Iron is a component of hemoglobin in red blood cells (RBC) and as such, an iron deficient diet can result in iron deficiency anemia characterized by the production of RBC that do not contain a full complement of hemoglobin and are inefficient at delivering oxygen to cells. Pregnancy and childbirth place women at risk for iron deficiency anemia due to a marked blood volume expansion during pregnancy, increased maternal needs, fetal requirements, and blood loss associated with childbirth. Iron deficiency anemia is the most common nutritional deficiency in the United States and the world, affecting 7.8 million adolescent girls and women of childbearing age . The iron requirements of pregnancy are thoroughly discussed in Chap. 16, ("Iron requirements and Adverse Outcomes").
Although the role of iron status remains unclear with respect to postpartum depression, current investigations point to increased risk for postpartum depression in women who have anemia [80, 81]. Corwin and colleagues  measured hemoglobin levels at 7, 14, and 28 days postpartum and depressive symptoms using the Center for Epidemiological Studies-Depressive Symptomatology Scale (CES-D) at 28 days postpartum. Hemoglobin levels on day 7 were negatively correlated with CES-D scores obtained on day 28 post-partum. Further, Beard et al.  demonstrated that iron treatment resulted in a 25% improvement in previously iron deficient mothers' depression and stress scales. Anemic mothers who did not receive iron treatment did not display improvements in depression or stress scales. Beard further discusses these findings in Chap. 16 of this volume.
Folate deficiency has been associated with problems in nerve development and function and has classically been thought to pose more of a risk to fetuses, infants, children who are growing; however, recent reports have linked folate deficiency with depression [87-91]. Neural tube defects have been associated with inadequate folate intake prior to conception and during pregnancy are described in Chap. 17, "Folate: a Key to Optimal Pregnancy Outcome"). Excellent sources of folate include liver, yeast, asparagus, spinach, oranges, legumes, and fortified cereals/grain products [79 and see Chap. 17]. During the postpartum period, folate needs are 400 mcg/day unless the woman is breastfeeding, which increases the need to 500 mcg/day .
Folate deficiency has been linked to depression in several investigations [82-86]. Although the mechanism is unknown at this time, folate has been hypothesized to be related to serotonin production involving S-adenosylmethionine (SAMe), a major methyl donor formed from methionine, which is formed during regeneration of homocysteine . To date, no significant associations have been reported for folate and postpartum depression . The current folate fortification programs make dietary folate deficiency a unlikely culprit in current rates for postpartum depression.
19.13.3 Riboflavin/Vitamin B2
Riboflavin is important in the formation of key enzymes necessary for energy production via the citric acid cycle/electron transport chain. Based upon this role, adequate riboflavin intake during pregnancy and the postpartum period could be beneficial to maternal energy level and mood. Milk is the best source of riboflavin in the North American diet , with liver, red meat, poultry, fish, whole grains and enriched breads and cereals, asparagus, broccoli, mushrooms, and green leafy vegetables identified as other excellent sources. During the postpartum period, riboflavin needs are similar to those prior to pregnancy 1.1 mg/day . The riboflavin requirement for breastfeeding women is 1.6 mg/day, greater than that for pregnant women.
To our knowledge, there is only one report for the role of riboflavin in postpartum depression. Miyake and colleagues  reported that pregnant women with riboflavin consumption in the third quartile were independently related to a decreased risk for postpartum depression. It has been hypothesized that riboflavin coenzymes are involved in the regeneration of homocysteine which is involved in serotonin production .
Vitamin B12 is necessary for the maintenance of myelin, which insulates nerves and affects neurotransmission . Although dietary B12 deficiencies are rare due to efficient recycling, strict vegetarians and individuals with decreased appetite/anorexia should consider supplementing their diet. Neurological symptoms associated with deficiency include numbness and tingling, abnormalities in gait, memory loss, and disorientation. Vitamin B12 is found almost exclusively in animal products. Fortified cereal and grain products provide an alternative for those individuals who do not consume animal products. Although vitamin B12 is important to CNS functions, no associations have been reported for vitamin B12 and depression  or postpartum depression .
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