Symposium: Improving Adolescent Iron Status

before Childbearing

Iron Requirements in Adolescent Females1

John L. Beard
Nutrition Department, The Pennsylvania State University, University Park, PA 16802

ABSTRACT Adolescence is characterized by a large growth spurt and the acquisition of adult phenotypes and
biologic rhythms. During this period, iron requirements increase dramatically in both boys and girls as a result of
the expansion of the total blood volume, the increase in lean body mass and the onset of menses in young females.
The overall iron requirements increase from a preadolescent level of ⬃0.7– 0.9 mg Fe/d to as much as 2.2 mg Fe/d
or perhaps more in heavily menstruating young women. These increased requirements are associated with the
timing and size of the growth spurt as well as sexual maturation and the onset of menses. The available data on
iron intakes in adolescents suggest that adolescent girls are unlikely to acquire substantial iron stores during this
time period because intakes may average as little as 10 –11 mg Fe/d. The bioavailability from diets in developing
and industrialized countries indicates a negative iron balance is likely in many female populations. The low iron
stores in these young women of reproductive age will make them susceptible to iron deficiency anemia during
pregnancy because dietary intakes alone are insufficient, in most cases, to meet the requirements of
pregnancy. J. Nutr. 130: 440S– 442S, 2000.

KEY WORDS: ● iron deficiency ● adolescence ● pregnancy ● anemia

Recent estimates of the world-wide prevalence of iron
deficiency and anemia were presented by Dr. Bruno de Benoist
at a recent meeting of the International Nutritional Anemia
Consultative Group in Durban, South Africa. The current
information updates the previous ACC/SCN report from the
World Health Organization (ACC/SCN 1992). His estimates
are that 46% of the world’s 5- to 14-y-old children are anemic,
with the overwhelming majority of this anemia occurring in
individuals from the developing world. In addition, 48% of the
world’s pregnant women are anemic; 56% of pregnant women
from the Third World are anemic. It is unclear how many of
these are adolescents, nor is it certain how much of the anemia
is due to iron deficiency and how much to parasitic infections,
vitamin A deficiency, folate and B-12 deficiencies, and gen-
eralized undernutrition.
In the United States, recent national surveys document the
amount of anemia and iron deficiency in the adolescent por-
tion of the population. An examination of the distribution of
hemoglobin (Hb) concentrations and iron status indices in the
U.S. population from either the National Health and Nutri-
tion Examination Survey (NHANES) II or III data sets reveals
the clear effect of the adolescent growth spurt on iron metab-
olism and iron requirements. The prevalence of iron deficiency
1
Presented at the symposium entitled “Improving Adolescent Iron Status
before Childbearing” as part of the Experimental Biology 99 meeting held April
17–21 in Washington, DC. This symposium was sponsored by the American
Society for Nutritional Sciences and was supported in part by an educational
grant from Micronutrient Initiative. The proceedings of this symposium are pub-
lished as a supplement to The Journal of Nutrition. Guest editors for the sympo-
sium publication were Kathleen Kurz, International Center for Research on
Women and Rae Galloway, World Bank/Micronutrient Initiative.
averaged between 8 and 10% for girls aged 12–19 in the
NHANES III survey of the U.S. population (Dallman et al.
1996). This is a higher percentage than had been determined
in the 1976 –1980 national survey. In boys, the estimated
prevalence was ⬍1% in this same age group. This prevalence
in adolescent boys is diminished greatly from the nearly 11%
estimated prevalence derived from the NHANES II survey
(Expert Scientific Working Group 1985).
Iron balance is the difference between iron retention and
iron requirements and has been well described over the past 50
years (Beard et al. 1996). The retention of iron, frequently
called the absorbed iron, is the product of iron intake and the
bioavailability of that dietary, supplemental or contaminant
iron. The excess iron that accumulates beyond that necessary
for the daily requirement is stored within the core of the
ferritin molecule. This stored ferritin iron is then available for
cellular iron needs should dietary intake fall below the organ
needs. When this negative iron balance persists for a period of
time, the iron stores are depleted and the iron supply to the
essential iron pools of the body is diminished. Functional
consequences then result from insufficient iron-dependent
functioning for oxygen transport, oxidative metabolism, nu-
clear metabolism and gene transcription. Clinical sequelae to
this poor iron status include anemia, poor immune function
and decreased work performance. Poor fetal outcomes may
occur if iron deficiency occurs in the first trimester of preg-
nancy (see review by Beard et al. 1996).
The dynamics of iron movement in humans is well de-
scribed and is displayed in Figure 1 (Bothwell et al. 1979).
Iron lost from red cell mass turnover averages 0.38 mg Fe/d in
adults, bile losses between 0.22 and 0.28 mg Fe/d, desquamated

0022-3166/00 $3.00 © 2000 American Society for Nutritional Sciences.

440S

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 IRON REQUIREMENT IN ADOLESCENT FEMALES
FIGURE 1 Diagram of iron movement in adult humans with esti-
mates of iron trafficking derived from Bothwell et al. (1979).
gastrointestinal cells ⬃0.24 mg Fe/d and urinary losses of
⬃ 0.5–1.0 mg Fe/d. In adolescents, the amount of iron moving
from one compartment to another is likely to be modified
slightly on the basis of body size and the onset of menses in the
female portion of the adolescent population (Rossander-
Hulthen and Hallberg 1996). There are no clear data to
indicate that these numbers are appreciably different in ado-
lescent boys and girls once body size is considered (Hallberg
1996)
Iron requirements during the adolescent period are computed
using a factorial method (Fairweather-Tait 1996, Rossander-
Hulthen and Hallberg 1996). Total iron requirements for adoles-
cent boys (Fig. 2) are computed from the increased iron require-
ments for the expansion of the total blood volume (0.18 mg/d in
boys and 0.14 mg/d in girls on average) and the increase in the
total body essential iron pool with the increase in the lean body
mass (0.55 mg/d in boys and 0.33mg/d in girls median additional
requirements). The increase in iron requirements for the red cell
mass includes both the increase in total blood volume as well as
the increase in mean Hb concentration from the preadolescent
years through the adolescent growth spurt. The mean Hb con-
centration in the U.S. increases from 130 to 133 g/L in adolescent
girls and to 141g/L in adolescent boys during this time period.
The increase in mean total iron requirements may exceed 1.8
mg/d or more than double those requirements of preadolescent
males (Fig. 2).
The additional iron requirements for adolescent girls in-
clude the additional calculation for the amount of iron lost in
menses beyond the growth requirements (Hallberg 1996).
Hallberg concludes that menstrual losses in adolescents do not
differ from those of reproductive age women although actual
data on volume of menstrual losses were reported in his most
recent treatment of those data. The mean menstrual blood loss
of 84 mL/period (Hallberg 1996), assuming a mean Hb of 133
g/L, provides an estimate of 0.56 mg of additional iron per day.
The 10th percentile for this is 0.17 mg/d and the 90th per-
centile is 1.08 mg of additional iron per day. These additional
requirements for iron to balance the menstrual blood losses
may increase the daily iron requirements to as much as 2.1
mg/d in girls at the 75th percentile of blood loss.
Fairweather-Tait (1966) estimates the range of iron re-
quirements for adolescent boys to be between 1.45 and 2.03
mg/d based on data derived from United Kingdom and Euro-
pean surveys. Similarly, she estimates the iron requirements for
adolescent girls before menses to be between 1.22 and 1.46
mg/d, and after menses to be between 1.39 and 2.54 mg/d.
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441S
Thus, although there are some small quantitative differences
between her estimations and those of Hallberg, the fundamen-
tal conclusion that iron requirements nearly double during
adolescence remains intact.
This factorial method of estimation of iron requirements
has many implicit assumptions that are based on relatively
sparse data. These assumptions are as follows: 1) basal iron
losses can be scaled to body size to convert the adult basal loss
data to younger and smaller individuals; 2) menstrual blood
flow volume distributions in adolescent girls are similar to
those of adult women of reproductive age; 3) iron content of
lean body mass in growing organs is similar to that in the fully
formed adult organ. Some of these assumptions may carry
considerable risk (#2), whereas other assumptions are likely
reasonable (#1, #3). Some faith in the factorial method, how-
ever, is derived from an examination of the prevalence data
and dietary intake data. That is, the estimated prevalence,
based on requirements and dietary intakes, matches the mea-
sured prevalence in many cases (Hallberg and Rossander
1991).
Pooled estimates of iron intakes for adolescents have been
reported by Fairweather-Tait (1996) and are derived from
survey data in both the United Kingdom and continental
Europe. Female teens average 10 mg Fe/d up until age 15 and
then seem to increase intake to 13–14 mg/d. In contrast, teen
boys showed a gradual but steady increase in intake from 10
mg/d at age 11 y to 15 mg/d at age 16 y and then a large
increase to ⬎20 mg/d at 17 y and beyond. This suggests that
iron intakes may be adequate to meet requirements to prevent
depletion of iron stores in many young females, but are insuf-
ficient to actually increase iron stores substantially. Because
efficiency of iron absorption declines as iron status increases, a
large increase in intake is necessary to increase significantly
the mean plasma ferritin of the adolescent female population
(Hallberg and Rossander 1991).
Within the context of this symposium, it is worthwhile
reminding ourselves of the iron costs of pregnancy (Allen
1997, Viteri 1997). These calculations are again based on a
factorial method of estimating iron needs rather than true
empirical determinations of iron costs (Fig. 3). The sum of the
costs for expansion of the red cell mass in the second and third
trimester, the growth of the fetus and placenta in the second
and third trimester, and then blood losses at delivery can reach
1290 mg of iron. There is a considerable variation in this,
however, and much uncertainty regarding the blood loss at
FIGURE 2 Estimated iron requirements for adolescent girls and
boys. Figure derived from Rossander-Hulthen and Hallberg (1996).
 442S
FIGURE 3 Estimated iron requirements for pregnancy and lacta-
tion. Data derived from Viteri (1997).
delivery. The amenorrhea of pregnancy must be considered in
this iron balance equation and may constitute a saving of as
much as 290 mg of iron over the 9 mo of pregnancy. When the
lactational period is considered, this iron savings may rise as
high as 400 mg or more (Fig. 3). The average iron requirement
over this period of time then can be computed to be ⬃4 mg
Fe/d. The efficiency of iron absorption will increase dramati-
cally in the second and third trimesters in response to the
normal decline in iron status and will compensate in part for
the increased iron requirements (Barrett et al. 1994). In many
women, it is uncertain whether diet alone can provide the
additional iron needs of pregnancy (Allen 1997), and the need
for iron supplementation is actively debated (Beard 1998,
Hallberg 1998, Viteri 1997).
In conclusion, the following four major issues seem to be
present regarding pregnancy in adolescent females: 1) Dimin-
ished iron stores are likely in a significant proportion of ado-
lescent females in developed and developing countries. 2) The
overlap of the increase in iron requirement due to growth,
onset of menses and costs of pregnancy suggests that there is a
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SUPPLEMENT
limited opportunity to acquire sufficient iron before pregnancy
to have a storage iron pool of sufficient size to meet the
demands of pregnancy. 3) Functional consequences of iron
deficiency occur in both the mother and the infant when these
iron stores are depleted. 4) Iron deficiency anemia, early in
pregnancy, can been associated with negative fetal outcomes.
In other papers from this symposium, some of these issues will
be addressed and key points discussed more thoroughly. None-
theless, it should be clear that a large database that defines the
health consequences of iron deficiency in adolescent girls is
lacking and requires attention in future research.
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