Iron (elemental iron) - Iron deficiency anemia is more common in women. However, iron deficiency without anemia can result in hair loss, impaired cognitive function and can exacerbate heavy menstrual bleeding, thereby making the deficiency worse. It can also impact endurance capacity with aerobic training (1). Upon diagnosis of iron deficiency anemia, oral iron therapy should be started immediately (2).

In toddlers, after breastfeeding or formula is discontinued, supplementation with 10 mg of elemental iron daily is recommended to prevent deficiency and impaired cognitive development (3). Mental development scores are improved with supplementation (4). Starting oral iron in antenatal iron-deficient women immediately following delivery produces improvements in hemoglobin levels and iron stores (5).

Vitamin B-12 (methylcobalamin) - Megaloblastic anemia may occur when vitamin B12 is deficient. Pernicious anemia is another type of vitamin B12 deficient anemia where intrinsic factor which helps with absorption of B12 is lacking. Simple treatment is replacement of vitamin B12 which is often accomplished through intramuscular (IM) injections. However, research shows that oral methylcobalamin is just as effective a treatment for vitamin B12 deficient anemia, and is better tolerated and less expensive compared with IM treatment (even in cases of pernicious anemia) (6).

Also, patients given oral methylcobalamin showed rapid improvements (1 month recovery) in blood parameters and neurological defects (7). Maintenance doses of 1,500 micrograms daily for 7 days every 1-3 months can be used in some patients to maintain levels of vitamin B12.

Folic acid - Folic acid deficiency can also cause megaloblastic anemia. Although many grain based foods are fortified with folic acid, special diets can contribute to deficiency, as well as certain medications. Taking oral contraceptives can cause folic acid deficiency, megaloblastic anemia, vitamin B12 deficiency and polyneuropathy (8). Folic acid deficiency anemia is also very common in psychogeriatric patients, and should be routinely evaluated (9).

Trace Minerals: The following minerals have been shown to support oxygen transport on red blood cells, a process that is limited in anemia.

Zinc - Deficiency of zinc can play a role in development of anemia and iron deficiency, especially in pregnant women (10). Therefore, in pregnant women, not only should iron be routinely supplemented, zinc should be included in the protocol as well.

Copper - Whenever zinc is given long term to treat any condition, copper must be co-administered to prevent copper deficiency because they use the same transport system. Sideroblastic anemia and peripheral neuropathy can be caused by copper deficiency which is for the most part the result of unopposed zinc therapy (11).

Selenium - Deficiency of selenium can contribute to anemia in ill patients, like those with HIV infection (12). Plasma levels of selenium are also significantly lower in children with iron deficiency anemia than in controls (13).

Vitamin C - Administration of vitamin C enhances the absorption of dietary iron in the gut (14). Clinical research has shown that giving vitamin C with iron is a more effective treatment for iron deficiency anemia than iron alone, improving blood parameters and measures of iron status (15).

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