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2016
DAILY IRONSUPPLEMENTATIONin adult women andadolescent girls
GUIDELINE
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Guideline:DAILY IRON SUPPLEMENTATIONIN ADULT WOMEN
AND ADOLESCENT GIRLS
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WHO Guideline: Daily iron supplementation in adult women and adolescent girlsIV
WHO Library Cataloguing-in-Publicaon Data
Guideline: Daily iron supplementaon in adult women and adolescent girls
1.Iron - administraon and dosage. 2.Anaemia - prevenon and control. 3.Adolescent girls. 4.Adult women.
5.Menstruang women. 6.Guideline. I.World Health Organizaon.
ISBN 978 92 4 151019 6 (NLM classicaon: WH 160)
© World Health Organizaon 2016
All rights reserved. Publicaons of the World Health Organizaon are available on the WHO web site ( www.
who.int) or can be purchased from WHO Press, World Health Organizaon, 20 Avenue Appia, 1211 Geneva 27,
Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: [email protected]).
Requests for permission to reproduce or translate WHO publicaons – whether for sale or for non-commercial
distribuon – should be addressed to WHO Press through the WHO web site (www.who.int/about/licensing/
copyright_form/en/index.html).
The designaons employed and the presentaon of the material in this publicaon do not imply the expression
of any opinion whatsoever on the part of the World Health Organizaon concerning the legal status of any
country, territory, city or area or of its authories, or concerning the delimitaon of its froners or boundaries.
Doed lines on maps represent approximate borderlines for which there may not yet be full agreement.
The menon of specic companies or of certain manufacturers’ products does not imply that they are
endorsed or recommended by the World Health Organizaon in preference to others of a similar nature that
are not menoned. Errors and omissions excepted, the names of proprietary products are disnguished by
inial capital leers.
All reasonable precauons have been taken by the World Health Organizaon to verify the informaon
contained in this publicaon. However, the published material is being distributed without warranty of any
kind, either expressed or implied. The responsibility for the interpretaon and use of the material l ies with the
reader. In no event shall the World Health Organizaon be liable for damages arising from its use.
Cover design and layout: Chris Yuen ([email protected])
Document layout: Elysium sàrl
Printed by the WHO Document Producon Services, Geneva, Switzerland
SUGGESTED CITATION
Guideline: Daily iron supplementaon in adult women and adolescent girls. Geneva: World Health Organizaon;
2016.
http://www.who.int/http://www.who.int/mailto:[email protected]://www.who.int/about/licensing/copyright_form/en/index.htmlhttp://www.who.int/about/licensing/copyright_form/en/index.htmlhttp://../.pdfhttp://../.pdfhttp://www.who.int/about/licensing/copyright_form/en/index.htmlhttp://www.who.int/about/licensing/copyright_form/en/index.htmlmailto:[email protected]://www.who.int/http://www.who.int/
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WHO Guideline: Daily iron supplementation in adult women and adolescent girls VI
ACKNOWLEDGEMENTS
This guideline was coordinated by the World Health Organizaon (WHO) Evidence and Programme Guidance
Unit, Department of Nutrion for Health and Development. Dr Pura Rayco-Solon, Dr Lisa Rogers and Dr Juan
Pablo Peña-Rosas oversaw the preparaon of this document. WHO acknowledges the technical contribuons
of the following individuals (in alphabecal order): Dr Andrea Bosman, Ms Hala Boukerdenna, Dr Carmen
Casanovas, Dr Camila Chaparro, Dr Maria Nieves García-Casal, Dr Viviana Mangiaterra, Ms Zita Weise Prinzo
and Mr Gerardo Zamora. We also thank the peer-reviewers Ms Solange Durao, Dr Tran Khanh Van and Ms
Terrie Wefwafwa.
We would like to express our gratude to Dr Susan Norris from the WHO Guidelines Review Commiee
Secretariat and members of the Guidelines Review Commiee for their technical support throughout the
process. Thanks are also due to Ms Alma Alic from the Department of Compliance and Risk Management and
Ethics, for her support in the management of the conicts of interests procedures. Ms Jennifer Volonnino,
from the Evidence and Programme Guidance Unit, Department of Nutrion for Health and Development,
provided logisc support.
WHO gratefully acknowledges the technical input of the members of the WHO Steering Commiee for
Nutrion Guidelines Development and the WHO guidelines development groups, especially the chairs of the
meeng concerning this guideline, Ms Deena Alaasor and Dr Maria Elena del Socorro Jeerds.
Financial support WHO thanks the Bill & Melinda Gates Foundaon for providing nancial support for this work. The
Micronutrient Iniave and the Internaonal Micronutrient Malnutrion Prevenon and Control Program of
the United States Centers for Disease Control and Prevenon (CDC) provided nancial support to the Evidence
and Programme Guidance Unit, Department of Nutrion for Health and Development, for the commissioning
of systemac reviews of nutrion intervenons. Donors do not fund specic guidelines and do not parcipate
in any decision related to the guideline development process, including the composion of research quesons,
membership of the guideline groups, conduct and interpretaon of systemac reviews, or formulaon of
recommendaons.
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WHO Guideline: Daily iron supplementation in adult women and adolescent girls 1
WHO GUIDELINE1: DAILY IRON SUPPLEMENTATION IN ADULT WOMEN AND ADOLESCENT GIRLS
EXECUTIVE SUMMARYGlobally, one in three non-pregnant women, corresponding to almost 500 million women, were anaemic in
2011. Iron deciency is thought to contribute to at least half of the global burden of anaemia. Iron deciency
occurs following prolonged negave iron balance, the major causes of which include inadequate intake
(owing to insucient bioavailable iron in the diet or decreased iron absorpon), increased iron requirements
(for instance, during periods of growth) and chronic blood loss (from heavy hookworm infecon or menstrual
bleeding). In adolescent girls, menstrual blood losses, accompanied by rapid growth with expansion of the
red cell mass and increased ssue iron requirements, make them parcularly vulnerable to iron deciency
compared to male counterparts. This guideline reviews the evidence and updates the recommendaon for
daily iron supplementaon in menstruang adult women and adolescent girls.
Purpose of the guideline This guideline aims to help Member States and their partners in their eorts to make informed decisions onthe appropriate nutrion acons to achieve the Sustainable Development Goals (SDGs) ( 1 ), the global targets
set in the Comprehensive implementaon plan on maternal, infant and young child nutrion (2) and the
Global strategy for women’s, children’s and adolescent’s health (2016–2030) (3). The recommendaon in this
guideline is intended for a wide audience, including policy-makers, their expert advisers, and technical and
programme sta at organizaons involved in the design, implementaon and scaling-up of programmes for
anaemia prevenon and control, and in nutrion acons for public health. The recommendaon supersedes
those of previous WHO guidelines on iron supplementaon in menstruang adult women and adolescent
girls.
Guideline development methodology WHO developed the present evidence-informed recommendaon using the procedures outlined in the WHO
handbook for guideline development (4). The steps in this process included: (i) idencaon of priority quesonsand outcomes; (ii) retrieval of the evidence; (iii) assessment and synthesis of the evidence; (iv) formulaon
of recommendaon, including research priories; and planning for (v) disseminaon; (vi) implementaon,
equity and ethical consideraons; and (vii) impact evaluaon and updang of the guideline. The Grading
of Recommendaons Assessment, Development and Evaluaon (GRADE) methodology was followed ( 5 ), to
prepare evidence proles related to preselected topics, based on up-to-date systemac reviews.
The guideline development group consisted of content experts, methodologists and representaves of
potenal stakeholders and beneciaries. One guideline group parcipated in a meeng concerning this
guideline, held in Geneva, Switzerland, on 20–25 February 2010, where the guideline was scoped. A second
guideline group parcipated in a meeng held in Geneva, Switzerland, on 14–18 March 2011, to discuss
the safety of iron supplementaon in menstruang adult women and adolescent girls living in areas of high
malaria transmission, and a third meeng was convened in Geneva, Switzerland, on 23–26 June 2014, wherethe guideline was nalized. Three experts served as technical peer-reviewers of the dra guideline.
Available evidence The available evidence comprised a systemac review (6) that followed the procedures of the Cochrane
1 This publicaon is a World Health Organizaon (WHO) guideline. A WHO guideline is any document, whatever its tle, containing WHOrecommendaons about health intervenons, whether they be clinical, public health or policy intervenons. A standard guideline is
produced in response to a request for guidance in relaon to a change in pracce, or controversy in a single clinical or policy area, andis not expected to cover the full scope of the condion or public health problem. A recommendaon provides informaon about whatpolicy-makers, health-care providers or paents should do. It implies a choice between dierent intervenons that have an impact onhealth and that have ramicaons for the use of resources. All publicaons containing WHO recommendaons are approved by theWHO Guidelines Review Commiee.
https://sustainabledevelopment.un.org/topicshttps://sustainabledevelopment.un.org/topicshttps://sustainabledevelopment.un.org/topicshttps://sustainabledevelopment.un.org/topicshttp://www.who.int/nutrition/topics/WHA65.6_resolution_en.pdf?ua=1http://www.who.int/nutrition/topics/WHA65.6_resolution_en.pdf?ua=1http://www.who.int/nutrition/topics/WHA65.6_resolution_en.pdf?ua=1http://www.who.int/life-course/partners/global-strategy/globalstrategyreport2016-2030-lowres.pdf?ua=1http://www.who.int/life-course/partners/global-strategy/globalstrategyreport2016-2030-lowres.pdf?ua=1http://www.who.int/kms/handbook_2nd_ed.pdf,http://www.who.int/kms/handbook_2nd_ed.pdf,http://www.who.int/kms/handbook_2nd_ed.pdf,http://www.who.int/kms/handbook_2nd_ed.pdf,http://www.gradeworkinggroup.org/http://www.gradeworkinggroup.org/http://www.gradeworkinggroup.org/http://www.gradeworkinggroup.org/http://community.cochrane.org/handbookhttp://community.cochrane.org/handbookhttp://www.gradeworkinggroup.org/http://www.gradeworkinggroup.org/http://www.who.int/kms/handbook_2nd_ed.pdf,http://www.who.int/kms/handbook_2nd_ed.pdf,http://www.who.int/life-course/partners/global-strategy/globalstrategyreport2016-2030-lowres.pdf?ua=1http://www.who.int/nutrition/topics/WHA65.6_resolution_en.pdf?ua=1https://sustainabledevelopment.un.org/topicshttps://sustainabledevelopment.un.org/topics
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WHO Guideline: Daily iron supplementation in adult women and adolescent girls2
handbook for systemac reviews of intervenons (7) and assessed the eects of daily iron supplementaon
in menstruang adult women and adolescent girls. The reviews included individually randomized and cluster-
randomized controlled trials. All studies compared a group of non-pregnant adolescent girls and menstruangadult women who received daily oral iron supplementaon to a group that did not receive iron. The overall
quality of the available evidence for daily iron supplementaon in menstruang adult women and adolescent
girls was moderate for the crical outcomes of anaemia and iron deciency. No evidence was available for
the outcomes of iron deciency anaemia and malaria-related morbidity. The WHO Secretariat conducted an
addional search for evidence prior to the nalizaon of the guideline (November 2015), and did not idenfy
any addional relevant studies.
Recommendation 1
Daily iron supplementaon is recommended as a public health intervenon in menstruang adult women
and adolescent girls, living in sengs where anaemia is highly prevalent (≥40% anaemia prevalence),2 for the
prevenon of anaemia and iron deciency (strong recommendaon, moderate quality of evidence).
Suggested scheme for daily iron supplementation in adult women and adolescent girls
TARGET GROUP Menstruang adult women and adolescent girls (non-pregnant females in thereproducve age of group)
SUPPLEMENT COMPOSITION 30–60 mg elemental irona
SUPPLEMENT FORM Tablets
FREQUENCY Daily
DURATION Three consecuve months in a year
SETTINGSWhere the prevalence of anaemia in menstruang adult women and adolescent
girls is 40% or higherb
a 30–60 mg of elemental iron equals 150–300 mg of ferrous sulfate heptahydrate, 90–180 mg of ferrous fumarate or 250–500 mg offerrous gluconate.
b In the absence of prevalence data in this group, consider proxies for hig h risk of anaemia. For the most recent esmates, visit theWHO - hosted Vitamin and Mineral Nutrion Informaon System (VMNIS) ( 8 ).
Remarks The remarks in this secon are intended to give some consideraons for implementaon of the
recommendaon, based on the discussion of the guideline development group.
• Daily oral iron supplementaon is a prevenve strategy for implementaon at the populaon level.
If a menstruang woman or adolescent girl is diagnosed with anaemia, naonal guidelines for the
treatment of anaemia should be followed.
• Daily iron supplementaon should be considered in the context of other intervenons containing
iron (fored foods, mulple micronutrient powders, lipid-based nutrient supplements).
1 This recommendaon supersede those of previous WHO guidelines on iron supplementaon in menstruang adult women andadolescent girls.
2 Where the prevalence of anaemia is 40% or higher in this age group. For the latest esmates, please refer to the WHO-hosted Vitaminand Mineral Nutrion Informaon System (VMNIS) ( 8 ).
http://community.cochrane.org/handbookhttp://community.cochrane.org/handbookhttp://www.who.int/vmnis/enhttp://www.who.int/vmnis/en/http://www.who.int/vmnis/enhttp://www.who.int/vmnis/enhttp://www.who.int/vmnis/enhttp://www.who.int/vmnis/enhttp://www.who.int/vmnis/enhttp://www.who.int/vmnis/en/http://http//www.who.int/vmnis/en/,%20accessed%204%20December%202015).http://http//www.who.int/vmnis/en/,%20accessed%204%20December%202015).http://http//www.who.int/vmnis/en/,%20accessed%204%20December%202015).http://http//www.who.int/vmnis/en/,%20accessed%204%20December%202015).http://http//www.who.int/vmnis/en/,%20accessed%204%20December%202015).http://http//www.who.int/vmnis/en/,%20accessed%204%20December%202015).http://http//www.who.int/vmnis/en/,%20accessed%204%20December%202015).http://www.who.int/vmnis/en/http://www.who.int/vmnis/en/http://http//www.who.int/vmnis/en/,%20accessed%204%20December%202015).http://http//www.who.int/vmnis/en/,%20accessed%204%20December%202015).http://www.who.int/vmnis/en/http://www.who.int/vmnis/enhttp://community.cochrane.org/handbook
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WHO Guideline: Daily iron supplementation in adult women and adolescent girls 3
• The selecon of the most appropriate delivery plaorm should be context specic, with the aim
of reaching the most vulnerable populaons and ensuring a mely and connuous supply of
supplements.
• All women, from the moment they begin trying to conceive unl 12 weeks of gestaon, should
take a folic acid supplement. Daily oral iron and folic acid supplementaon should be part of
roune antenatal care, begun as early as possible and connued throughout pregnancy. Where
the prevalence of anaemia in pregnant women is high (40% or more), supplementaon should
connue for 3 months in the postpartum period ( 10 , 11 ).
Research priorities Discussions between the members of the WHO guideline development group and the external review group
highlighted the limited evidence available in some knowledge areas, mering further research on iron
supplementaon in menstruang adult women and adolescent girls, parcularly in the following areas:
• the opmal dose, schedule and duraon of iron supplementaon; the eect of dierent doses and
duraon of iron supplementaon on dierent severity, prevalence or causes of anaemia in all WHO
regions;
• addional data on the safety of iron supplementaon (liver damage; iron overload aer connuing
the supplementaon programme for a number of years; iron supplementaon given in conjuncon
with other intervenons; insulin resistance; eects on non-anaemic or non-iron-decient women
and adolescent girls);
• the eect of adding other micronutrients to the iron supplement on haemoglobin concentraons
and the prevalence of anaemia;
• implementaon research on eecve behaviour-change strategies for sustained adherence andinnovave delivery mechanisms for iron supplements;
• addional long-term studies on funconal outcomes (e.g. exercise performance and producvity);
• cost, cost–benet and feasibility analysis of the distribuon of iron supplementaon to be taken
daily or intermiently among menstruang adult women and adolescent girls.
http://apps.who.int/iris/bitstream/10665/69735/1/a91272.pdfhttp://apps.who.int/iris/bitstream/10665/77770/1/9789241501996_eng.pdf?ua=1http://apps.who.int/iris/bitstream/10665/77770/1/9789241501996_eng.pdf?ua=1http://apps.who.int/iris/bitstream/10665/69735/1/a91272.pdf
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WHO Guideline: Daily iron supplementation in adult women and adolescent girls4
WHO GUIDELINE1: DAILY IRON SUPPLEMENTATION IN ADULT WOMEN AND ADOLESCENT GIRLS
SCOPE AND PURPOSEThis guideline provides a global, evidence-informed recommendaon on daily iron supplementaon in menstruang
adult women and adolescent girls, as a public health intervenon for the prevenon of anaemia and iron deciency.
The guideline aims to help Member States and their partners in their eorts to make informed decisions on
the appropriate nutrion acons to achieve the Sustainable Development Goals (SDGs) ( 1 ), in parcular, Goal
2: End hunger, achieve food security and improved nutrion and promote sustainable agriculture. It will also
support Member States in their eorts to achieve the global targets set in the Comprehensive implementaon
plan on maternal, infant and young child nutrion, as endorsed by the Sixty-h World Health Assembly in
2012, in resoluon WHA65.6 ( 2 ), and the Global strategy for women’s, children’s, and adolescent’s health
(2016–2030) (3).
The recommendaon in this guideline is intended for a wide audience, including policy-makers, their expertadvisers, and technical and programme sta at government instuons and organizaons involved in the design,
implementaon and scaling-up of programmes for anaemia prevenon and control, and in nutrion acons for public
health. This guideline is intended to contribute to discussions among stakeholders when selecng or priorizing
intervenons to be undertaken in their specic context. This document presents the key recommendaon and a
summary of the supporng evidence.
BACKGROUND
Globally, one in three non-pregnant women, corresponding to almost 500 million women, were anaemic in
2011 ( 12 ). Iron deciency is thought to contribute to at least half of the global burden of anaemia, though this
proporon can vary widely and is very context specic. Iron deciency occurs following prolonged negave
iron balance, the major causes of which include inadequate intake (owing to insucient bioavailable iron in
the diet or decreased iron absorpon), increased iron requirements (for instance, during periods of growth)
and chronic blood loss (from heavy hookworm infecon or menstrual bleeding) ( 13 ).
From the me that girls enter menarche unl menopause, women are at high risk of iron deciency, owing
to menstrual blood losses. In adolescent girls, menstrual blood losses, accompanied by rapid growth with
expansion of the red cell mass and increased ssue iron requirements, make them parcularly vulnerable to
iron deciency compared to their male counterparts (14).
Public health intervenons that improve iron status in populaons include nutrion counselling that promotes
diet diversity and food combinaons that improve iron absorpon; forcaon of staple or rounely
consumed foods with iron; point-of-use forcaon with mulple micronutrients including iron; treatment of
preventable causes of iron losses such as hookworm infestaon; and iron supplementaon.
In 2001, WHO recommended prevenve supplementaon of 60 mg/day iron for three months for non-pregnant
women of reproducve age in sengs where the prevalence of anaemia is above 40% ( 13 ). This guideline
reviews the evidence and updates the recommendaon for daily iron supplementaon in menstruang adult
women and adolescent girls.
1 This publicaon is a World Health Organizaon (WHO) guideline. A WHO guideline is any document, whatever its tle, containing WHOrecommendaons about health intervenons, whether they be clinical, public health or policy intervenons. A standard guideline is
produced in response to a request for guidance in relaon to a change in pracce, or controversy in a single clinical or policy area, and isnot expected to cover the full scope of the condion or public health problem. A recommendaon provides informaon about what policy-makers, health-care providers or paents should do. It implies a choice between dierent intervenons that have an impact on health andthat have ramicaons for the use of resources. All publicaons containing WHO recommendaons are approved by the WHO GuidelinesReview Commiee.
http://sustainabledevelopment.un.org/topics,%20accessed%204%20December%202015http://apps.who.int/gb/ebwha/pdf_files/WHA65/A65_11-en.pdf?ua=1http://apps.who.int/gb/ebwha/pdf_files/WHA65/A65_11-en.pdf?ua=1https://sustainabledevelopment.un.org/topicshttp://who.int/life-course/partners/global-strategy/globalstrategyreport2016-2030-lowres.pdf?ua=1http://who.int/life-course/partners/global-strategy/globalstrategyreport2016-2030-lowres.pdf?ua=1http://who.int/life-course/partners/global-strategy/globalstrategyreport2016-2030-lowres.pdf?ua=1http://www.who.int/nutrition/publications/micronutrients/global_prevalence_anaemia_2011/en/http://apps.who.int/iris/bitstream/10665/66914/1/WHO_NHD_01.3.pdf?ua=1http://apps.who.int/iris/bitstream/10665/66914/1/WHO_NHD_01.3.pdf?ua=http://apps.who.int/iris/bitstream/10665/66914/1/WHO_NHD_01.3.pdf?ua=http://apps.who.int/iris/bitstream/10665/66914/1/WHO_NHD_01.3.pdf?ua=1http://www.who.int/nutrition/publications/micronutrients/global_prevalence_anaemia_2011/en/http://who.int/life-course/partners/global-strategy/globalstrategyreport2016-2030-lowres.pdf?ua=1http://who.int/life-course/partners/global-strategy/globalstrategyreport2016-2030-lowres.pdf?ua=1https://sustainabledevelopment.un.org/topicshttp://apps.who.int/gb/ebwha/pdf_files/WHA65/A65_11-en.pdf?ua=1http://apps.who.int/gb/ebwha/pdf_files/WHA65/A65_11-en.pdf?ua=1http://sustainabledevelopment.un.org/topics,%20accessed%204%20December%202015
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WHO Guideline: Daily iron supplementation in adult women and adolescent girls 5
OBJECTIVES
The recommendaon in this guideline supersedes those of previous WHO guidelines on iron supplementaon,
such as Iron deciency anaemia: assessment, prevenon, and control. A guide for programme managers ( 13 ),
where they pertain specically to daily oral iron supplementaon among menstruang adult women and
adolescent girls (non-pregnant females in the reproducve age group). This guideline complements the WHO
Guideline: intermient iron and folic acid supplementaon in menstruang women ( 9 ), which is applicable to
sengs where the prevalence of anaemia among non-pregnant women of reproducve age is 20% or higher.
SUMMARY OF AVAILABLE EVIDENCE
The evidence that informed the recommendaon on daily iron supplementaon in menstruang adult women
and adolescent girls is based on a systemac review of women and adolescent girls beyond menarche and
prior to menopause who were not pregnant or lactang and did not have any condion that impedes the
presence of menstrual periods (6). The systemac review also included studies for which results for girls and
women aged between 12 and 50 years (plausible age range for menstruaon) could be extracted separately, orin which more than half of the parcipants fullled this criterion. The review excluded studies on populaons
with condions aecng iron metabolism, intesnal malabsorpon condions, ongoing excessive blood loss
(including ongoing blood donaons), inammatory bowel disease, cancer, chronic congesve cardiac failure,
chronic renal failure, chronic liver failure or chronic infecous disease, or hospitalized or il l paents.
The review included randomized controlled trials comparing daily iron supplementaon (with or without a
co-intervenon such as folic acid or vitamin C) to placebo or supplementaon without iron. Daily
supplementaon was dened as receiving iron for at least 5 days in a week.
The systemac review searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE,
Embase (Ovid), CINAHL (EBSCOHost), Conference Proceedings Citaon Index – Science (CPCI-S), Science
Citaon Index (SCI), POPLINE, IMSEAR, LILACS, IMERMR, African Index Medicus, and the following databasesfor grey literature: WorldCat, DART-Europe E-theses Portal, Australasian Digital Theses Program, Theses
Canada Portal, and ProQuest-Dissertaons and Theses. The search for evidence was done in September 2014.
The review included 62 trials involving 7523 women and adolescent girls (3951 in the intervenon arm and
3572 in the control arm). These studies were conducted in 24 countries with representaon from low-, middle-
and high-income countries. The sample size ranged between 10 and 1390 parcipants. Overall, the sample
size tended to be small; 96% of the studies included fewer than 400 women and adolescent girls.
Menstruang women and adolescent girls who received daily iron supplementaon had a lower risk for the
crical outcomes of anaemia (risk rao [RR]: 0.34; 95% condence interval [CI]: 0.20 to 0.57; 9 trials, n = 2905)
and iron deciency (RR: 0.61; 95% CI: 0.47–0.77; 6 trials, n = 1033) compared to menstruang women and
adolescent girls receiving placebo or supplementaon without iron. No trials reported on the outcome of irondeciency anaemia.
There were 48 studies that reported on haemoglobin concentraon. The large number of studies and parcipants
for this outcome allowed for evaluaon of subgroup dierences. Haemoglobin levels were signicantly higher
among those given iron supplementaon compared to those given placebo or supplementaon without iron
(mean dierence [MD]: 5.61 g/L; 95% CI: 4.44 to 6.79; 48 trials, n = 6390). There was no evidence of dierence
in the eect of iron supplementaon compared to placebo or supplementaon without iron on haemoglobin
by dose (100 mg; test for subgroup dierence χ 2 = 1.32; P = 0.72) or duraon
(3 months; test for subgroup dierence χ 2 = 4.12; P = 0.13).
Only one study specically reported being performed in a malaria-endemic area (15). One of the two villages
http://apps.who.int/iris/bitstream/10665/66914/1/WHO_NHD_01.3.pdf?ua=1http://apps.who.int/iris/bitstream/10665/66914/1/WHO_NHD_01.3.pdf?ua=1http://apps.who.int/iris/bitstream/10665/66914/1/WHO_NHD_01.3.pdf?ua=1http://apps.who.int/iris/bitstream/10665/66914/1/WHO_NHD_01.3.pdf?ua=http://apps.who.int/iris/bitstream/10665/44648/1/9789241502009_eng.pdfhttp://apps.who.int/iris/bitstream/10665/44648/1/9789241502009_eng.pdfhttp://apps.who.int/iris/bitstream/10665/44648/1/9789241502009_eng.pdfhttp://apps.who.int/iris/bitstream/10665/44648/1/9789241502009_eng.pdfhttp://apps.who.int/iris/bitstream/10665/66914/1/WHO_NHD_01.3.pdf?ua=http://apps.who.int/iris/bitstream/10665/66914/1/WHO_NHD_01.3.pdf?ua=1
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WHO Guideline: Daily iron supplementation in adult women and adolescent girls 7
haemoglobin concentraon had high quality. The eect sizes of the intervenon on the outcomes
with data were large. There was no evidence presented for malaria-related morbidity.
• Adherence may be a concern if the intervenon is perceived as non-essenal. Barriers to
adherence may need to be addressed (for instance, with behaviour-change communicaon if
the intervenon is not perceived as necessary among the beneciaries). Among the studies that
measured compliance, between 65% and 98% of the tablets were consumed, with no dierence
between the iron supplementaon and control arms.
• Costs will largely be determined by operaonal challenges rather than the cost of the supplement
itself. Distribuon of daily iron supplementaon in this populaon, parcularly in sengs where
health-care intervenons do not specically target menstruang adult women and adolescent girls,
may entail operaonal challenges. The resources and investments needed should be considered in
designing programmes to reach this populaon.
REMARKSThe remarks in this secon are intended to give some consideraons for implementaon of the
recommendaon, based on the discussion of the guideline development group.
• Daily oral iron supplementaon is a prevenve strategy for implementaon at the populaon
level. If a menstruang woman is diagnosed with anaemia, naonal guidelines for the treatment of
anaemia should be followed.
• The prevalence of anaemia should be considered when determining the dose, duraon and
frequency of iron supplementaon among menstruang adult women and adolescent girls. If
the prevalence of anaemia is less than 40%, other guidelines are available for consideraon. For
instance, for anaemia prevalence of 20–40%, intermient regimens of iron supplementaon may
be an opon ( 9 ).
• Daily iron supplementaon should be considered in the context of other intervenons containing
iron (fored foods, mulple micronutrient powders, lipid-based nutrient supplements).
• The selecon of the most appropriate delivery plaorm should be context specic, with the aim
of reaching the most vulnerable populaons and ensuring a mely and connuous supply of
supplements.
• All women, from the moment they begin trying to conceive unl 12 weeks of gestaon, should
take a folic acid supplement. Daily oral iron and folic acid supplementaon should be part of
roune antenatal care, begun as early as possible and connued throughout pregnancy. Where
the prevalence of anaemia in pregnant women is high (40% or more), supplementaon shouldconnue for 3 months in the postpartum period ( 10 , 11 ).
Iron supplementaon is the customary intervenon that comes to mind to address anaemia but it should
ideally form only a part of a comprehensive, integrated programme for anaemia reducon and addressing
women’s health across the life-course. Intervenons for decreasing iron deciency or iron deciency anaemia
should include nutrion counselling that promotes diet diversity and food combinaons that improve iron
absorpon; malaria-control programmes, including intermient prevenve treatment of malaria in pregnancy
and in children, as well as use of inseccide-treated bednets; control of parasic infecons; and improvement
in sanitaon. Once, a woman is pregnant, antenatal programmes help promote adequate gestaonal weight
gain and other complementary measures for monitoring, prevenon and control of anaemia, such as screening
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WHO Guideline: Daily iron supplementation in adult women and adolescent girls8
for anaemia, deworming treatment and a referral system for the management of cases of severe anaemia.
Delayed umbilical cord clamping is eecve in prevenng iron deciency in infants and young children. Other
opons include forcaon of staple foods and provision of micronutrient powders, including iron.
RESEARCH PRIORITIES
Discussions between the members of the WHO guideline development group and the external review group
highlighted the limited evidence available in some knowledge areas, mering further research on iron
supplementaon in menstruang adult women and adolescent girls, parcularly in the following areas:
• the opmal dose, schedule and duraon of iron supplementaon; the eect of dierent doses and
duraon of iron supplementaon on dierent severity, prevalence or causes of anaemia in all WHO
regions;
• addional data on the safety of iron supplementaon (liver damage; iron overload aer connuing
the supplementaon programme for a number of years; iron supplementaon given in conjuncon
with other intervenons; insulin resistance; eects in non-anaemic or non-iron-decient
menstruang adult women and adolescent girls);
• the eect of adding other micronutrients to the iron supplement on haemoglobin concentraons
and the prevalence of anaemia;
• implementaon research on eecve behaviour-change strategies for sustained adherence and
innovave delivery mechanisms for iron supplements;
• addional long-term studies on funconal outcomes (e.g. exercise performance and producvity)
• cost, cost–benet and feasibility analysis of the distribuon of iron supplementaon to be takendaily or intermiently among menstruang adult women and adolescent girls.
DISSEMINATION, IMPLEMENTATION AND ETHICAL CONSIDERATIONS
Dissemination The current guideline will be disseminated through electronic media, such as slide presentaons and the
World Wide Web, through the WHO Nutrion mailing lists, social media, the WHO nutrion website
(18) or the
WHO e-Library of Evidence for Nutrion Acons (eLENA) (19). eLENA compiles and displays WHO guidelines
related to nutrion, along with complementary documents such as systemac reviews and other evidence
that informed the guidelines; biological and behavioural raonales; and addional resources produced by
Member States and global partners. In addion, the guideline will be disseminated through a broad network
of internaonal partners, including WHO country and regional oces, ministries of health, WHO collaborang
centres, universies, other United Naons agencies and nongovernmental organizaons. Derivave productssuch as summaries and collaon of recommendaons related to iron supplementaon will be developed for
a more tailored product that is useful for end-users.
Parcular aenon will be given to improving access to these guidelines for stakeholders that face more,
or specic, barriers in access to informaon, or to those who play a crucial role in the implementaon of
the guideline recommendaon, for example, policy-makers and decision-makers at subnaonal level that
disseminate the contents of the guideline, and health workers and educaon sta that contribute to the
delivery of the intervenon. Disseminated informaon may emphasize the benets of iron supplementaon
in menstruang adult women and adolescent girls in populaons or regions presenng an important risk of
anaemia and iron deciency. In addion, these guidelines and the informaon contained therein should be
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WHO Guideline: Daily iron supplementation in adult women and adolescent girls 9
accessible to the nongovernmental organizaons working in coordinaon with naonal authories on the
implementaon of nutrion intervenons, especially those related to the prevenon and control of anaemia.
in menstruang adult women and adolescent girls.
Implementation As this is a global guideline, it should be adapted to the context of each Member State. Prior to implementaon,
a public health programme that includes the provision of iron supplements to menstruang adult women
and adolescent girls should have well-dened objecves that take into account available resources, exisng
policies, suitable delivery plaorms and suppliers, communicaon channels, and potenal stakeholders.
Ideally, iron supplementaon should be implemented as part of an integrated programme on adolescent and
reproducve health, which includes addressing micronutrient deciencies.
Considering the experiences of menstruang adult women and adolescent girls with the intervenon is
also a relevant implementaon consideraon: ongoing assessment of the accessibility and acceptability
of the intervenon can inform programme design and development, in order to increase adherence tosupplementaon and beer assess the impact of the programme. This is parcularly relevant in sengs where
the prevailing social norms and determinants may set unequal condions and opportunies for dierent
groups. For instance, in some sengs, social percepons around ethnicity and race intervene in how certain
populaon groups access and use an intervenon.
Supplementaon programmes in menstruang adult women and adolescent girls need to be carefully
designed, based on locally available evidence and experience. These can include data that can inform
the implementaon strategies on procurement and supply-chain issues, opmal distribuon channels,
behaviour-change communicaon and specic strategies to idenfy and reach the most vulnerable adult
women and adolescent girls. These are parcularly important in the absence of a well-funconing health-care
system that reaches this populaon.
Accessing hard-to-reach populaon groups is extremely important during implementaon stages, as it
contributes to prevenng or tackling health inequies. Appropriate surveillance and monitoring systems can
thus provide informaon on the impact of the disseminated guidelines and their implementaon (including
informaon on the adequacy of funding and the eecveness of the supply chain and distribuon channels).
Regulatory considerations The WHO Essenal Medicines List (EML) compiles medicines that sasfy the priority health-care needs of
populaons and are selected with due regard to disease prevalence, evidence on ecacy and safety, and
comparave cost-eecveness ( 20 ). Hence, the WHO EML is used by countries for the development of their
own naonal essenal medicines lists. The quality criteria for vitamins and minerals included in the WHO EML
take into account Food and Agriculture Organizaon of the United Naons/WHO standards ( 21 ).
Monitoring and evaluation of guideline uptake and adaptation A plan for monitoring and evaluaon with appropriate indicators, including equity-oriented indicators,
is encouraged at all stages ( 22 ). The impact of this guideline can be evaluated within countries (i.e.
monitoring and evaluaon of the programmes implemented at naonal or regional scale) and across
countries (i.e. adopon and adaptaon of the guideline globally). The WHO Department of Nutrion for
Health and Development, Evidence and Programme Guidance Unit, jointly with the United States Centers
for Disease Control and Prevenon (CDC) Internaonal Micronutrient Malnutrion Prevenon and Control
(IMMPaCt) programme, and with input from internaonal partners, has developed a generic logic model
for micronutrient intervenons in public health ( 23), to depict the plausible relaonships between inputs
and expected SDGs, by applying the micronutrient programme evaluaon theory. Member States can adjust
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WHO Guideline: Daily iron supplementation in adult women and adolescent girls10
the model and use it in combinaon with appropriate indicators, for designing, implemenng, monitoring
and evaluang the successful escalaon of nutrion acons in public health programmes. Addionally, the
WHO/CDC eCatalogue of indicators for micronutrient programmes
(24), which ulizes the logic model, has beendeveloped as a user-friendly and non-comprehensive web resource for those acvely engaged in providing
technical assistance in monitoring, evaluaon and surveillance of public health programmes implemenng
micronutrient intervenons. Indicators for iron supplementaon are currently being developed and, once
complete, will provide a list of potenal indicators with standard denions that can be selected, downloaded
and adapted to a local programme context. The eCatalogue will serve as a repository of indicators to monitor
and evaluate micronutrient intervenons. While it does not provide guidance for designing or implemenng
a monitoring or evaluaon system in public health, some key indicators may include useful references for that
purpose.
Since 1991, WHO has hosted the VMNIS micronutrients database ( 8 ). Part of WHO’s mandate is to assess
the micronutrient status of populaons, monitor and evaluate the impact of strategies for the prevenon
and control of micronutrient malnutrion, and track related trends over me. The Evidence and Programme
Guidance Unit of the Department of Nutrion for Health and Development manages the VMNIS micronutrient
database, through a network of regional and country oces, and in close collaboraon with naonal health
authories.
For evaluaon at the global level, the WHO Department of Nutrion for Health and Development has
developed a web-based WHO Global Targets Tracking Tool that allows users to explore dierent scenarios
to achieve the rates of progress required to meet the 2025 global nutrion targets, including target 2: 50%
reducon of anaemia in women of reproducve age, as well as a centralized plaorm for sharing informaon
on nutrion acons in public health pracce implemented around the world. By sharing programmac
details, specic country adaptaons and lessons learnt, this plaorm will provide examples of how guidelines
are being translated into acons. The Global database on the Implementaon of Nutrion Acon (GINA) (25)
provides valuable informaon on the implementaon of numerous nutrion policies and intervenons. The
use of GINA has grown steadily since its launch in November 2012.
An ecient system for the roune collecon of relevant data, including relevant determinants of health,
therapeuc adherence, and measures of programme performance, is crical to ensure supplementaon
programmes are eecve and sustained, and drivers to the achievement of the right to health for all populaon
groups. Monitoring dierences across groups in terms of accessibility, availability, acceptability and the quality
of the intervenons contributes to the design of beer public health programmes. The creaon of indicators
for monitoring can be informed by the approaches of social determinants of health ( 26), so inequies can
be idened and tackled. Appropriate monitoring requires suitable data, so eorts to collect and organize
informaon on the implementaon are also fundamental.
GUIDELINE DEVELOPMENT PROCESS
This guideline was developed in accordance with the WHO evidence-informed guideline-development
procedures, as outlined in the WHO handbook for guideline development (4).
Advisory groups The WHO Steering Commiee for Nutrion Guidelines Development (see Annex 3), led by the Department
of Nutrion for Health and Development, was established in 2009 with representaves from all WHO
departments with an interest in the provision of scienc nutrion advice. The WHO Steering Commiee for
Nutrion Guidelines Development met twice yearly and both guided and provided overall supervision of the
guideline development process. Two addional groups were formed: a guideline development group and an
external review group.
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WHO Guideline: Daily iron supplementation in adult women and adolescent girls 11
One guideline development group parcipated in the development of this guideline (see Annex 4). Its role
was to advise WHO on the choice of important outcomes for decision-making and on interpretaon of the
evidence. The WHO guideline development group – nutrion acons includes experts from various WHOexpert advisory panels and those idened through open calls for specialists, taking into consideraon a
balanced mix of sex, mulple disciplinary areas of experse, and representaon from all WHO regions. Eorts
were made to include content experts, methodologists, representaves of potenal stakeholders (such as
managers and other health professionals involved in the health-care process), and ministries of health from
Member States. Representaves of commercial organizaons may not be members of a WHO guideline group.
The nal dra guideline was peer-reviewed by three content experts, who provided technical feedback. These
peer-reviewers (see Annex 7) were idened through various expert panels within and outside WHO ( 5 , 18,
27 ).
Scope of the guideline, evidence appraisal and decision-making
An inial set of quesons (and the components of the quesons) to be addressed in the guideline formed thecrical starng point for formulang the recommendaon. The quesons were draed by technical sta at
the Evidence and Programme Guidance Unit, Department of Nutrion for Health and Development, based on
the policy and programme guidance needs of Member States and their partners. The populaon, intervenon,
control, outcomes (PICO) format was used (see Annex 8). The quesons were discussed and reviewed by
the WHO Steering Commiee for Nutrion Guidelines Development and the guideline development group –
nutrion acons, and were modied as needed.
A meeng of the guideline development group – nutrion acons was held on 14–16 March 2010, in Geneva,
Switzerland, to nalize the scope of the quesons and rank the outcomes and populaons of interest for the
recommendaon on iron supplementaon. The guideline development group discussed the relevance of the
quesons and modied them as needed. The group scored the relave importance of each outcome from 1
to 9 (where 7–9 indicated that the outcome was crical for a decision, 4–6 indicated that it was important and1–3 indicated that it was not important). The nal key quesons on this intervenon, along with the outcomes
that were idened as crical for decision-making, are listed in PICO format in Annex 8.
A systemac review (6) was used to summarize and appraise the evidence using the Cochrane methodology
( 7 ) for randomized controlled trials and observaonal studies. Evidence summaries were prepared according
to the (GRADE) approach to assess the overall quality of the evidence ( 5 , 16, 17). GRADE considers the
study design; the limitaons of the studies in terms of their conduct and analysis; the consistency of the
results across the available studies; the directness (or applicability and external validity) of the evidence with
respect to the populaons, intervenons and sengs where the proposed intervenon may be used; and the
precision of the summary esmate of the eect.
Both the systemac review and the GRADE evidence proles for each of the crical outcomes were used fordraing this guideline. The dra recommendaon was discussed by the WHO Steering Commiee for Nutrion
Guidelines Development and in consultaons with the WHO guideline development group – nutrion acons,
held on 14–18 March 2011 and 23–26 June 2014 in Geneva, Switzerland.
The procedures for decision-making are established at the beginning of the meengs, including a minimal set
of rules for agreement and decision-making documentaon. At least two thirds of the guideline development
group should be present for an inial discussion of the evidence and proposed recommendaon and
remarks. The members of the guideline development group secretly noted the direcon and strength of
the recommendaon, using a form designed for this purpose that also included a secon for documenng
their views on (i) the desirable and undesirable eects of the intervenon; (ii) the quality of the available
evidence; (iii) values and preferences related to the intervenon in dierent sengs; and (iv) the cost of
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WHO Guideline: Daily iron supplementation in adult women and adolescent girls12
opons available to health-care workers in dierent sengs (see Annex 2). Abstenons were not allowed.
The process was improved with the availability of a predened link to an online form prepared using survey
soware. Subsequent deliberaons among the members of the guideline development group were of privatecharacter. The WHO Secretariat collected the forms and disclosed a summary of the results to the guideline
development group. If there was no unanimous consensus (primary decision rule), more me was given for
deliberaons and a second round of online vong took place. If no unanimous agreement was reached, a two-
thirds vote of the guideline development group was required for approval of the proposed recommendaon
(secondary decision rule). Divergent opinions could be recorded in the guideline. The results from vong
forms are kept on le by WHO for up to 5 years. Although there was no unanimous consensus, more than 80%
of the vong members of the guideline development group decided that the recommendaon was strong.
WHO sta present at the meeng, as well as other external technical experts involved in the collecon and
grading of the evidence, were not allowed to parcipate in the decision-making process. Two co-chairs
with experse in managing group processes and interpreng evidence were nominated at the opening of
the consultaon, and the guideline development group approved the nominaon. Members of the WHO
Secretariat were available at all mes, to help guide the overall meeng process, but did not vote and did not
have veto power.
MANAGEMENT OF COMPETING INTERESTS
According to the rules in the WHO Basic documents ( 28 ) and the processes recommended in the WHO
handbook for guideline development ( 4 ), all experts parcipang in WHO meengs must declare any interests
relevant to the meeng, prior to their parcipaon. The responsible technical ocer and the relevant
departments reviewed the declaraons-of-interests statements for all guideline development group members
before nalizaon of the group composion and invitaon to aend a guideline development group meeng.
All members of the guideline development group, and parcipants of the guideline development meengs,
submied a declaraon-of-interests form, along with their curriculum vitae, before each meeng. Parcipants
of the guideline development group meengs parcipated in their individual capacity and not as instuonalrepresentaves. In addion, they verbally declared potenal conicts of interests at the beginning of each
meeng. The procedures for management of compeng interests strictly followed the WHO guidelines for
declaraon of interests. The management of the perceived or real conicts of interests declared by the
members of the guideline group is summarized next.1
Dr Beverley-Ann Biggs declared that the University of Melbourne received funding from the Naonal Health
and Medical Research Council and Australian Research Council for research on intermient iron and folic
acid supplementaon in pregnancy, conducted in collaboraon with the Research and Training Center for
Community Development, the Key Centre for Women’s Health and the Murdoch Children’s’ Research Instute.
It was agreed that she could parcipate fully in the deliberaons and decision-making on this guideline.
Dr Luz Maria De-Regil declared that her present employer is an internaonal nongovernmental organizaondevoted to the improvement of micronutrient status among infants, children and women. These acvies
are primarily nanced by the government of Canada. The Micronutrient Iniave is a leading organizaon
working exclusively to eliminate vitamin and mineral deciencies in the world’s most vulnerable populaons.
It was decided that Dr De-Regil could be a member of the guideline development group and would disclose
her interests and the interests of her organizaon in the relevant guidelines related to micronutrient
intervenons. She parcipated in the deliberaons related to the recommendaon for iron supplementaon
but recused herself from vong on this guideline.
1 A conict-of-interest analysis must be performed whenever WHO relies on the independent advice of an expert in order to take adecision or to provide recommendaons to Member States or other stakeholders. The term “conict of interest” means any interest
declared by an expert that may aect, or be reasonably perceived to aect, the expert’s objecvity and independence in providingadvice to WHO. WHO’s conict-of-interest rules are designed to avoid potenally compromising situaons that could undermine orotherwise aect the work of the expert, the commiee or the acvity in which the expert is involved, or WHO as a whole. Consequently,
the scope of the inquiry is any interest that could reasonably be perceived to aect the funcons that the expert is performing.
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WHO Guideline: Daily iron supplementation in adult women and adolescent girls 13
Dr Lynnee Neufeld declared that her current employer has received funding in the past 4 years for research
and programming related to iron supplementaon. At the moment she is not leading any of these iniaves. In
a prior posion she held with MI, she commissioned research related to iron supplementaon. It was decided
that Dr Neufeld could be a member of the guideline development group and had to disclose her and her
organizaon’s interests in the relevant guidelines related to micronutrient intervenons. She could parcipate
in the deliberaons but she recused herself from the decision-making (vong) on the recommendaon related
to iron supplementaon.
Dr Héctor Bourges Rodriguez declared being chair of the execuve board of the Danone Instute in Mexico
(DIM), a non-prot organizaon promong research and disseminaon of scienc knowledge in nutrion,
and receiving funds as chair honorarium from DIM. Some of the acvies of DIM may generally relate to
nutrion and are funded by Danone Mexico, a food producer. It was agreed that he could parcipate fully in
the deliberaons and decision-making on this guideline.
All other members made a verbal declaraon of their interests and it was considered that they were not
relevant for this guideline on iron supplementaon in adult women and adolescent girls. External resource
persons also declared their interests but did not parcipate in the deliberaons or decision-making process.
PLANS FOR UPDATING THE GUIDELINE
The WHO Secretariat will connue to follow the research development in the area of oral iron supplementaon
in menstruang adult women and adolescent girls in malaria-endemic and non-malaria endemic sengs,
parcularly for quesons in which the quality of evidence was found to be low or very low. If the guideline
merits an update, or if there are concerns about the validity of the guideline, the Department of Nutrion for
Health and Development will coordinate the guideline update, following the formal procedures of the WHO
handbook for guideline development (4).
As the guideline nears the 10-year review period agreed by the guideline development group, the Departmentof Nutrion for Health and Development at the WHO headquarters in Geneva, Switzerland, along with its
internal partners, will be responsible for conducng a search for new evidence.
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velopment Goals (hps://sustainabledevelopment.un.org/topics, accessed 4 December 2015).
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3. Global strategy for women’s children’s and adolescent girls’ health (2016–2030). Survive,thrive, transform. Geneva: Every
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5. GRADE Working Group (hp://www.gradeworkinggroup.org/, accessed 4 December 2015).
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menstruang women. Cochrane Database Syst Rev. 2015: in press.
7. Higgins JPT, Green S, editors. Cochrane handbook for systemac reviews of intervenons. Version 5.1.0 (updated March
2011). London: The Cochrane Collaboraon; 2011 (hp://community.cochrane.org/handbook, accessed 4 December 2015).
8. World Health Organizaon. Vitamin and Mineral Nutrion Informaon System (VMNIS). Micronutrients database (hp://
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9. Guideline: intermient iron and folic acid supplementaon in menstruang women. Geneva: World Health Organizaon;
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13. Iron deciency anaemia: assessment, prevenon and control: a guide for programme managers. 2001, Geneva: World Health
Organizaon; 2001 (hp://apps.who.int/iris/bitstream/10665/66914/1/WHO_NHD_01.3.pdf?ua=1, accessed 4 December
2015).
14. Beard JL. Iron requirements in adolescent females. J Nutr. 2000;130(2S Suppl.):440S–442S.
15. Charoenlarp P, Dhanamia S, Kaewvichit R, Silprasert A, Suwanaradd C, Na-Nakorn S, Prawatnuang P et al. A WHO collabora-
ve study on iron supplementaon in Burma and in Thailand. Am J Clin Nutr. 1988;47:280–97.
16. Guya GH, Oxman AD, Vist GE, Kunz R, Falck-Yer Y, Alonso-Coello P et al., GRADE Worknig Group. GRADE: an emerging
consensus on rang quality of evidence and strength of recommendaons. BMJ. 2008;336(7650):924–6. doi:10.1136/
bmj.39489.470347.AD.
17. Guya G, Oxman AD, Akl EA, Kunz R, Vist G, Brozek J et al. GRADE guidelines: 1. Introducon-GRADE evidence proles and
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https://sustainabledevelopment.un.org/topicshttp://www.who.int/nutrition/topics/WHA65.6_resolution_en.pdf?ua=1http://www.who.int/life-course/partners/global-strategy/globalstrategyreport2016-2030-lowres.pdf?ua=1http://www.who.int/life-course/partners/global-strategy/globalstrategyreport2016-2030-lowres.pdf?ua=1http://www.who.int/kms/handbook_2nd_ed.pdfhttp://www.who.int/kms/handbook_2nd_ed.pdfhttp://www.gradeworkinggroup.org/http://community.cochrane.org/handbookhttp://www.who.int/vmnis/en/http://www.who.int/vmnis/en/http://apps.who.int/iris/bitstream/10665/44648/1/9789241502009_eng.pdfhttp://apps.who.int/iris/bitstream/10665/69735/1/a91272.pdfhttp://apps.who.int/iris/bitstream/10665/69735/1/a91272.pdfhttp://apps.who.int/iris/bitstream/10665/69735/1/a91272.pdfhttp://apps.who.int/iris/bitstream/10665/77770/1/9789241501996_eng.pdf?ua=1http://apps.who.int/iris/bitstream/10665/77770/1/9789241501996_eng.pdf?ua=1http://www.who.int/nutrition/publications/micronutrients/global_prevalence_anaemia_2011/en/http://www.who.int/nutrition/publications/micronutrients/global_prevalence_anaemia_2011/en/http://www.who.int/nutrition/publications/micronutrients/global_prevalence_anaemia_2011/en/http://apps.who.int/iris/bitstream/10665/66914/1/WHO_NHD_01.3.pdf?ua=1http://localhost/var/www/apps/conversion/tmp/scratch_7/10.1136/bmj.39489.470347.ADhttp://localhost/var/www/apps/conversion/tmp/scratch_7/10.1136/bmj.39489.470347.ADhttp://localhost/var/www/apps/conversion/tmp/scratch_7/10.1016/j.jclinepihttp://localhost/var/www/apps/conversion/tmp/scratch_7/10.1016/j.jclinepihttp://localhost/var/www/apps/conversion/tmp/scratch_7/10.1136/bmj.39489.470347.ADhttp://localhost/var/www/apps/conversion/tmp/scratch_7/10.1136/bmj.39489.470347.ADhttp://apps.who.int/iris/bitstream/10665/66914/1/WHO_NHD_01.3.pdf?ua=1http://www.who.int/nutrition/publications/micronutrients/global_prevalence_anaemia_2011/en/http://www.who.int/nutrition/publications/micronutrients/global_prevalence_anaemia_2011/en/http://apps.who.int/iris/bitstream/10665/77770/1/9789241501996_eng.pdf?ua=1http://apps.who.int/iris/bitstream/10665/77770/1/9789241501996_eng.pdf?ua=1http://apps.who.int/iris/bitstream/10665/69735/1/a91272.pdfhttp://apps.who.int/iris/bitstream/10665/69735/1/a91272.pdfhttp://apps.who.int/iris/bitstream/10665/44648/1/9789241502009_eng.pdfhttp://www.who.int/vmnis/en/http://www.who.int/vmnis/en/http://community.cochrane.org/handbookhttp://www.gradeworkinggroup.org/http://www.who.int/kms/handbook_2nd_ed.pdfhttp://www.who.int/kms/handbook_2nd_ed.pdfhttp://www.who.int/life-course/partners/global-strategy/globalstrategyreport2016-2030-lowres.pdf?ua=1http://www.who.int/life-course/partners/global-strategy/globalstrategyreport2016-2030-lowres.pdf?ua=1http://www.who.int/nutrition/topics/WHA65.6_resolution_en.pdf?ua=1https://sustainabledevelopment.un.org/topics
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18. World Health Organizaon. Nutrion (hp://www.who.int/nutrion/en/, accessed 4 December 2015).
19. World Health Organizaon, e-Library of Evidence for Nutrion Acons (eLENA) Guideline development process (hp://www.who.int/elena/about/guidelines_process/en/, accessed 4 December 2015).
20. World Health Organizaon. Essenal medicines and health products (hp://www.who.int/medicines/services/essmedi-
cines_def/en/, accessed 4 December 2015).
21. World Health Organizaon (WHO) and Food and Agriculture Organizaon of the United Naons (FAO). Codex Alimentarius:
Guidelines for vitamin and mineral food supplements. Geneva: World Health Organizaon and the Food and Agriculture
Organizaon; 2005 (CAC/GL 55; hp://www.codexalimentarius.org/standards/list-of-standards/en/?provide=standards&ord
erField=fullReference&sort=asc&num1=CAC/GL, accessed 4 December 2015).
22. Evaluaon of the Good Governance for Medicines programme (2004–2012). Brief summary of ndings. Geneva: World
Health Organizaon; 2013 (WHO/EMP/MPC/2013.1; hp://apps.who.int/medicinedocs/documents/s20188en/s20188en.
pdf , accessed 4 December 2015).
23. Centers for Disease Control and Prevenon (CDC). Division of Nutrion, Physical Acvity, and Obesity. Internaonal Micronu-
trient Malnutrion Prevenon and Control (IMMPaCt) (hp://www.cdc.gov/immpact/, accessed 4 December 2015).
24. World Health Organizaon. eCatalogue of indicators for micronutrient programmes ( hps://extranet.who.int/indcat/, ac-
cessed 4 December 2015).
25. World Health Organizaon. Global database on the Implementaon of Nutrion Acon (GINA) (hp://www.who.int/nutri-
on/gina/en/, accessed 4 December 2015).
26. Handbook on health inequality monitoring: with a special focus on low- and middle-income countries. Geneva: World Health
Organizaon; 2013 (hp://apps.who.int/iris/bitstream/10665/85345/1/9789241548632_eng.pdf , accessed 4 December
2015).
27. United Naons System Standing Commiee on Nutrion (SCN) (hp://www.unscn.org, accessed 4 December 2015).
28. World Health Organizaon Basic Documents, 48th ed. Geneva: World Health Organizaon; 2014 (hp://apps.who.int/gb/
bd/, accessed 4 December 2015).
http://www.who.int/nutrition/enhttp://www.who.int/elena/about/guidelines_process/enhttp://www.who.int/elena/about/guidelines_process/enhttp://www.who.int/medicines/services/essmedicines_def/enhttp://www.who.int/medicines/services/essmedicines_def/enhttp://www.who.int/medicines/services/essmedicines_def/enhttp://www.codexalimentarius.org/standards/list-of-standards/en/?provide=standards&orderField=fullReference&sort=asc&num1=CAChttp://www.codexalimentarius.org/standards/list-of-standards/en/?provide=standards&orderField=fullReference&sort=asc&num1=CAChttp://apps.who.int/medicinedocs/documents/s20188en/s20188en.pdfhttp://apps.who.int/medicinedocs/documents/s20188en/s20188en.pdfhttp://www.cdc.gov/immpacthttps://extranet.who.int/indcathttp://www.who.int/nutrition/gina/enhttp://www.who.int/nutrition/gina/enhttp://www.who.int/nutrition/gina/enhttp://apps.who.int/iris/bitstream/10665/85345/1/9789241548632_eng.pdfhttp://www.unscn.org/http://apps.who.int/gb/bdhttp://apps.who.int/gb/bdhttp://apps.who.int/gb/bdhttp://apps.who.int/gb/bdhttp://www.unscn.org/http://apps.who.int/iris/bitstream/10665/85345/1/9789241548632_eng.pdfhttp://www.who.int/nutrition/gina/enhttp://www.who.int/nutrition/gina/enhttps://extranet.who.int/indcathttp://www.cdc.gov/immpacthttp://apps.who.int/medicinedocs/documents/s20188en/s20188en.pdfhttp://apps.who.int/medicinedocs/documents/s20188en/s20188en.pdfhttp://www.codexalimentarius.org/standards/list-of-standards/en/?provide=standards&orderField=fullReference&sort=asc&num1=CAChttp://www.codexalimentarius.org/standards/list-of-standards/en/?provide=standards&orderField=fullReference&sort=asc&num1=CAChttp://www.who.int/medicines/services/essmedicines_def/enhttp://www.who.int/medicines/services/essmedicines_def/enhttp://www.who.int/elena/about/guidelines_process/enhttp://www.who.int/elena/about/guidelines_process/enhttp://www.who.int/nutrition/en
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WHO Guideline: Daily iron supplementation in adult women and adolescent girls 17
ANNEX 2. SUMMARY OF THE CONSIDERATIONS OF THE MEMBERS OF THE GUIDELINE DEVELOPMENT GROUP FOR DETER-MINING THE STRENGTH OF THE RECOMMENDATION FOR DAILY ORAL IRON SUPPLEMENTATION IN MENSTRUATING ADULT
WOMEN AND ADOLESCENT GIRLS
QUALITY OF EVIDENCE: Anaemia and iron deciency had moderate-quality evidence. Theeect sizes of the intervenon on these outcomes were large.
The quality of the evidence for the eect on haemoglobin is high
though there is currently no evidence on the outcome of iron
deciency anaemia. Although the evidence of either loose or hard
stools is of high quality, the quality of the evidence for adverse ef -
fects or gastrointesnal eects in general is low or very low.
VALUES AND PREFERENCES: Adherence may be a concern. If the intervenon is perceived as
non-essenal, there may be lile demand for it.
Where access to health facilies is limited, as in many rural areas,
the problem may be more prevalent. Inequies in access may thus
negavely aect successful implementaon.
TRADE-OFF BETWEEN BENEFITS ANDHARMS:
Benets include improved haemoglobin and lower risk of anaemia
or iron deciency, which have funconal consequences such as im-
proved exercise performance. Potenal harms include gastrointes-
nal eects, but evidence is of low quality. There is increased risk of
either diarrhoea or conspaon, with high quality of evidence.
Not enough data are available on adverse events, or long-term
harm, for instance on overdose, specically for those who are iron
replete.
COSTS AND FEASIBILITY: The cost will largely be determined by the operaonal challengesrather than the cost of the supplementaon itself. The diculty will
lie in aempng to set up vercal programmes, which can prove
very costly. Health services that do not have prevenve health care
in menstruang adult women and adolescent girls may be more
likely to nd this intervenon infeasible.
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WHO Guideline: Daily iron supplementation in adult women and adolescent girls18
ANNEX 3. WHO STEERING COMMITTEE FOR NUTRITION GUIDELINES DEVELOPMENT
Dr Najeeb Mohamed Al Shorbaji
Director, Deparment of Knowledge Management andSharingWorld Health OrganizaonAvenue Appia 20, 1211 Geneva 27 Switzerland
Dr Douglas Becher
Director, Department of Prevenon of NoncommunicableDiseasesWorld Health Organizaon
Avenue Appia 20, 1211 Geneva 27,Switzerland
Dr Ties Boerma
Director, Department of Health System Policies andWorkforceWorld Health OrganizaonAvenue Appia 20, 1211 Geneva 27 Switzerland
Dr Francesco Branca
Director, Department of Nutrion for Health andDevelopmentWorld Health OrganizaonAvenue Appia, 20, 1211 Geneva 27
Switzerland
Dr Richard Brennan
Director, Department of Emergency Risk Managementand Humanitarian ResponseWorld Health OrganizaonAvenue Appia 20, 1211 Geneva 27 Switzerland
Dr Goried Oo Hirnschall
Director, Department of HIV/AIDSWorld Health OrganizaonAvenue Appia 20, 1211 Geneva 27Switzerland
Dr Knut Lonnroth
Medical Ocer, Global TB ProgrammeWorld Health OrganizaonAvenue Appia 20, 1211 Geneva 27Switzerland
Dr Elizabeth Mason
Director, Director of Maternal, Newborn, Child andAdolescent Health World Health OrganizaonAvenue Appia 20, 1211 Geneva 27
Switzerland
Dr Kazuaki Miyagishima
Director, Department of Food Safety, Zoonoses and
Foodborne Diseases
World Health Organizaon
Avenue Appia 20, 1211 Geneva 27
Switzerland
Dr Maria Puricacion Neira
Director, Department of Public Health, Environmental and
Social Determinants of Health
World Health OrganizaonAvenue Appia 20, 1211 Geneva 27
Switzerland
Dr Jean-Marie Okwo-Bele
Director, Department of Immunizaon, Vaccines and
Biologicals
World Health Organizaon
Avenue Appia 20, 1211 Geneva 27
Switzerland
Professor John Charles Reeder
Director, Special Programme for Research and Training in
Tropical Diseases
World Health OrganizaonAvenue Appia 20, 1211 Geneva 27
Switzerland
Dr Isabelle Romieu
Secon Head, Nutrional Epidemiology Group
Internaonal Agency for Research on Cancer
150, cours Albert Thomas
69372 Lyon Cedex 08
France
Dr Nadia Slimani
Group Head, Nutrional Epidemiology Group
Internaonal Agency for Research on Cancer
150, cours Albert Thomas
69372 Lyon Cedex 08
France
Dr Marleen Temmerman
Director, Department of Reproducve Health and
Research
World Health Organizaon
Avenue Appia 20, 1211 Geneva 27
Switzerland
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WHO Guideline: Daily iron supplementation in adult women and adolescent girls 19
ANNEX 4. WHO GUIDELINE DEVELOPMENT GROUP
Ms Deena Alasfoor
Directorate of Training and Educaon
Ministry of Health
Oman
Health programme management, food legislaons,
surveillance in primary health care
Dr Beverley-Ann Biggs
Head, Internaonal and Immigrant Health Group
Department of Medicine
University of MelbourneAustralia
Micronutrients supplementaon, clinical infecous
diseases
Dr Norma Campbell
Professor
Departments of Medicine
Community Health Sciences and Physiology and
Pharmacology
University of Calgary
Canada
Physiology and pharmacology, hypertension prevenon
and control
Dr Mary Chea
Deputy Manager of Naonal Nutrion Programme
Naonal Maternal and Child Health Centre
Ministry of Health
Cambodia
Programme implementaon, midwifery
Dr Maria Elena del Socorro Jeerds
Behavioural Scienst, Division of Nutrion, Physical
Acvity and Obesity
Centers for Disease Control and Prevenon
United States of America
Behaviour science, programme evaluaon
Dr Luz Maria De-Regil
Director, Research and Evaluaon and Chief Technical
Adviser
Micronutrient Iniave
Canada
Epidemiology, systemac reviews, programme
implementaon
Dr Heba El Laithy
Professor of Stascs and Head of Stascal
Departments at Faculty of Economics
Cairo University
Egypt
Stascs, economics
Dr Rafael Flores-Ayala
Team lead, Internaonal Micronutrient Malnutrion
Prevenon and Control Programme
Centers for Disease Control and PrevenonUnited States of America
Nutrion and human capital formaon, nutrion and
growth, impact of micronutrient intervenons
Professor Davina Ghersi
Senior Principal Research Scienst
Naonal Health and Medical Research Council
Australia
Policy-making, systemac reviews, evidence
Professor Malik Goonewardene
Senior Professor and Head of Department
Department of Obstetrics and Gynaecology
University of RuhunaSri Lanka
Obstetrics and gynaecology, clinical pracce
Dr Rukhsana Haider
Chairperson
Training and Assistance for Health and Nutrion Foundaon
Bangladesh
Breaseeding, capacity-building on counselling and
nutrion
Dr Junsheng Huo
Professor
Naonal Instute for Nutrion and Food Safety
Chinese Centre for Disease Control and Prevenon
China
Food forcaon, food science and technology, standards
and legislaon
Dr Janet C King
Children’s Hospital Oakland Research Instute
United States of America
Micronutrients, maternal and child nutrion, dietary
requirements
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WHO Guideline: Daily iron supplementation in adult women and adolescent girls 21
Dr Carol Tom
Regional Food Forcaon Advisor
A2Z Project
East, Central and Southern African Health Community
United Republic of Tanzania
Food forcaon technical regulaons and standards,
policy harmonizaon
Dr Igor Veljkovik
Health and Nutrion Ocer
United Naons Children’s Fund (UNICEF) Oce in Skopje
The former Yugoslav Republic of Macedonia
Programme implementaon
Dr Maged Younes
Independent internaonal expert on global public health
ItalyFood safety, public health, programme management
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WHO Guideline: Daily iron supplementation in adult women and adolescent girls22
ANNEX 5. EXTERNAL RESOURCE EXPERTS
Dr Nancy Aburto
Nutrion Adviser
United Naons World Food Programme
Italy
Dr Guillermo Carroli
Director
Centro Rosarino de Estudios Perinatales
Argenna
Ms Nita DalmiyaNutrion Specialist, Micronutrients
United Naons Children’s Fund
United States of America
Dr Maria Cecilia Dedios Sanguine
Independent consultant, Evaluaon
United States of America
Dr Kathryn Dewey
Professor, Department of Nutrion
Director, Program in Internaonal and Community
Nutrion
University of California
United States of America
Ms Mary-Anne Land
Research Associate
The George Instute for Global Health
Australia
Dr Sant-Rayn Pasricha
MRC Human Immunology Unit
Weatherall Instute of Molecular Medicine
University of Oxford
John Radclie Hospital
United Kingdom of Great Britain and Northern Ireland
Dr Usha Ramakrishnan
Program Director, Doctoral Program in Nutrion and
Health Sciences
Department of Global Health
Rollins School of Public Health
Emory University
United States of America
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WHO Guideline: Daily iron supplementation in adult women and adolescent girls 23
ANNEX 6. WHO SECRETARIAT
Ms Sanjhavi Agarwal
Intern, Evidence and Programme Guidance
Department of Nutrion for Health and Development
Ms Maryam Bigdeli
Technical Ocer
Alliance for Health Policy and Systems Research
Dr Carmen Casanovas
Technical Ocer, Evidence and Programme Guidance
Department of Nutrion for Health and Development
Dr Laragh Gollogly
Editor, WHO Press
Department of Knowledge Management and Sharing
Dr Maria de las Nieves Garcia-Casal
Consultant, Micronutrients
Department of Nutrion for Health and Development
Dr Eyerusalem Kebede Negussie
Medical Ocer, HIV Treatment and Care
Department of HIV/AIDS
Dr Suzanna McDonald (rapporteur)Consultant, Immunology, Evidence and Programme
Guidance
Department of Nutrion for Health and Development
Ms Daniela Meneses (rapporteur)
Intern, Evidence and Programme Guidance
Department of Nutrion for Health and Development
Dr Juan Pablo Peña-Rosas
Coordinator, Evidence and Programme Guidance
Department of Nutrion for Health and Development
Dr Pura Rayco-Solon
Epidemiologist (infecous disease and nutrion), Evidence
and Programme Guidance
Department of Nutrion for Health and Development
Dr Lisa Rogers
Technical Ocer, Evidence and Programme Guidance
Department of Nutrion for Health and Development
Dr Nigel Rollins
Medical Ocer, Research and Development
Department of Maternal, Newborn, Child and
Adolescent Health
Ms Victoria Saint
Technical Ocer, Social Determinants of Health
Department of Public Health, Environmental and Social
Determinants of Health
Dr Eugenio Villar Montesinos
Coordinator, Social Determinants of Health
Department of Public Health, Environmental and Social
Determinants of Health
Ms Zita Weise PrinzoTechnical Ocer, Evidence and Programme Guidance
Department of Nutrion for Health and Development
Mr Gerardo Zamora
Technical Ocer (implementaon research and equity),
Evidence and Programme Guidance
Department of Nutrion for Health and Development
WHO regional offices Regional Office for Africa
Dr Mercy Chikoko
Acng Regional Adviser for NutrionWHO Regional Oce for Africa
Cité du Djoué, PO Box 06 Brazzaville,
Congo
Regional Office for the Americas/Pan American HealthOrganization
Dr Chessa Luer
Regional Adviser, Child and Adolescent Health
Pan American Health Organizaon
525 23rd Street, NW, Washington DC 20037
United States of America
Regional Office for South-East Asia
Dr Kunal Bagchi
Regional Adviser – Nutrion and Food Safety
Healthy Ageing
WHO Regional Oce for South-East Asia
World Health House
Indraprastha Estate, Mahatama Gandhi Road
New Delhi 110002
India
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WHO Guideline: Daily iron supplementation in adult women and adolescent girls24
ANNEX 7. PEER-REVIEWERS
Ms Solange Durao
Senior Scienst
South Africa Cochrane Collaboraon Centre
South Africa
Dr Tran Khanh Van
Vice Head of Nutrion
Naonal Instute of Nutrion
Vietnam
Ms Terrie WefwafwaChief Execuve Ocer
Karibuni Kenya (Consultancy)
Kenya
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