestrel intrauterine system, Levosert(®), on heavy menstrual bleeding: results of a one-year randomised controlled trial

Objective

To evaluate a new levonorgestrel-releasing intrauterine system (LNG-IUS) called Levosert^® for the treatment of heavy menstrual bleeding (HMB) in comparison to the reference product Mirena^®.

Methods

A multicentre, randomised, controlled trial, in non-menopausal women diagnosed with functional HMB (defined as menstrual blood loss [MBL] ≥ 80 mL) randomised to either Levosert^® or Mirena^® and followed for up to one year. MBL was evaluated using a validated modified version of the Wyatt pictogram.

Results

A total of 280 women were randomised (141 to Levosert^® and 139 to Mirena^®). During the one-year treatment period, both Levosert^® and Mirena^® dramatically decreased MBL and increased haemoglobin and ferritin levels. There were no statistically significant differences between Levosert^® and Mirena^® regarding any of the parameters evaluated during the study. Similar bleeding patterns were observed in both groups. Levosert^® was inserted with the same ease as Mirena^®. Both treatments were associated with identical expulsion rates and no perforations occurred in either treatment group.

Conclusion

Levosert^®, a new LNG-IUS designed to release the same daily amount of LNG as Mirena^®, is highly effective in the treatment of HMB. No differences were observed between Levosert^® and Mirena^® regarding all evaluated outcomes, including safety profile.

Iron status and dietary iron intake of female blood donors

BACKGROUND

The aim was to assess iron status and dietary iron intake in a sample of premenopausal female regular and new blood donors.

STUDY DESIGN AND METHODS

Premenopausal women blood donors were invited to participate. Blood samples were analyzed for serum ferritin and hemoglobin. An iron checklist assessed dietary iron intake. Donors were classified as regular donors or new donors.

RESULTS

Twenty-one new donors (mean [SD] age, 28.6 [6.0] years; body mass index [BMI], 25.6 [4.5] kg/m(2) ) and 172 regular donors (mean age, 29.4 [5.5] years; BMI, 24.7 [3.8] kg/m(2) ) participated. Fifty percent of regular donors and 24% of new donors had depleted iron stores (serum ferritin <15 μg/L; difference p = 0.036). Dietary iron intake was higher in regular donors (mean [SE], 12.6 [0.7] mg/day) compared to new donors (9.9 [0.4] mg/day; p = 0.006). Eighty-five percent of regular donors and 79% of new donors met the estimated average requirement for iron.

CONCLUSIONS

Despite the fact that most of these donors had an adequate dietary iron intake, more than half of the blood donors had depleted iron stores. Increasing dietary iron intake through supplements and/or dietary means is expected to be necessary to maintain adequate iron status in this group.

Psychobehavioral Effects of Hormonal Contraceptive Use

Although female use of hormonal contraceptives (HCs) has been associated with a variety of physical side effects, the psychological and behavioral side effects have received comparatively little attention until recently. Indeed, the long-term impact of HC use on human psychology has been vastly under-researched and has only recently become a focus for mainstream scholars. Women who use HCs report higher rates of depression, reduced sexual functioning, and higher interest in short-term sexual relationships compared to their naturally-cycling counterparts. Also, HC use may alter women's ability to attract a mate, as well as the mate retention behaviors in both users and their romantic partners. Some evidence even suggests that HC use alters mate choice and may negatively affect sexual satisfaction in parous women, with potential effects on future offspring. Interestingly, HCs have become a standard method of population control for captive nonhuman primates, opening up exciting avenues for potential comparative research. Here, the existing literature on the psychobehavioral effects of HCs in humans and nonhuman primates is reviewed and discussed. The potential resulting downstream consequences for the path of human evolution and recommendations for how future research could tease apart the underlying causes of these psychobehavioral effects of HC use are discussed, including suggestions for research involving nonhuman primates.

Effect of increasing hemoglobin cutoff in male donors and increasing interdonation interval in whole blood donors at a hospital-based blood donor center

BACKGROUND

The NHANES-III survey found hemoglobin (Hb) concentrations of more than 13.5 g/dL and more than 12.0 g/dL in normal Caucasian males and females. In the United States, a Hb of least 12.5 g/dL is required for blood donation, which allows "anemic" males to donate while excluding "normal" females. Low Hb is the major cause of deferral in donors and deferrals are associated with decreased donor return rates. Additionally, frequent blood donations are associated with depletion of body iron stores. Analysis of the effect of various Hb cutoffs and interdonation intervals on our center's blood supply is presented.

STUDY DESIGN AND METHODS

Whole blood donor data for a 12-month period were studied. Potential effects on the blood supply by increasing male Hb eligibility levels and/or increasing the interdonation interval were analyzed.

RESULTS

A total of 13,519 individuals (females, 56%) donated 30,678 units (mean frequency, male 2.7 and females 2.1) with the majority (42%) donating once. Increasing the male Hb eligibility to at least 13.5 g/dL will decrease collections by 1457 (5%) units. In addition, decreasing the female Hb eligibility to at least 12.0 g/dL will result in total gain of 307 (1%) units. Considering 12-week interdonation interval and Hb eligibility of at least 13.5 g/dL (male) and at least 12.5 g/dL (female) results in decrease of 11% (3352) units.

CONCLUSIONS

Increasing the Hb cutoff for male donors and/or interdonation interval for all donors will decrease available blood, some of which may be reduced by decreasing the Hb cutoff for females to at least 12.0 g/dL. As a majority of the donors donate only once with mean donation frequency being 2.4, it may be possible to overcome this shortfall by targeted recruitment of donors donating once.

Iron replacement therapy in the routine management of blood donors

BACKGROUND

Iron depletion or deficiency in blood donors frequently results in deferrals for low hemoglobin (Hb), yet blood centers remain reluctant to dispense iron replacement therapy to donors.

STUDY DESIGN AND METHODS

During a 39-month period, 1236 blood donors deferred for a Hb level of less than 12.5 g/dL and 400 nondeferred control donors underwent health history screening and laboratory testing (complete blood counts, iron studies). Iron depletion and deficiency were defined as a ferritin level of 9 to 19 and less than 9 µg/L in females and 18 to 29 and less than 18 µg/L in males. Deferred donors and iron-deficient control donors were given a 60-pack of 325-mg ferrous sulfate tablets and instructed to take one tablet daily. Another 60-pack was dispensed at all subsequent visits.

RESULTS

In the low-Hb group, 30 and 23% of females and 8 and 53% of males had iron depletion or deficiency, respectively, compared with 29 and 10% of females and 18 and 21% of males in the control group. Iron-depleted or -deficient donors taking iron showed normalization of iron-related laboratory parameters, even as they continued to donate. Compliance with oral iron was 68%. Adverse gastrointestinal effects occurred in 21% of donors. The study identified 13 donors with serious medical conditions, including eight with gastrointestinal bleeding. No donors had malignancies or hemochromatosis.

CONCLUSION

Iron depletion or deficiency was found in 53% of female and 61% of male low-Hb donors and in 39% of female and male control donors. Routine administration of iron replacement therapy is safe and effective and prevents the development of iron depletion and deficiency in blood donors.

Effective treatment of heavy and/or prolonged menstrual bleeding with an oral contraceptive containing estradiol valerate and dienogest: a randomized, double-blind Phase III trial

BACKGROUND

This double-blind trial investigated the efficacy and safety of estradiol valerate/dienogest (E(2)V/DNG) for the treatment of heavy menstrual bleeding without recognizable organic pathology.

METHODS

Otherwise healthy women with idiopathic heavy, prolonged or frequent menstrual bleeding, confirmed during a 90-day run-in phase, were randomized (2:1) according to a permuted-block, computer-generated schedule to E(2)V/DNG or placebo for 196 days at 34 centres in Europe and Australia. The primary efficacy end-point was the proportion of women with a 'complete' response (i.e. a return to 'menstrual normality') during a 90-day efficacy phase. Secondary end-points included changes in measured menstrual blood loss (MBL) and iron metabolism parameters.

RESULTS

The intention-to-treat population comprised 231 women. The E(2)V/DNG response rate was much higher than with placebo (P < 0.0001). The mean reduction in MBL volume in E(2)V/DNG recipients was 69.4% (median 79.2%) versus 5.8% (median 7.4%) in placebo recipients. The between-treatment difference in MBL volume was 373 ml in favour of E(2)V/DNG (95% confidence interval 490, 255 ml; P < 0.0001). Significant improvements in iron metabolism parameters were observed with E(2)V/DNG but not placebo. Overall, 14 women (9.7%) treated with E(2)V/DNG and 5 (6.2%) treated with placebo prematurely discontinued treatment because of adverse events, headache being the most prevalent. Serious adverse events occurred in both the E(2)V/DNG and placebo groups (each n = 2).

CONCLUSIONS

E(2)V/DNG is an effective treatment in women with heavy and/or prolonged menstrual bleeding without organic pathology. Further study of E(2)V/DNG compared with an active comparator is warranted. ClinicalTrials.gov identifier: NCT00307801.

Iron status in Norwegian blood donors: comparison of iron status in new blood donors registered in 1993-1997 and in 2005-2006

BACKGROUND AND OBJECTIVES

The impact of a poor iron status on the difficulties to keep recruitment of new donors at pace with the ongoing increased demand for blood transfusions was studied by comparing the iron status of new donors recruited in 1993-1997 and in 2005-2006.

MATERIALS AND METHODS

Iron status was defined by haemoglobin and serum ferritin. Inclusion criteria for approving new donors were haemoglobin >/= 12.5 g/dl for women and >/= 13.5 g/dl for men, and serum ferritin > 15 microg/l for both genders. Data were gathered retrospectively from 943 subjects (55% women) in the 1990 ties and prospectively from 1013 subjects (63% women) 10 years later.

RESULTS

In women, there was a significant fall in haemoglobin and serum ferritin mean values from 13.2 to 13.1 g/dl and from 30.9 to 26.9 microg/l, respectively. Rejection due to low haemoglobin was significantly increased from 14% to 24%. In men, there were minor changes that did not affect rejection rates.

CONCLUSION

Iron status of women who want to serve as blood donors has deteriorated in the last 10 years, leading to an increased rejection due to haemoglobin below the inclusion criterion for blood donors.

Postpartum anemia I: definition, prevalence, causes, and consequences

This review provides a status on the definition, prevalence, causes, and consequences of anemia in women who have given childbirth, i.e., postpartum anemia. The diagnosis of iron deficiency anemia relies on a full blood count including hemoglobin, serum ferritin, and serum soluble transferrin receptor, which appear to be reliable indicators of anemia and iron status 1 week postpartum while serum transferrin saturation is an unreliable indicator several weeks after delivery. It is recommended that postpartum anemia should be defined by hemoglobin <110 g/L at 1 week postpartum and <120 g/L at 8 weeks postpartum. The major causes of postpartum anemia are prepartum anemia combined with acute bleeding anemia due blood losses at delivery. Normal peripartum blood losses are approximately 300 ml, but hemorrhage >500 ml occur in 5-6% of the women. In healthy women after normal delivery, the prevalence of anemia (hemoglobin <110 g/L) 1 week postpartum is 14% in iron-supplemented women and 24% in non-supplemented women. In consecutive series of European women, the prevalence of anemia 48 h after delivery is approximately 50%. In developing countries, the prevalence of postpartum anemia is in the range of 50-80%. Postpartum anemia is associated with an impaired quality of life, reduced cognitive abilities, emotional instability, and depression and constitutes a significant health problem in women of reproductive age.

Iron status in elite young athletes: gender-dependent influences of diet and exercise

Iron depletion seems to occur more frequently among athletes than in the general population and may affect performance capacity. Only little information is available about the prevalence of iron status abnormalities in young elite athletes and whether iron depletion is associated with gender, sport, age or nutrition- and exercise-related factors in this group. Hence, diet, exercise and haematological data from 193 elite athletes (96 males, 97 females; 16.2 ± 2.7 years) from 24 different sports were analyzed retrospectively. Most female athletes failed to meet the recommended daily allowance for iron, even though dietary iron density was higher than in males (5.75 ± 0.78 vs. 6.17 ± 0.98 mg/1,000 kcal; P = 0.001). Iron depletion (serum ferritin < 35 μg/L) occurred in 31% of male and 57% of female athletes (P < 0.001). Low haemoglobin (males: <13 g/dL; females: <12 g/dL) and haematocrit (males: <40%; females: <36%) values were equally prevalent in both genders [haemoglobin: 7.3% (males), 6.2% (females); haematocrit: 13.5% (males); 15.5% (females)]. In females, reduced ferritin levels were associated with a lower dietary iron density (5.9 ± 0.8 vs. 6.6 ± 1.1 mg/1,000 kcal; P = 0.002). Males with iron depletion had a significantly higher estimated energy expenditure (48.7 ± 7.0 vs. 44.4 ± 7.6 kcal/kg/day; P = 0.009).

Dietary iron intake during early pregnancy and birth outcomes in a cohort of British women

BACKGROUND Iron deficiency during pregnancy is associated with adverse birth outcomes, particularly, if present during early gestation. Iron supplements are widely recommended during pregnancy, but evidence of their benefit in relation to infant outcomes is not established. This study was performed in the UK, where iron supplements are not routinely recommended during pregnancy, to investigate the association between iron intake in pregnancy and size at birth. METHODS From a prospective cohort of 1274 pregnant women aged 18-45 years, dietary intake was reported in a 24-h recall administered by a research midwife at 12-week gestation. Dietary supplement intake was ascertained using dietary recall and three questionnaires in the first, second and third trimesters. RESULTS Of the cohort of pregnant women, 80% reported dietary iron intake below the UK Reference Nutrient Intake of 14.8 mg/day. Those reported taking iron-containing supplements in the first, second and third trimesters were 24, 15 and 8%, respectively. Women with dietary iron intake >14.8 mg/day were more likely to be older, have a higher socioeconomic profile and take supplements during the first trimester. Vegetarians were less likely to have low dietary iron intake [odds ratio = 0.5, 95% confidence interval (CI): 0.4, 0.8] and more likely to take supplements during the first and second trimesters. Total iron intake, but not iron intake from food only, was associated with birthweight centile (adjusted change = 2.5 centiles/10 mg increase in iron, 95% CI: 0.4, 4.6). This association was stronger in the high vitamin C intake group, but effect modification was not significant. CONCLUSION There was a positive relationship between total iron intake, from food and supplements, in early pregnancy and birthweight. Iron intake, both from diet and supplements, during the first trimester of pregnancy was higher in vegetarians and women with a better socioeconomic profile.

Anemia--still a major health problem in many parts of the world!

Anemia is a major global health problem, especially in developing countries. This fundamental health issue still has not been solved and continues to exist affecting the health, quality of life, and working capacity in billions of people all over the world. This paper gives a review on the prevalence and major causes of anemia seen on a global scale. Most cases of anemia are due to iron deficiency, which often work in symphony with folate deficiency and/or vitamin B12 deficiency as well as with infections. More efforts should be dedicated to tackle this massive problem--we have the tools, and we know the ways. Iron fortification of appropriate food items combined with iron supplements in specific population groups has proven to be efficient. Initially, the efforts should be centered on the specific risk groups for iron deficiency anemia, i.e., young children, adolescent females, women of reproductive age, as well as pregnant women and postpartum lactating mothers.

Hormonal contraceptive practices in young Australian women (≤ 25 years) and their possible impact on menstrual frequency and iron requirements

OBJECTIVES

To investigate the hormonal contraceptive practices of female university students aged ≤ 25 years, their menstrual bleeding frequency, and interest in contraceptive regimens that reduce menstrual frequency or duration.

STUDY DESIGN

A 20-item questionnaire was distributed to female students at Griffith University, Gold Coast campus. This included questions relating to: demographics, menstrual bleeding frequency, current contraceptive practices, and interest in future oral contraceptive regimens that reduce menstrual bleeding frequency and duration.

MAIN OUTCOME MEASURES

Determination of hormonal contraceptive practices and menstrual bleeding frequency undertaken by the sample population.

RESULTS

Eight hundred and fifty one participants completed the questionnaire, ~ 2/3rds of respondents are currently using a hormonal contraceptive (66% of all respondents), with the oral contraceptive pill (OCP) being most common. Most women (73%) reported monthly menstruation, although 16% indicated that they sometimes missed their monthly period, with bleeding every two months. Of all OCP users, approximately 2/3rds have skipped their monthly period at some time, the most common reasons being for convenience (89%). Approximately 70% of respondents were interested in OCP regimens that reduced frequency or duration of menstruation.

CONCLUSION

OCP use is popular amongst Australian university women, with many being interested in the concept of using the OCP to delay menstruation. Given this interest and the availability of hormonal contraceptives that reduce menstrual frequency and duration, assessing the impact of reduced menstrual blood loss on iron stores may be warranted.

Extrinsic factors modifying expressivity of the HFE variant C282Y, H63D, S65C phenotypes in 1,294 Danish men

This study analysed the influence of extrinsic factors on the phenotypic expression of HFE gene variants in ethnic Danish men. A cohort of 6,020 men aged 30-53 years was screened for HFE C282Y, H63D and S65C variants. Serum iron, serum transferrin, transferrin saturation, and serum ferritin were analysed in 1,452 men and 1,294 men completed a questionnaire on factors, which could influence iron balance. The C282Y allele was present in 5.6%, H63D in 12.8% and S65C in 1.8% of the men. In the entire series, 3% had elevated iron status markers (transferrin saturation > or =50%, ferritin > or =300 microg/L). Self-reported liver disease had an elevating effect and peptic ulcer a lowering effect on iron status markers. Age increased the fraction of men with elevated ferritin from 8.3% at 32-38 years to 16.2% at 46-53 years of age (p = 0.002). Blood donation had a lowering effect on iron status markers (p = 0.0001). Alcohol consumption elevated serum iron and serum ferritin (p = 0.001). Meat consumption had an elevating effect (p = 0.02) and milk consumption a lowering effect (p = 0.03) on serum ferritin. There was no influence of vitamin-mineral tablets on iron status markers. In adjusted logistic regression analysis, the HFE genotype had the highest impact on iron status markers; high alcohol consumption was significantly associated with elevated transferrin saturation. High age and high alcohol consumption were significantly associated with elevated ferritin and high egg consumption and blood donation was significantly associated with normal ferritin levels. In conclusion, the expressivity of HFE variant phenotypes in Danish men was enhanced by alcohol and meat consumption and decreased by milk and egg consumption and blood donation.