Effects of calcium supplementation and lactation on iron status1–4
Heidi J Kalkwarf and Sonja D Harrast
ABSTRACT Calcium has been shown to inhibit iron
absorption. The consequences of chronic calcium supplementa-
tion on iron status are unclear, however. As part of a randomized
calcium-supplementation trial in lactating and nonlactating
women in the postpartum period, we determined whether long-
term calcium supplementation and lactation status affected iron
stores as measured by serum ferritin concentrations. Subjects
(95 lactating and 92 nonlactating) were enrolled at <6 mo post-
partum and then randomly assigned to receive either 500 mg Ca
as calcium carbonate or a placebo twice daily with meals for 6
mo. Lactating women weaned their infants <2 mo after enroll-
ment (ie, <8 mo postpartum). Calcium supplementation had no
effect on serum ferritin concentrations. At the end of the study,
geometric mean serum ferritin concentrations were 28.4 mg/L
in the calcium-supplemented group and 27.5 mg/L in the place-
bo group (P > 0.5). Lactation status was significantly related to
serum ferritin concentrations. At baseline, serum ferritin con-
centrations were higher in lactating women than in nonlactat-
ing women (47.7 compared with 31.5 mg/L, P < 0.001). In lac-
tating women, serum ferritin concentrations decreased by a
mean of 17 mg/L after weaning. By 12 mo postpartum, mean
serum ferritin concentrations in women who were previously
lactating were not significantly higher than those of nonlactat-
ing women (30.5 compared with 25.5 mg/L). These findings
provide reassurance that long-term calcium supplementation
does not impair iron stores. Furthermore, lactation status
should be considered when assessing iron nutriture of women
and determinants of iron status in populations. Am J Clin
Nutr 1998;67:1244–9.
KEY WORDS Lactation, weaning, postpartum period, fer-
ritin, iron stores, iron status, calcium supplementation, calcium
carbonate, randomized trial, women
INTRODUCTION
Consumption of calcium supplements has become more com-
mon as the health and economic consequences of osteoporosis
have come to be better appreciated (1). However, calcium, given
as a supplement or in the form of dairy products, may reduce
both heme- and nonheme-iron absorption by 40–60% (2–6). Cal-
cium appears to have the largest effect on iron absorption when
consumed with an iron-containing meal and no effect if con-
sumed ≥ 2 h after the meal (7). Consumption of calcium supple-
ments with meals is recommended to enhance the bioavailability
1244 Am J Clin Nutr 1998;67:1244–9. Printed in USA. © 1998 American Society for Clinical Nutrition
of calcium in the supplement (8). Iron status may, therefore, be
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compromised by long-term use of calcium supplements or intake
of foods high in calcium, particularly in women of reproductive
age in whom iron deficiency is common (9).
The nutritional consequences of long-term calcium supple-
mentation in free-living individuals has received little attention.
Yan et al (10) found no effect on serum ferritin concentrations of
giving lactating Gambian women (n = 60) a daily dose of 1 g Ca
as calcium carbonate. However, the supplement was given
between meals so the opportunity for inhibition of iron absorp-
tion was minimized. Sokoll and Dawson-Hughes (11) found no
effect on serum ferritin concentrations when healthy pre-
menopausal women (n = 109) were given 250 mg Ca as calcium
carbonate twice daily with meals for 12 wk.
As part of a randomized calcium-supplementation trial in lac-
tating and nonlactating women in the postpartum period, we
determined whether long-term supplementation with 500 mg Ca
taken twice daily with meals affected iron stores as measured by
serum ferritin concentrations. Because of the nature of the study
population, we also describe the effects of lactation and weaning
on maternal iron stores. To our knowledge, no reports in the lit-
erature have specifically evaluated the effects of lactation and
weaning on maternal iron stores.
SUBJECTS AND METHODS
Study subjects participated in a randomized calcium-supple-
mentation trial in women that was designed to evaluate the effects
of calcium supplementation on changes in bone density postpar-
tum (12, 13). Women were recruited from postpartum hospital
wards, through newspaper advertisements, and by word of mouth.
Iron status was assessed only in subjects who participated in the
1
From the Department of Pediatrics, Children’s Hospital Medical Center,
Cincinnati.
2
Presented in part at Experimental Biology ‘97, New Orleans, April 9,
1997.
3
Supported in part by grants from the NIH (RO1 AR41366 and MO1
RR08084 from the General Clinical Research Centers Program, National
Center for Research Resources).
4
Address reprint requests to HJ Kalkwarf, Division of General and Com-
munity Pediatrics, Children’s Hospital Medical Center, 3333 Burnet Avenue,
Cincinnati, OH 45229. E-mail: heidi.kalkwarf@chmcc.org.
Received August 15, 1997.
Accepted for publication November 25, 1997.
 CALCIUM SUPPLEMENTATION AND IRON STORES
study between <6 and 12 mo postpartum. These women (95 lac-
tating and 92 nonlactating) were enrolled in the study an average
of 5.6 ± 0.8 mo postpartum. Lactating women were breast-feeding
5.4 ± 1.1 times daily and providing no more than one supplemen-
tal formula feed per day (111 ± 90 mL) at the time of enrollment.
Lactating women weaned their infants from breast milk in the first
2 mo (7 ± 4 wk) after enrollment (ie, <8 mo postpartum). We refer
to this group as lactating or previously lactating to reflect their sta-
tus at the time measurements were obtained. Nonlactating women
had either fed their infants formula exclusively from birth (n = 86)
or had breast-fed for ≤ 2 wk (n = 6).
Four study groups were created by randomly assigning half of
the women in each feeding group (lactating and nonlactating) to
receive either 1 g Ca/d as calcium carbonate (Os-Cal; Marion
Merrell Dow, Kansas City, MO) or a placebo containing lactose.
Both subjects and study personnel were blinded to calcium treat-
ment assignment. The supplements were provided as two tablets
containing 500 mg Ca each, and subjects were instructed to con-
sume the supplement at two separate meals to facilitate absorption
of the calcium. There was no measure of whether the supplements
were consumed with meals. The calcium supplement and placebo
were consumed for 6 mo. Compliance with supplementation was
determined by pill counts performed every 3 mo. All women in the
study had low to moderate habitual calcium intakes (≤ 800 mg/d)
as determined by a food-frequency questionnaire (14) as part of
the main trial design. Subjects were also given a standard multivi-
tamin containing 60 mg vitamin C to consume daily throughout
the study and were asked to discontinue use of all other vitamin
and mineral supplements before enrollment.
Blood samples were obtained at enrollment (ie, <6 mo post-
partum) and 12 and 24 wk after calcium supplementation began
(ie, 9 and 12 mo postpartum). Hemoglobin, hematocrit, and mean
corpuscular volume (MCV) were measured immediately in the
clinical laboratory at Children’s Hospital Medical Center. Serum
samples were frozen at 270 °C for ferritin and C-reactive protein
(CRP) determinations so that all samples for a given subject could
be included in the same assay. Serum ferritin was measured by a
double-antibody radioimmunoassay (Diagnostic Products Corpo-
ration, Los Angeles). The intraassay and interassay CVs in our
laboratory for the low control (35 mg ferritin/L) were 10.5% and
17.7% and for the high control (189 mg ferritin/L) were 4.0% and
5.3%, respectively. Subjects were classified as having depleted
iron stores (ferritin < 12 mg/L), microcytosis (MCV < 80 fL), or
anemia (hemoglobin < 120 g/L) (16). CRP was measured by a
latex agglutination test (IMMUNEX CRP; Wampole Laboratories,
Cranbury, NJ). This test provided qualitative information: samples
were either positive or negative for CRP. Positive and negative
controls were run with each sample. CRP was measured to control
for the potential effects of inflammation and infection on serum
ferritin concentrations because ferritin and CRP are both increased
in these situations (15, 16).
Subjects kept two 3-d food records during the study, during
the 11th and 23rd study weeks. Nutrient intake was estimated
with the NUTRITION DATA SYSTEM (University of Min-
nesota Coordinating Center, Minneapolis). Information on iron
supplement use before enrollment in the study was recorded.
Subjects were questioned about brand names, iron content, fre-
quency, and duration of use of multivitamins, prenatal vitamins,
and iron supplements.
The study was approved by the Institutional Review Board at
Children’s Hospital Medical Center and all women provided
1245
written, informed consent to participate. Of the 187 women who
enrolled, 158 completed the study successfully. The reasons for
subjects being dropped from the study included loss of interest
in the study (n = 1), prolonged illness or chronic medication use
(n = 5), iron supplementation for anemia (n = 1 nonlactating
woman in the placebo group), use of hormonal contraceptives
(n = 1), pregnancy (n = 8), not weaning infant within 3 mo (n =
9), inability to swallow pills (n = 1), and relocation of subject or
inability to contact subject (n = 3).
The effect of calcium supplementation on iron status was
determined with repeated-measures analysis of variance, in
which the primary outcome variable was serum ferritin concen-
tration. Similar analyses were performed for the secondary out-
comes of hemoglobin concentration, MCV, and hematocrit. The
distribution of serum ferritin concentrations was skewed upward
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so the square roots of the ferritin values were used in all analy-
ses. Potential confounders considered in the analyses included
lactation group (lactating or nonlactating), dietary iron and vita-
min C intakes during the study, and duration of iron supplement
use before enrollment. Interaction terms with calcium-supple-
mentation group (supplement or placebo) and baseline iron sta-
tus and lactation group were also tested.
The effects of lactation on iron status were evaluated in two
ways. First, cross-sectional analyses were performed by compar-
ing mean serum ferritin concentrations at baseline (ie, <6 mo
postpartum) between lactating and nonlactating women. Analy-
sis of covariance was used to adjust for differences in the dura-
tion of postpartum use of iron-containing supplements between
groups. Second, we compared the changes in serum ferritin con-
centrations that occurred in lactating women coincident with
weaning with the changes observed in nonlactating women over
the same time interval by using analysis of covariance. These
changes were calculated as the differences between serum fer-
ritin concentrations at baseline (<6 mo postpartum), when lac-
tating women were still fully breast-feeding, and serum ferritin
concentrations at 9 and 12 mo postpartum (all lactating women
had completely ceased breast-feeding by 9 mo postpartum).
Duration of postpartum iron supplement use, calcium supple-
ment group, and dietary iron and vitamin C intakes were
included as covariates in the analyses.
All analyses were performed with and without subjects with
positive CRP results. Because the results were not appreciably
altered when subjects with positive CRP results were excluded,
only results for the whole sample are presented. Statistical analy-
ses were performed with JMP statistical software (version 3;
SAS Institute Inc, Cary, NC).
RESULTS
There were no significant differences among groups in age,
parity, dietary iron intake, or vitamin C intake during the study
(Table 1). At enrollment, only 14.5% of lactating women had
resumed menses whereas 98.8% of nonlactating women had;
these proportions did not differ by calcium supplement group.
All but one woman in the lactating group had resumed menses by
the end of the study (ie, <12 mo postpartum).
By design, all women had taken prenatal vitamin and mineral
supplements during pregnancy that contained 60–90 mg Fe. In
addition to prenatal vitamin and mineral supplements, 25%
(39/158) of women took supplemental iron during pregnancy for
a mean (± SD) of 6.4 ± 2.6 mo. There was variable use of iron-
1246 KALKWARF AND HARRAST

TABLE 1
Descriptive characteristics of the study subjects1
Lactating women Nonlactating women
Calcium (n = 38) Placebo (n = 38) Calcium (n = 40) Placebo (n = 42)
Age (y) 30 ± 32 31 ± 3 31 ± 3 31 ± 4
Parity 2±1 2±1 2±1 2±1
Height (m) 164.5 ± 6.7 163.9 ± 6.7 165.0 ± 6.9 164.9 ± 6.0
Weight (kg)2 60.7 ± 14.03 61.4 ± 10.83 65.1 ± 11.8 66.4 ± 10.5
Dietary iron intake (mg/d) 13.2 ± 4.7 14.0 ± 4.2 13.3 ± 6.0 12.1 ± 3.7
Dietary vitamin C intake (mg/d) 69 (41, 114) 4 66 (34, 128) 64 (37, 112) 54 (29, 100)
Dietary calcium intake (mg/d) 684 ± 239 776 ± 222 744 ± 214 679 ± 212
Percentage of women who took ≥ 80% of pills (%) 92.1 94.7 87.5 85.7
Menses at enrollment 5/38 5 6/38 5 40/40 41/42
Time to resumption of menses (wk postpartum) 30 ± 7 5 29 ± 9 5 8±2 8±5
Breast-feeding at enrollment (no. of feeds/d) 5.5 ± 1.1 5.3 ± 1.2 — —

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Total duration of lactation (wk) 31.4 ± 5.7 29.7 ± 6.4 — —
Time to complete weaning after enrollment (wk) 7.9 ± 3.7 7.1 ± 3.7 — —
Duration of iron supplement use postpartum,
tertile distribution (%)
0–0.5 mo (n = 49) 133 10.53 45.0 52.4
0.5–4.0 mo (n = 56) 31.63 34.23 35.0 40.5
> 4.0 mo (n = 53) 55.33 52.33 20.0 7.1
1
Women in the calcium and placebo groups received 500 mg Ca as calcium carbonate or placebo twice daily with meals, respectively.
2 –x ± SD.
3, 5
Significantly different from nonlactating women: 3 P < 0.05, 5 P < 0.01 (tested as the main effect of lactation).
4
Geometric mean (± 1 SD). Vitamin C intake does not include the 60 mg contained in the daily multivitamin supplement.

containing supplements postpartum before enrollment into the
study: 78% reported taking prenatal vitamin and mineral supple-
ments or other multivitamins containing iron postpartum and
15% reported taking iron supplements postpartum. Almost all
subjects who took supplements reported that they took them
daily. Because many women could not remember the brand name
or the iron content of the supplement they consumed, subjects
were classified according to the maximum duration of iron or
iron-containing supplement use. The tertile distributions of dura-
tion of iron-containing supplement use by lactation and calcium
supplement groups are given in Table 1. Lactating women were
more likely than nonlactating women to take iron or iron-con-
taining supplements postpartum (92% compared with 71%,
respectively, P < 0.0001) and took them longer.
Overall, 60 of 457 (13%) serum samples tested positive for
CRP, and there were no differences in the proportion testing pos-
itive across the four study groups at any sampling time (data not
shown). There were insufficient serum samples available to per-
form the CRP test on 17 samples (3.6% of the total). One subject
was excluded from all subsequent statistical analyses because
her initial serum ferritin concentration was 465 mg/L, which was
14.5 SDs above the group mean. The mean serum ferritin con-
centration was higher for samples that tested positive for CRP
than for those that tested negative (P < 0.01): the geometric
means (21 SD, +1 SD) were 40.3 (14.4, 79.2) and 31.9 (13.2,
59.1) mg/L, respectively. Hemoglobin concentration, MCV, and
hematocrit did not differ between CRP-positive and CRP-nega-
tive samples (P ≥ 0.3).
Effects of calcium supplementation on iron status
The mean serum ferritin concentrations of each of the four
study groups during the study are shown in Figure 1. At base-
line, serum ferritin concentrations differed between the lactating
and nonlactating groups (see the next section), but there were no
significant differences between the calcium-supplemented and
placebo groups within each lactation group or averaged across
lactation groups (P > 0.40). Calcium supplementation did not
significantly affect serum ferritin concentrations. The supple-
ment group 3 time interaction term, which formally tests the
effect of calcium supplementation, was not significant (P = 0.8),
and the three-way interaction term (lactation group 3 supple-
ment group 3 time) also was not significant (P = 0.16). At the
end of the study (<12 mo postpartum), the geometric mean
serum ferritin concentrations (21 SD, +1 SD) averaged across
lactation groups were 28.4 (12.3, 51.0) mg/L in the calcium-sup-
plemented women and 27.5 (9.3, 55.0) mg/L in the placebo-sup-
plemented women (P = 0.7). The results did not change 1) when
the outcome variable was expressed as change from baseline (eg,
final 2 initial serum ferritin concentration) and dietary iron and
vitamin C intakes and iron supplementation use postpartum were
included as covariates in the analyses, or 2) when the sample was
restricted to the 142 women whose baseline serum ferritin con-
centration was ≥ 12 mg/L. Furthermore, the proportion of sub-
jects with depleted iron stores (serum ferritin < 12 mg/L) at the
end of study did not differ between calcium-supplemented
(15.6%) and placebo (21.2%) groups (P = 0.4).
Mean hemoglobin concentrations, MCV, and hematocrit by
lactation and calcium-supplementation groups are given in Table
2. As for serum ferritin, there was no effect of calcium supple-
mentation on these indicators of iron status (P ≥ 0.3).
Effects of lactation on iron status
At baseline, serum ferritin concentrations were significantly
higher in lactating than in nonlactating women; the geometric
 CALCIUM SUPPLEMENTATION AND IRON STORES
FIGURE 1. Effects of calcium supplementation and lactation on
serum ferritin concentrations. Points represent the geometric mean fer-
ritin concentration for each group. Women received 500 mg Ca as calci-
um carbonate or placebo twice daily with meals. Lactating women were
breast-feeding an average of 5.4 times daily at baseline; the arrow
labeled “weaned” indicates the average time of complete cessation of
breast-feeding. Calcium effect (calcium group 3 time interaction),
P = 0.8; lactation effect (lactation group 3 time interaction), P < 0.001.
Serum ferritin concentrations were significantly greater for lactating
than for nonlactating women at baseline (P < 0.001) and significantly
decreased over time (P < 0.01).
means (21 SD, +1 SD) were 47.7 (22.4, 82.3) and 31.5 (12.6,
58.9) mg/L, respectively (P < 0.001). There were no significant
differences in baseline hemoglobin concentrations, MCV, or
hematocrit between lactating and nonlactating women (Table 2;
P ≥ 0.07). Because the duration of iron supplementation post-
partum differed between lactating and nonlactating women, it
was necessary to adjust for this potentially confounding factor in
the analyses. Categorizing the duration of iron supplement use
into tertiles provided a better statistical fit than did including
duration as a continuous variable. The magnitude of the differ-
ence in serum ferritin concentrations between groups and the sta-
tistical significance diminished after duration of iron supple-
mentation use postpartum was controlled for; however, serum
ferritin concentrations still remained higher in lactating women
than in nonlactating women after this adjustment. The adjusted
means (21 SEM, +1 SEM) were 44.0 (40.7, 47.5) and 34.5
(31.6, 37.4) mg/L, respectively (P = 0.044).
Serum ferritin concentrations decreased significantly in lac-
tating women after they weaned their infants, and the difference
in serum ferritin concentrations between women who were pre-
viously lactating and nonlactating women diminished over time.
The mean (± SD) decreases in serum ferritin concentrations at 9
and 12 mo postpartum (1.2 and 4.2 mo after complete weaning,
respectively) were 13.9 ± 16.4 and 18.4 ± 17.5 mg/L for lactat-
ing women compared with 2.3 ± 17.7 and 6.2 ± 19.1 mg/L for
nonlactating women. The percentage of lactating women with
depleted iron stores (serum ferritin < 12 mg/L) increased from
6.7% at baseline when the women were fully lactating to 19.7%
at the end of the study, an average of 4.2 mo after weaning
(P = 0.03). The respective percentages for nonlactating women
were 11.1% and 17.2% (P = 0.37). After adjustment for postpar-
tum iron supplement use and dietary iron intake during the study,
the mean (± SEM) decrease in serum ferritin concentration by 12
1247
mo postpartum in women who were previously lactating was
17.6 ± 2.3 mg/L compared with 7.1 ± 2.1 mg/L in nonlactating
women (P < 0.01). By the end of the study (12 mo postpartum),
there was no difference in serum ferritin concentrations between
previously lactating women and nonlactating women; the geo-
metric means were 30.5 and 25.5 mg/L, respectively (P = 0.14).
Changes in hemoglobin concentration, MCV, and hematocrit
over the study did not differ between lactating and nonlactating
women whether or not previous postpartum iron supplementa-
tion or iron intake during the study was included in the analyses
(P > 0.2).
We investigated whether the length of postpartum amenorrhea
could account for some of the variability in serum ferritin con-
centration among lactating women and whether it was associated
with the decreased serum ferritin concentrations after weaning.
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There was no difference in baseline serum ferritin concentrations
among lactating women who had resumed menses before enroll-
ment (n = 11) and those who had not (n = 65); the geometric
means were 44.7 and 48.2 mg/L, respectively (P = 0.7). Further-
more, the length of postpartum amenorrhea in lactating women
was not associated with the change in serum ferritin concentra-
tion during the 6-mo study (P > 0.3).
DISCUSSION
Effects of calcium supplementation on iron status
The goals of the present study were to determine whether long-
term calcium supplementation has a deleterious effect on iron sta-
tus in women in the postpartum period and to describe the effects
of lactation and weaning on maternal iron status. We found that
consumption of supplements containing 500 mg Ca twice daily for
6 mo did not alter serum ferritin concentrations, despite the fact
that women were instructed to consume their calcium supplement
at mealtime, a regimen that should have maximized the potential
inhibitory effect of calcium on iron absorption. These findings
provide reassurance that consumption of calcium supplements
with the goal of optimizing bone health should not have the nega-
tive consequence of compromising iron status.
Several studies using radioisotopes to label iron in meals have
shown that calcium inhibits both heme- and nonheme-iron
absorption from a test meal and that the inhibitory effect occurs
for a variety of calcium salts (3, 4, 6). Although calcium may
decrease iron absorption from a test meal, our data indicate that
daily calcium supplementation does not significantly reduce
serum ferritin concentrations or result in overt iron deficiency.
Our sample size was sufficient for detecting a minimum differ-
ence in serum ferritin concentration of <7 mg/L between the cal-
cium-supplemented and placebo groups with 80% power. Our
findings are consistent with those from one other study in which
calcium supplements were provided twice daily with meals,
although the calcium dose used in that study was 250 mg Ca
compared with 500 mg Ca in this study (11). In that study, both
the iron intake (15.1 mg/d) and vitamin C intake (227 mg/d) of
the study subjects were high, which may have overcome any
potential inhibitory effect on iron absorption. Our failure to find
an effect of calcium supplements on serum ferritin cannot be
explained by an abundance of dietary iron compensating for
reduced absorption efficiency because serum ferritin concentra-
tions decreased among lactating women after weaning when
menstrual blood loss resumed.
1248 KALKWARF AND HARRAST
TABLE 2
Effects of calcium supplementation and lactation group on hematologic indicators of iron status1
Lactating women
Calcium (n = 38)
Hemoglobin (g/L)
Baseline (6 mo) 135 ± 8
9 mo2, 3 134 ± 8
12 mo2 133 ± 7
Mean corpuscular volume (fL)
Baseline (6 mo) 89 ± 4
9 mo2 89 ± 3
12 mo2 90 ± 4
Hematocrit
Baseline (6 mo) 0.39 ± 0.03
9 mo2, 3 0.39 ± 0.02
12 mo2, 3 0.40 ± 0.03
1 –
x ± SD. Women in the calcium and placebo groups received 500 mg Ca as calcium carbonate or placebo twice daily with meals, respectively.
2
Lactating women had completely weaned their infants and were no longer lactating at these times.
3
Main effect of lactating compared with nonlactating, P < 0.05.
There are several possible reasons we did not find an effect of
long-term calcium supplementation on serum ferritin concentra-
tions. The moderate amount of calcium in the diet may have been
enough to maximally inhibit iron absorption so that no further
inhibition occurred with calcium supplementation. The
inhibitory effect of calcium on iron absorption from test meals
has been shown to be dose dependent up to <165–300 mg, with
no further increase in inhibition between 300 and 600 mg Ca (5).
It is also possible that women took their supplements between
meals rather than with their meals as instructed, thereby mini-
mizing the potential for inhibition of iron absorption.
Alternately, the test meal approach may overestimate the
inhibitory effect of calcium on iron absorption, and the true
inhibitory effect on iron absorption in the context of a complete
diet may be small. Studies using isotopically labeled single test
meals have found that calcium reduces iron absorption by <50%
(3, 4, 6), whereas the inhibitory effect is <25% when iron
absorption is measured from the whole diet (17, 18). Further-
more, balance studies in which subjects consume complete
meals have generally not found an inhibitory effect of calcium
on net iron absorption (19–21). The complex interplay of
enhancing and inhibiting factors in a complete diet makes it dif-
ficult to predict the overall effect of diet on iron absorption (22).
Last, iron absorption appears to be a highly regulated process,
although the exact mechanisms are unknown. Iron absorption is
inversely related to iron stores and the serum ferritin concentra-
tion has been shown to be the most important determinant of iron
absorption from a complete diet (22). It is possible that the ini-
tial inhibitory effect of calcium on iron absorption diminishes
over time in the presence of daily calcium supplementation. Fur-
thermore, it is not known whether low iron absorption at one
meal enhances absorption at another.
One limitation of this study is that we measured indicators of
iron status that best reflect the extremes in iron nutriture (ie, iron
stores, microcytosis, and anemia) and did not measure indicators
that reflect iron-deficient erythropoiesis, the intermediate stage
of iron deficiency after depletion of iron stores (15). It is possi-
ble that we missed an effect of calcium supplementation on iron
status that we could have detected by measuring serum transfer-
rin receptor concentrations, transferrin saturation, or erythrocyte
protoporphyrin. However, the subjects in this study were consid-
Nonlactating women
Placebo (n = 38) Calcium (n = 40) Placebo (n = 42)
133 ± 7 132 ± 7 132 ± 8
131 ± 6 129 ± 8 131 ± 8
130 ± 6 129 ± 7 130 ± 8
89 ± 4 88 ± 4 88 ± 4
89 ± 4 88 ± 4 88 ± 4
88 ± 4 88 ± 4 88 ± 4
0.39 ± 0.02 0.39 ± 0.02 0.39 ± 0.02
0.39 ± 0.02 0.38 ± 0.02 0.38 ± 0.02
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0.38 ± 0.02 0.38 ± 0.02 0.38 ± 0.02
ered at risk for impaired iron stores, not iron-deficient erythro-
poiesis. We chose to measure serum ferritin concentrations
because these are thought to best reflect iron stores and are the
most sensitive indicator of iron status in well-nourished popula-
tions. Furthermore, we measured CRP to rule out potential spu-
rious results due to increases in ferritin secondary to inflamma-
tion and infection (15, 16).
Effects of lactation on iron status
We found that lactating women had greater serum ferritin con-
centrations, and presumably iron stores, than nonlactating
women in the postpartum period and that serum ferritin concen-
trations decreased after weaning. The higher serum ferritin con-
centrations at baseline in lactating women may have been due in
part to the increased use of iron supplements by lactating women
before enrollment in the study. However, serum ferritin concen-
trations were still higher in lactating women after prior iron sup-
plement use was statistically controlled for.
Prolonged postpartum amenorrhea in lactating women likely
contributed to the differences in serum ferritin concentrations
between lactating and nonlactating women. Only 14.5% of lactat-
ing women had resumed menses by 6 mo postpartum (baseline)
whereas 98.8% of nonlactating women had resumed menses by
this time. Menstrual blood iron loss is estimated to be 0.5 mg/d
(23) in contrast with iron losses in breast milk of 0.24 mg/d (24).
The drop in serum ferritin concentrations in lactating women after
weaning may also have been due to the return of menses, which
occurred in all but one of the participants by the final measurement
taken in the study at 12 mo postpartum. We were unable to show
a relation between the length of postpartum amenorrhea and
change in serum ferritin concentration. It is possible that length of
postpartum amenorrhea is too crude of a measure to adequately
quantify the variability in iron loss with menses. Differences in
volume of menstrual blood loss constitute the largest source of
variability in iron status in menstruating women (23, 25). The vari-
ability in menstrual blood loss may be even greater postpartum
because first menstrual cycles in lactating women may be anovu-
latory, irregular, and of short duration (26).
Whether other hormonal or metabolic changes that accompany
lactation also contributed to the differences in serum ferritin con-
centration are unknown. Some acute phase proteins (eg, cerulo-
 CALCIUM SUPPLEMENTATION AND IRON STORES
plasmin) are increased in lactation whereas others (eg, CRP and
a1-antitrypsin) are not (27). Theoretically, redistribution of iron
among different body pools may also occur to facilitate transfer of 10.
iron to the mammary glands for milk production. To our knowl-
edge there are no reports that systematically evaluated the effects
of lactation and weaning on maternal iron status or iron metabo- 11.
lism. We presume that the decrease in serum ferritin concentra-
tions that we observed after weaning was a consequence of wean-
ing because we did not see a comparable decrease in the 12.
nonlactating women at the same time postpartum. However, we
did not follow lactating women who continued to breast-feed after 13.
9 mo postpartum, so we do not know whether serum ferritin con-
centrations would have decreased in these women as well.
Despite the decrease in serum ferritin concentrations that 14.
occurred after weaning, there was no effect on the incidence of
microcytosis or anemia in this population. Whether lactation and 15.
weaning have a greater hematologic effect in populations with
greater compromise in iron status is unknown. The fact that serum 16.
ferritin concentrations were influenced by lactation status is impor-
tant for understanding the determinants of iron status in populations
of women at different stages of reproduction. From a clinical or pro-
grammatic perspective, lactation status should be considered when 17.
screening for depletion of iron stores. Because lactation is a tempo-
rary physiologic state (usually ≤ 6 mo in the United States),
reassessment of iron stores after weaning may be warranted.
18.
We thank Donna C Bianchi for recruitment and maintenance of the study
cohort and Kay Ellis for performing all of the serum ferritin assays for this 19.
study.
20.
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