Food-insecure Pregnant Females may be at greater risk of iron deficiency (ID) This may result in a higher risk of infant low birth weight and possibly cognitive impairment in the neonate. Food Insecurity status may be a better indicator to identify populations at whom to direct interventions.
Food-insecure Pregnant Females may be at greater risk of iron deficiency (ID) This may result in a higher risk of infant low birth weight and possibly cognitive impairment in the neonate. Food Insecurity status may be a better indicator to identify populations at whom to direct interventions.
Food-insecure Pregnant Females may be at greater risk of iron deficiency (ID) This may result in a higher risk of infant low birth weight and possibly cognitive impairment in the neonate. Food Insecurity status may be a better indicator to identify populations at whom to direct interventions.
Iron Deciency Is Associated with Food Insecurity in Pregnant Females in the United States: National Health and Nutrition Examination Survey 1999-2010 Clara Y. Park, PhD; Heather A. Eicher-Miller, PhD ARTICLE INFORMATION Article history: Accepted 24 April 2014 Keywords: Iron deciency Pregnancy Food security Iron intake National Health and Nutrition Examination Survey (NHANES) Copyright 2014 by the Academy of Nutrition and Dietetics. 2212-2672/$36.00 http://dx.doi.org/10.1016/j.jand.2014.04.025 ABSTRACT Food-insecure pregnant females may be at greater risk of iron deciency (ID) because nutrition needs increase and more resources are needed to secure food during preg- nancy. This may result in a higher risk of infant low birth weight and possibly cognitive impairment in the neonate. The relationships of food insecurity and poverty income ratio (PIR) with iron intake and ID among pregnant females in the United States were investigated using National Health and Nutrition Examination Survey 1999-2010 data (n1,045). Food security status was classied using the US Food Security Survey Module. One 24-hour dietary recall and a 30-day supplement recall were used to assess iron intake. Ferritin, soluble transferrin receptor, or total body iron classied ID. Dif- ference of supplement intake prevalence, difference in mean iron intake, and associa- tion of ID and food security status or PIR were assessed using c 2 analysis, Student t test, and logistic regression analysis (adjusted for age, race, survey year, PIR/food security status, education, parity, trimester, smoking, C-reactive protein level, and health in- surance coverage), respectively. Mean dietary iron intake was similar among groups. Mean supplemental and total iron intake were lower, whereas odds of ID, classied by ferritin status, were 2.90 times higher for food-insecure pregnant females compared with food-secure pregnant females. Other indicators of ID were not associated with food security status. PIR was not associated with iron intake or ID. Food insecurity status may be a better indicator compared with income status to identify populations at whom to direct interventions aimed at improving access and education regarding iron-rich foods and supplements. J Acad Nutr Diet. 2014;-:---. I RON DEFICIENCY (ID) IS ONE OF THE MOST COMMON nutritional deciencies. Among pregnant females in the United States, 16.1% were ID during 2003-2006. 1 Low maternal iron status is correlated with low and very- low infant birth weight, 2,3 preterm birth, 4 and low infant iron stores. 5,6 Low iron status during infancy has been linked with learning and memory decits and mental retardation. 7-9 Accordingly, the World Health Organization recommends iron supplementation 10 and the Healthy People 2020 objec- tives include the reduction of ID status 11 among pregnant fe- males. Despite the greater iron needs during pregnancy, 12 females in this life stage may have less energy and ability to prepare foods due to physical constraints. Pregnancy may also increase nancial burden because greater energy and nutrients are necessary to support the pregnancy and decreased or refrained employment may occur. This may exacerbate the difculties food-insecure pregnant females face to meet their nutrition needs and may incur food insecu- rity among females who were food secure preceding preg- nancy. Alternatively, pregnant females might be protected from nutritional decits related to food insecurity by the prioritized receipt of nutritious food and supplements within the household. Few studies investigating the relationship of food insecu- rity, iron intake, and ID have been documented among pregnant females. Previous research completed among chil- dren, 13,14 women with children, 15 and elderly persons 15,16 have shown greater likelihood for ID anemia and lower iron intakes among food-insecure compared with food-secure groups. Among pregnant women living in North Carolina, food insecurity was not associated with anemia, 17 but the relationships of food security to iron intake and status have not been described for all US pregnant females. Although the lack of access to food might facilitate the relationship of food insecurity to low iron intake and status among food-insecure groups, the low purchasing ability of those with a reduced household poverty income ratio (PIR) may facilitate a relationship to low iron intake and status among groups with low PIR. Food-insecure and reduced-PIR groups are similar but may comprise slightly different populations, resulting in the mixed ndings describing the relationship of PIR to iron intake and status in previous 2014 by the Academy of Nutrition and Dietetics. JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 1 studies. 18-22 Therefore, both food insecurity and PIR were examined in our study using a hypothesis that food-insecure pregnant females in the United States have lower iron intake from food, beverages, and supplements and higher odds of ID compared with food-secure pregnant females. In addition, the hypothesis that pregnant females in the United States with low PIR status have lower iron intake from diet and supplements and higher odds of ID compared to those with higher PIR status was also tested. SUBJECTS AND METHODS Study Population National Health and Nutrition Examination Survey (NHANES) data collected during 1999-2010 were used. NHANES pro- vides a cross-sectional representation of the health status and nutrition-related behaviors of noninstitutionalized civilian residents of the United States. Oversampling was performed for pregnant females during 1999-2006. 23-26 The study population was limited to participants with a positive urine pregnancy test that was performed at the mobile examination center (MEC) (n1,383). Pregnant fe- males missing food security status (n53), Day 1 24-hour dietary recall (n42), iron status (n85), or family PIR sta- tus (n69), and those whose race was not categorized as non-Hispanic white, non-Hispanic black, or Hispanic (n69) were excluded. A total of 1,045 females were included (aged 13 to 54 years). The National Center for Health Statistics Research Ethics Review Board approved the protocol for all NHANES content. 27 Dietary Assessment Dietary iron and energy intake information was obtained from the 24-hour dietary recall. 28,29 Mean daily supple- mental iron intake was calculated from the 30-day dietary supplement questionnaire. 30,31 Total iron intake was deter- mined as the sum of 24-hour dietary iron intake and mean daily supplemental iron intake. Only participants with complete information of iron supplement use or self- reported nonusers were included to calculate the mean daily iron supplement intake and total iron intake. Categor- ical variables for dietary iron intake were created as less than or greater than or equal to the Estimated Average Requirement (EAR) for pregnant females (aged 14 to 18 years: 23 mg/day; aged 19 to 50 years: 22 mg/day 32 ). Energy intake was categorized (ie, <1,500, 1,500 to 2,800, and >2,800 kcal/day). Iron Status Assessment and Other Laboratory Examinations Serum ferritin was assessed by immunoturbidimetric (NHANES 1999-2002 and 2004-2008), immunoradiometric (NHANES 2003), or sandwich immunoassay (NHANES 2009- 2010) and adjusted for comparability. 33,34 Details of analyses of soluble transferrin receptor (sTfR), hemoglobin, and he- matocrit are provided elsewhere. 23-26,35 Total body iron (TBI) calculations were computed using the equation developed by Cook and colleagues. 36,37 An equation was used to adjust sTfR obtained through the Roche method (used by NHANES) to values equivalent to the Flowers method (used by Cook and colleagues). 19,38,39 Afterward, TBI was calculated as: TBImg=kglog10sTfR1;000=ferritin2:8229=0:1207 Iron deciency was recognized if TBI <0 mg/kg, sTfR >4.4 mg/L, 19,40 or ferritin <12 mg/L for all races. C-reactive protein (CRP) was categorized as 5 mg/L or >5 mg/L. 19 Comparison between food-secure females and food-insecure females among those without inammation present, indicated by CRP 5 mg/L, was not possible due to the inadequate sample size of food-insecure females (n66). Food Security Assessment and Classication of Other Characteristics Food security was assessed using the US Food Security Survey Module. During NHANES 1999-2002, the questionnaire was administered as part of the household interview to one adult to classify food security among household adults or children. Individual-level food security status was determined at the MEC since 2001 for adults (aged 16 years) and children (aged <12 years), and for adolescents (aged 12 to 15 years) from 2005 onward. 41 Food security status was dened as either food secure or food insecure. For adults (aged 16 years) food secure classication included full food secu- rity and marginal food security, whereas food insecure encompassed low food security and very low food secu- rity. Child (aged <16 years) food security classication fol- lowed a similar classication scheme. Age was categorized as <20 years, 20 to 29 years, and 30 years at the time of the in-house survey. Race/ethnicity was self-reported and categorized as non-Hispanic white, non- Hispanic black, or Mexican American/other Hispanic. Other race/ethnic classications were not sampled to be represen- tative and, thus, were not included in the analyses. Survey year was categorized as 1999-2000, 2001-2002, 2003-2004, and 2005-2010. Years 2005-2010 comprise a greater span of time due to the small sample size representing years 2007- 2010 when the oversampling of pregnant females was dis- continued. Income was determined by family PIR and was categorized as 75% PIR, 76% to 130% PIR, or >130% PIR to ensure adequate sample size for the analyses and because the 130% cutoff is frequently used to determine eligibility for government programs. Education was categorized as less than high school or high school graduate/General Educational Development diploma. Smoking was determined by self- reported use (yes or no) of any tobacco product within the past 5 days. Parity was determined by the reported number of live births from a previous pregnancy and was categorized as zero to one, 2, or missing to maintain adequate sample size for the analysis. Trimester (3 months, 4 to 6 months, or 7 months pregnant) was classied by the reported number of months of pregnancy at the time of the in-house visit. Missing trimester data of 161 females (13.7% of the sample) were categorized as missing. Special Nutrition Assistance Program (previously known as Food Stamps) receipt was not included as a variable because 50% of participants were missing data. Current household receipt of Special Supple- mental Nutrition Program for Women, Infants, and Children benets was considered as a covariate in the analysis but ultimately not included because it did not affect the as- sociations reported nor was it a signicant variable in the RESEARCH 2 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS -- 2014 Volume - Number - regression models. Coverage by any type of health insurance (yes or no) was also assessed by questionnaire. Mean age, distribution of education, smoking status, parity, trimester, and health insurance coverage rate among the pregnant fe- males excluded from the analyses did not differ from those included in the analyses. Statistical Analysis Differences in characteristics and prevalence of supplement intake and ID among food security groups were investigated using Rao-Scott c 2 analysis. Geometric means of diet (food and beverage), supplement, and total iron intake were calculated and compared by t test. To account for those consuming no iron from diet and the nonnormal distribution of iron intake, a ln(x1) transformation was applied. Logistic regression analysis determined the odds of low dietary iron intake and ID by food security status and PIR levels. All lo- gistic regression models were adjusted for age, race, survey year, education, parity, trimester, health insurance coverage, and either food security or PIR. ID models were additionally controlled for smoking and CRP, whereas the dietary iron intake model was additionally controlled for energy intake. Day 1 dietary weights (WTD4YR/3 [1999-2002], WTDRD/6 [2003-2010]) and MEC weights (WTMEC4YR/3 [1999-2002], WTMEC2YR/6 [2003-2010]) were applied to iron intake and ID models, respectively. Analysis was performed using SAS 9.2 (2002, SAS Institute Inc). Null hypotheses were rejected when P<0.05. RESULTS AND DISCUSSION Among the total 1,045 pregnant females, 881 were food secure and 164 were food insecure. The distributions of race, PIR, education, smoking status, and health insurance coverage differed among the food-secure and food-insecure pregnant females (Table 1). Meanstandard error of the mean iron intake from diet (food and beverage) of the population was 151 mg/day, which is 7 to 8 mg/day lower than the EAR, and did not differ between the food-secure and food-insecure respondents (Table 2). Dietary iron intake was not associated with food security status (data not shown). Mean daily iron intake from supplements among supple- ment users was 10 mg/day higher among food-secure preg- nant females compared with food insecure pregnant females (P0.02) (Table 2). As a result, mean total (diet plus supple- ment) iron intake was higher in food-secure pregnant fe- males compared with those who were food insecure (38 and 26 mg/day, respectively; P0.002). Both groups mean total iron intake surpassed the EAR. However, the prevalence of iron-containing supplement consumption was not signi- cantly different between food-secure or food-insecure preg- nant females with complete supplement consumption data. The higher iron intake from supplements despite the similar prevalence of supplement intake in food-secure compared with food-insecure pregnant females suggests more frequent prescription, adherence to prescribed intake schedule, and intake monitoring in the former population. Also, food-secure females may have more access to and awareness of the need for iron supplements compared with food-insecure females, as evidenced by the higher rate for health insurance coverage and education. When using ferritin to classify ID, food-insecure pregnant females had a higher prevalence of ID (31% vs 22% in food- secure females; P0.0025) (Table 2) and were 2.90-fold more likely to have ID than food-secure pregnant females after adjusting for covariates (P<0.05) (Table 3). The lower prev- alence and risk of ID in food-secure pregnant females may be due to differences in the amount and source of iron intake. First, supplemental iron intake may strongly inuence iron status. Iron supplement use, but not dietary iron intake, is associated with lower odds of ID and higher iron status in nonpregnant US women 18 and has been reported to be an effective method to increase iron status in controlled trials. 42-44 Interestingly, the higher risk of ID in food-insecure females despite adjustment for health insurance coverage indicates that these females may have less physical access to and/or awareness of health care services and healthy behaviors, or have other priorities in use of time and nances compared with food-secure females. Second, bioavailability of dietary iron may differ among food-secure and food-insecure fe- males despite similar intake. Heme iron is used more ef- ciently than nonheme iron, whereas nonheme iron absorption is negatively associated with maternal iron status and the iron dose consumed. 45 Sources of heme iron (ie, red meat, sh, and poultry) may be more expensive compared with foods high in nonheme iron, such as lentils, beans, and iron-enriched and iron-fortied cereals and foods. 46,47 This may decrease the availability of heme ironecontaining foods for persons with food insecurity. Hence, increased and consistent intake of supplemental iron and heme iron may be an effective strategy to prevent further ID especially among food-insecure pregnant females. Neither prevalence nor odds for ID classied by TBI and sTfR were different among food security groups. The low number of food-insecure pregnant females with ID by TBI (n32) and sTfR (n39) may be a cause of these results. However, another explanation of the different association with food security status among ID markers (ferritin vs TBI and sTfR) may be provided by the stages of iron depletion that each marker indicates. Previous reports suggest that low ferritin precedes the depletion of functional or tissue iron stores, which is indicated by high sTfR concentrations and low TBI. 48,49 In light of these ndings, food-insecure females may be more likely to experience functional ID and anemia postpartum due to blood loss during delivery. Thus, our re- sults suggest a need for additional screening among pregnant and postpartum food-insecure females to prevent ID and anemia. PIR was also not associated with iron intake or ID (data not shown). PIR and food security may be closely related, but their associations with iron intake and status are clearly different. Those at 130% PIR are eligible for many federal assistance programs, but pregnant females with lower in- come are reported to be less likely to take iron-containing supplements. 50 Others have also found no association of PIR with ID or anemia in non-Hispanic white women and preg- nant US women. 19 Perhaps food-insecure, rather than low- PIR, females should be the population specically targeted to receive supplemental iron and heme sources of dietary iron during pregnancy. A limitation of our investigation was the differential timeframe for assessment of food security and PIR (12 months), iron intake (24 hours), iron supplementation RESEARCH -- 2014 Volume - Number - JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 3 Table 1. Characteristics of 1,045 pregnant female participants in the National Health and Nutrition Examination Survey 1999-2010 by food security status (aged 13 to 54 y) a Characteristic Food Secure (n[881) Food Insecure (n[164) Weighted c 2 P value b n Percentage n Percentage Unweighted Weighted Unweighted Weighted Age (y) 0.24 <20 106 12 71 26 16 103 20-29 492 56 553 100 61 585 30 283 32 392 38 23 326 Race <0.0001 Non-Hispanic white 461 52 643 30 18 308 Non-Hispanic black 143 16 152 27 16 216 Mexican Americans /other Hispanics 277 31 202 107 65 507 Survey year 0.94 1999-2000 161 18 192 29 19 166 2001-2002 219 25 192 35 21 205 2003-2004 181 21 172 28 18 156 2005-2010 320 36 453 72 42 497 Poverty income ratio (%) <0.0001 75 143 16 111 72 44 466 76-130 128 15 101 52 32 264 >130 610 69 792 40 24 287 Education <0.0001 <High school/GED c 237 27 192 96 59 486 Parity 0.75 0-1 353 40 433 53 32 377 2 256 29 293 66 40 316 Missing 272 31 283 45 27 316 Trimester 0.19 1 145 16 222 33 20 184 2 317 36 303 53 32 286 3 302 34 313 43 26 266 Missing 117 13 172 35 21 286 Smoking d <0.0001 Yes 84 10 102 29 19 285 C-reactive protein 0.33 >5 mg/L 452 51 483 98 60 546 Health insurance coverage e Yes 763 88 901 97 59 655 <0.0001 a Total of percentages may exceed 100 due to rounding. b Weights from the mobile examination center visit (WTMEC4YR/3 [1999-2002], WTMEC2YR/6 [2003-2010]) were applied according to the directions of the Centers for Disease Control and Prevention. c GEDgeneral education development diploma. d Forty-nine subjects are missing data. e One subject is missing data. RESEARCH 4 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS -- 2014 Volume - Number - (30 days), pregnancy (<10 months), and iron markers (<4 months). A 24-hour dietary recall may provide a partic- ularly crude estimate of mean dietary iron intake for the small sample of food-insecure pregnant females. However, because NHANES has discontinued the oversampling of pregnant females and 2-day diet recalls were only available for 51% of our study population, our analysis was an optimal opportunity for a nationally representative analysis. In addi- tion, self-reported diet and supplement intake may be biased. Erroneous reporting of energy intake is common among fe- males 51-53 and may indicate erroneous iron intake because energy and iron intake are positively associated. Actual iron intake is most likely higher than indicated in these results. NHANES data do not include participants who are homeless or those temporarily residing in shelters, which may make up a signicant portion of the food-insecure population. Finally, the cross-sectional data used in this analysis did not provide information on the cause of ID, nor whether this status was due to prepregnancy nutritional status. CONCLUSIONS Our study is the rst to compare iron intake and ID among food-secure and food-insecure pregnant females in the United States using a nationally representative dataset. Food- insecure pregnant females have similar mean dietary intakes of iron but consume less iron from supplements and, thus, have lower total iron intake compared with food-secure pregnant females. Food-insecure pregnant females are more likely to deplete circulating iron stores, but not functional iron, compared with food-secure females. However, iron intake and risk of ID was not different among different PIR statuses. Public health policy should continue to focus on improving access to iron-rich foods and iron supplements for food-insecure pregnant females. References 1. Health Indicators warehouse: Iron deciencyPregnant females. 2012. http://www.healthindicators.gov. Accessed April 21, 2014. 2. Ronnenberg AG, Wood RJ, Wang X, et al. Preconception hemoglobin and ferritin concentrations are associated with pregnancy outcome in a prospective cohort of Chinese women. J Nutr. 2004;134(10): 2586-2591. Table 2. Iron intake and prevalence of supplement intake and iron deciency among pregnant US females aged 13 to 54 y by food security status using data from the National Health and Nutrition Examination Survey 1999-2010 (n1,045) a Food secure Food insecure P value Mean iron intake (SEM b ) n mg/d n mg/d Diet (food and beverages) 881 15.41.0 164 14.81.1 0.59 Supplement c 533 30.31.1 80 20.31.2 0.02 Total d 707 38.11.1 141 26.01.1 0.002 Supplement use d (prevalence) n % n % Yes 533 633 80 527 0.15 No 348 373 84 487 Iron deciency (prevalence) n % n % Ferritin 192 222 51 316 0.0025 Soluble transferrin receptor 154 142 29 144 0.95 Total body iron 148 132 36 184 0.19 a n are unweighted; means are geometric means; meanSEM and % are weighted. Iron intake comparisons were completed through weighted t tests and prevalence assessments were analyzed by weighted Rao-Scott c 2 analyses. Weights were used according to the guidelines of the Centers for Disease Control and Prevention. To account for those that did not consume any iron from diet (food and drink) and the nonnormal distribution of iron intake, a ln(x1) transformation was applied and then back-transformed to report the geometric mean. Iron deciency was determined if total body iron was <0 mg/kg, soluble transferrin receptor >4.4 mg/L, or ferritin <12 mg/L for all races. b SEMstandard error of the mean. c Mean supplemental iron intake of supplement users only. d Includes only subjects with complete information on supplemental iron use. Table 3. Adjusted odds ratios (95% CI) of iron deciency by food security status in pregnant females aged 13 to 54 y in the United States using data from the National Health and Nutrition Examination Survey 1999-2010 (n1,045) a Food security status Iron Deciency Ferritin Soluble transferrin receptor Total body iron Food insecure 2.90* (1.29-6.51) 1.14 (0.42-3.10) 1.86 (0.75-4.59) Food secure (reference) 1 1 1 a Logistic regression analysis was used to estimate the odds ratio of iron deciency for food-insecure pregnant females relative to food-secure pregnant females. All models were adjusted for clustering and stratication, age, race, trimester, parity, education, survey year, poverty income ratio, smoking status, health insurance coverage, and C- reactive protein level. Sample weights were applied according to the directions of the Centers for Disease Control and Prevention. Iron deciency was determined as ferritin <12.0 mg/L, soluble transferrin receptor >4.4 mg/L, or total body iron <0 mg/kg. *P<0.05. RESEARCH -- 2014 Volume - Number - JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 5 3. Steer P, Alam MA, Wadsworth J, Welch A. Relation between maternal haemoglobin concentration and birth weight in different ethnic groups. BMJ. 1995;310(6978):489-491. 4. Scanlon KS, Yip R, Schieve LA, Cogswell ME. High and low hemo- globin levels during pregnancy: Differential risks for preterm birth and small for gestational age. Obstet Gynecol. 2000;96(5 pt 1): 741-748. 5. Colomer J, Colomer C, Gutierrez D, et al. Anaemia during pregnancy as a risk factor for infant iron deciency: Report from the Valencia Infant Anaemia Cohort (VIAC) study. Paediatr Perinat Epidemiol. 1990;4(2):196-204. 6. Kilbride J, Baker TG, Parapia LA, Khoury SA, Shuqaidef SW, Jerwood D. Anaemia during pregnancy as a risk factor for iron- deciency anaemia in infancy: A case-control study in Jordan. Int J Epidemiol. 1999;28(3):461-468. 7. Lozoff B, Jimenez E, Hagen J, Mollen E, Wolf AW. Poorer behavioral and developmental outcome more than 10 years after treatment for iron deciency in infancy. Pediatrics. 2000;105(4):E51. 8. Idjradinata P, Pollitt E. Reversal of developmental delays in iron- decient anaemic infants treated with iron. Lancet. 1993; 341(8836):1-4. 9. Hurtado EK, Claussen AH, Scott KG. Early childhood anemia and mild or moderate mental retardation. Am J Clin Nutr. 1999;69(1):115-119. 10. Guideline: Daily Iron and Folic Acid Supplementation in Pregnant Women. Geneva, Switzerland: World Health Organization; 2012. 11. Healthy People 2020: Topics & objectives. 2012. http://www. healthypeople.gov/2020/topicsobjectives2020/default.aspx. Accessed April 21, 2014. 12. Tapiero H, Gate L, Tew KD. Iron: Deciencies and requirements. Biomed Pharmacother. 2001;55(6):324-332. 13. Eicher-Miller HA, Mason AC, Weaver CM, McCabe GP, Boushey CJ. Food insecurity is associated with iron deciency anemia in US ad- olescents. Am J Clin Nutr. 2009;90(5):1358-1371. 14. Park K, Kersey M, Geppert J, Story M, Cutts D, Himes JH. Household food insecurity is a risk factor for iron-deciency anaemia in a multi- ethnic, low-income sample of infants and toddlers. Public Health Nutr. 2009;12(11):2120-2128. 15. Tarasuk VS, Beaton GH. Womens dietary intakes in the context of household food insecurity. J Nutr. 1999;129(3):672-679. 16. Lee JS, Frongillo EA Jr. Nutritional and health consequences are associated with food insecurity among US elderly persons. J Nutr. 2001;131(5):1503-1509. 17. Laraia BA, Siega-Riz AM, Gundersen C. Household food insecurity is associated with self-reported pregravid weight status, gestational weight gain, and pregnancy complications. J Am Diet Assoc. 2010;110(5):692-701. 18. Frith-Terhune AL, Cogswell ME, Khan LK, Will JC, Ramakrishnan U. Iron deciency anemia: Higher prevalence in Mexican American than in non-Hispanic white females in the third National Health and Nutrition Examination Survey, 1988-1994. Am J Clin Nutr. 2000; 72(4):963-968. 19. Mei Z, Cogswell ME, Looker AC, et al. Assessment of iron status in US pregnant women from the National Health and Nutrition Ex- amination Survey (NHANES), 1999-2006. Am J Clin Nutr. 2011;93(6): 1312-1320. 20. Watts V, Rockett H, Baer H, Leppert J, Colditz G. Assessing diet quality in a population of low-income pregnant women: A com- parison between Native Americans and whites. Matern Child Health J. 2007;11(2):127-136. 21. Champagne CM, Casey PH, Connell CL, et al. Poverty and food intake in rural America: Diet quality is lower in food insecure adults in the Mississippi Delta. J Am Diet Assoc. 2007;107(11):1886-1894. 22. Peffer CM, Sternberg MR, Caldwell KL, Pan Y. Race-ethnicity is related to biomarkers of iron and iodine status after adjusting for sociodemographic and lifestyle variables in NHANES 2003e2006. J Nutr. 2013;143(6):977S-985S. 23. National Health and Nutrition Examination Survey (NHANES) 1999-2000. http://www.cdc.gov/nchs/nhanes/nhanes1999-2000/ nhanes99_00.htm. Accessed April1, 2013. 24. National Health and Nutrition Examination Survey (NHANES) 2001-2002. http://www.cdc.gov/nchs/nhanes/nhanes2001-2002/ nhanes01_02.htm. Accessed April 1, 2013. 25. National Health and Nutrition Examination Survey (NHANES) 2003-2004. http://www.cdc.gov/nchs/nhanes/nhanes2003-2004/ nhanes03_04.htm. Accessed April 1, 2013. 26. National Health and Nutrition Examination Survey (NHANES) 2005-2006. http://www.cdc.gov/nchs/nhanes/nhanes2005-2006/ nhanes05_06.htm. Accessed April 1, 2013. 27. NCHS Research Ethics Review Board (ERB) approval. 2012. http:// www.cdc.gov/nchs/nhanes/irba98.htm. Accessed April 1, 2013. 28. Blanton CA, Moshfegh AJ, Baer DJ, Kretsch MJ. The USDA Automated Multiple-Pass Method accurately estimates group total energy and nutrient intake. J Nutr. 2006;136(10):2594-2599. 29. NHANES 2001-2002 data documentation, codebook, and fre- quencies: Dietary interviewIndividual foods le (DRXIFF_B). 2010; http://www.cdc.gov/nchs/nhanes/nhanes2001-2002/DRXIFF_B.htm. Accessed April 1, 2013. 30. NHANES 1999-2000 dietary supplement useFile 1: Supplement counts (past months) (DSQFILE1). 2009. http://www.cdc.gov/nchs/ nhanes/nhanes1999-2000/DSQFILE1.htm. Accessed April 1, 2013. 31. NHANES 2007-2008 data documentation, codebook, and fre- quencies: 30-Day dietary supplement use (DSQDOC_E). 2010. http:// www.cdc.gov/nchs/nhanes/nhanes2007-2008/DSQDOC_E.htm. Accessed April 1, 2013. 32. Institute of Medicine, Food and Nutrition Board. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Washington, DC: National Academies Press; 2001. 33. 2003-2004 data documentation, codebook, and frequencies: Ferritin and transferrin receptor (L06TFR_C). 2007. http://www.cdc.gov/ nchs/nhanes/nhanes2003-2004/L06TFR_C.htm. Accessed April 1, 2013. 34. NHANES 2009-2010 data documentation, codebook, and fre- quencies: Ferritin (FERTIN_F). 2012. http://www.cdc.gov/nchs/ nhanes/nhanes2009-2010/FERTIN_F.htm. Accessed April 1, 2013. 35. National Health and Nutrition Examination Survey (NHANES) 2007-2008. http://www.cdc.gov/nchs/nhanes/nhanes2007-2008/ nhanes07_08.htm. Accessed April 1, 2013. 36. Cook JD, Flowers CH, Skikne BS. The quantitative assessment of body iron. Blood. 2003;101(9):3359-3364. 37. Skikne BS, Flowers CH, Cook JD. Serum transferrin receptor: A quantitative measure of tissue iron deciency. Blood. 1990;75(9): 1870-1876. 38. Flowers CH, Skikne BS, Covell AM, Cook JD. The clinical measurement of serum transferrin receptor. J Lab Clin Med. 1989;114(4):368-377. 39. Pfeiffer CM, Cook JD, Mei Z, Cogswell ME, Looker AC, Lacher DA. Evaluation of an automated soluble transferrin receptor (sTfR) assay on the Roche Hitachi analyzer and its comparison to two ELISA as- says. Clin Chim Acta. 2007;382(1-2):112-116. 40. Second National Report on Biochemical Indicators of Diet and Nutrition in the U.S. Population 2012. 2012. http://www.cdc.gov/ nutritionreport/report.html. Accessed May 12, 2014. 41. NHANES 2005-2006 data documentation, codebook, and fre- quencies: Food security. 2008. http://www.cdc.gov/nchs/nhanes/ nhanes2005-2006/FSQ_D.htm. Accessed April 1, 2013. 42. Taylor DJ, Mallen C, McDougall N, Lind T. Effect of iron supplemen- tation on serum ferritin levels during and after pregnancy. Br J Obstet Gynaecol. 1982;89(12):1011-1017. 43. Milman N, Agger AO, Nielsen OJ. Iron status markers and serum erythropoietin in 120 mothers and newborn infants. Effect of iron supplementation in normal pregnancy. Acta Obstet Gynecol Scand. 1994;73(3):200-204. 44. OBrien KO, Zavaleta N, Cauleld LE, Yang DX, Abrams SA. Inuence of prenatal iron and zinc supplements on supplemental iron ab- sorption, red blood cell iron incorporation, and iron status in preg- nant Peruvian women. Am J Clin Nutr. 1999;69(3):509-515. 45. Young MF, Grifn I, Pressman E, et al. Utilization of iron from an animal-based iron source is greater than that of ferrous sulfate in pregnant and nonpregnant women. J Nutr. 2010;140(12): 2162-2166. 46. Uzel C, ME C. Absorption of Heme Iron. Semin Hematol. 1998;35(1): 27-34. 47. Hunt JR, Roughead ZK. Nonheme-iron absorption, fecal ferritin excretion, and blood indexes of iron status in women consuming RESEARCH 6 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS -- 2014 Volume - Number - controlled lactoovovegetarian diets for 8 wk. Am J Clin Nutr. 1999;69(5):944-952. 48. Carriaga MT, Skikne BS, Finley B, Cutler B, Cook JD. Serum transferrin receptor for the detection of iron deciency in pregnancy. Am J Clin Nutr. 1991;54(6):1077-1081. 49. Akesson A, Bjellerup P, Berglund M, Bremme K, Vahter M. Serum transferrin receptor: A specic marker of iron deciency in preg- nancy. Am J Clin Nutr. 1998;68(6):1241-1246. 50. Branum AM, Bailey R, Singer BJ. Dietary supplement use and folate status during pregnancy in the United States. J Nutr. 2013;143(4): 486-492. 51. Hebert JR, Ebbeling CB, Matthews CE, et al. Systematic errors in middle-aged womens estimates of energy intake: Comparing three self-report measures to total energy expenditure from doubly labeled water. Ann Epidemiol. 2002;12(8):577-586. 52. Horner NK, Patterson RE, Neuhouser ML, Lampe JW, Beresford SA, Prentice RL. Participant characteristics associated with errors in self- reported energy intake from the Womens Health Initiative food- frequency questionnaire. Am J Clin Nutr. 2002;76(4):766-773. 53. Archer E, Hand GA, Blair SN. Validity of U.S. Nutritional Surveillance: National Health and Nutrition Examination Survey Caloric Energy Intake Data, 1971e2010. PLoS One. 2013;8(10):e76632. AUTHOR INFORMATION C. Y. Park is a postdoctoral fellow, Department of Nutrition Science, Purdue University, West Lafayette, IN, and a postdoctoral fellow, Department of Biochemistry and Cell Biology, BK21 Plus KNU Biomedical Convergence Program, Kyungpook National University School of Medicine, Daegu, Korea. H. A. Eicher-Miller is an assistant professor, Department of Nutrition Science, Purdue University, West Lafayette, IN. Address correspondence to: Heather A. Eicher-Miller, PhD, Department of Nutrition Science, Purdue University, 700 W State St, West Lafayette, IN 47907-2059. E-mail: heicherm@purdue.edu STATEMENT OF POTENTIAL CONFLICT OF INTEREST No potential conict of interest was reported by the authors. FUNDING/SUPPORT This research was funded by the Department of Nutrition Science, Purdue University, West Lafayette, IN. ACKNOWLEDGEMENTS The authors thank Amy Branum, PhD, MSPH, branch chief of the Reproductive Statistics Branch at the National Center for Health Statistics, for her thoughtful review and helpful comments. RESEARCH -- 2014 Volume - Number - JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 7
Kenneth Dean Austin v. Howard Ray, Warden, Jackie Brannon Correctional Center and Attorney General of The State of Oklahoma, 124 F.3d 216, 10th Cir. (1997)