A spinach-enriched fish snack combined with regular iron supplements helped pregnant women with anemia increase their blood iron levels significantly more than supplements alone in a 21-day Indonesian study of 60 women. According to Gram Research analysis, the fortified food group showed substantially greater hemoglobin improvements (p<0.001), suggesting that adding iron-rich foods to standard prenatal care may enhance anemia treatment while reducing supplement side effects.
Pregnant women with anemia often struggle with iron supplements because they cause stomach problems. Researchers in Indonesia tested a new approach: a ready-to-eat snack made from spinach-enriched fish floss (shredded fish mixed with red spinach). In a 21-day study of 60 pregnant women, those who ate this special snack along with their regular iron pills showed much bigger improvements in their blood iron levels than women taking pills alone. According to Gram Research analysis, this food-based approach could help more pregnant women get the iron they need without the uncomfortable side effects that make many women stop taking supplements.
Key Statistics
A quasi-experimental study of 60 pregnant women in Indonesia found that those receiving spinach-enriched fish floss alongside iron supplements showed significantly greater increases in hemoglobin levels compared to the supplement-only group (p<0.001), indicating the fortified food provided meaningful additional iron benefit.
Research published in the African Journal of Reproductive Health in 2026 demonstrated that food-based iron fortification using locally produced snakehead fish and red spinach may improve hemoglobin recovery in pregnant women with mild-to-moderate anemia when combined with routine iron-folic acid supplementation.
A 21-day intervention study found that ready-to-eat fortified fish floss significantly outperformed standard iron supplementation alone in raising hemoglobin concentrations among pregnant women, with statistical significance of p<0.001, suggesting the complementary food strategy effectively enhanced iron absorption.
The Quick Take
- What they studied: Whether a special snack made from spinach-enriched fish floss could help pregnant women with anemia improve their blood iron levels better than iron pills alone.
- Who participated: 60 pregnant women in Malang Regency, Indonesia, who had mild-to-moderate anemia (low iron in their blood). Half received the fortified fish snack plus regular iron pills, and half received only the iron pills.
- Key finding: Women who ate the spinach-fish snack showed significantly greater increases in hemoglobin (the protein that carries oxygen in blood) compared to the control group (p<0.001, meaning this result was very unlikely to happen by chance).
- What it means for you: If you’re pregnant and struggling with iron supplement side effects, adding iron-rich foods like spinach-fortified fish snacks might help you absorb more iron naturally. However, this study was small and conducted in Indonesia, so talk to your doctor before making changes to your prenatal care routine.
The Research Details
This was a quasi-experimental study, which means researchers assigned pregnant women to two groups but didn’t randomly select who got what treatment. One group received a ready-to-eat snack made from snakehead fish (a type of freshwater fish) mixed with red spinach, along with their regular iron and folic acid supplements. The other group received only the standard supplements. Both groups were followed for 21 days. Before and after the study period, researchers measured hemoglobin levels (the amount of iron-carrying protein in the blood) using blood tests. They then compared how much each group’s hemoglobin improved using statistical tests.
Many pregnant women stop taking iron supplements because they cause nausea, constipation, and stomach upset. This study tested whether adding iron-rich foods could work alongside supplements to improve results. Using locally available foods like fish and spinach is practical for communities with limited access to medications and addresses a real problem: poor compliance with iron supplements among pregnant women.
The study had a clear before-and-after measurement design with a comparison group, which is stronger than just observing one group. However, the sample size was relatively small (60 women), and the study lasted only 21 days. The study was conducted in one region of Indonesia, so results may not apply everywhere. The researchers used standard blood tests to measure hemoglobin, which is reliable. The statistical analysis showed very strong results (p<0.001), suggesting the findings are unlikely due to chance.
What the Results Show
The intervention group, which received the spinach-enriched fish floss snack plus regular iron supplements, showed significantly greater increases in hemoglobin levels compared to the control group receiving supplements alone. The difference between groups was highly statistically significant (p<0.001), meaning there’s less than a 0.1% chance this result happened randomly. This suggests the fortified food provided meaningful additional iron that helped pregnant women’s bodies produce more hemoglobin. The snack appears to have worked as a complementary strategy, meaning it worked best when combined with regular iron supplements rather than replacing them.
The study suggests that ready-to-eat fortified foods may improve compliance with iron therapy because they’re convenient and don’t cause the gastrointestinal side effects that make many women stop taking pills. Using locally produced foods like snakehead fish and red spinach makes this intervention affordable and culturally appropriate for communities in Southeast Asia. The 21-day timeframe showed measurable improvements, suggesting benefits can appear relatively quickly when combining food-based and supplement-based iron sources.
Previous research has shown that iron supplements alone often fail because of side effects and poor adherence. This study builds on earlier work showing that food-based iron sources can complement pharmaceutical supplements. The combination approach aligns with public health recommendations to use multiple strategies for addressing anemia in pregnancy. However, most previous studies focused on supplements alone or single food interventions, making this combination approach relatively novel.
The study included only 60 women in one region of Indonesia, so results may not apply to pregnant women in other countries or with different diets. The study lasted only 21 days, so we don’t know if benefits continue longer or if there are any long-term effects. There was no random assignment to groups, which means some differences between groups could have existed before the study started. The study didn’t measure whether women actually preferred the snack or had fewer side effects compared to supplements alone. We also don’t know the exact nutritional content of the fortified snack or how much iron it provided per serving.
The Bottom Line
Pregnant women with anemia who experience side effects from iron supplements should discuss adding iron-rich foods like spinach-fortified fish snacks with their healthcare provider. This approach appears to enhance hemoglobin recovery when combined with regular supplements (moderate confidence based on this single study). Women should not replace prescribed iron supplements with food alone, as the study showed the snack worked best alongside standard supplementation. Healthcare providers in regions with access to similar fortified foods may consider recommending them as part of routine antenatal care.
Pregnant women with mild-to-moderate anemia who struggle with supplement side effects should find this research relevant. Healthcare providers in Southeast Asia and similar regions with access to snakehead fish and red spinach may benefit from this approach. Public health officials planning nutrition programs for pregnant women should consider food-based fortification strategies. Women with severe anemia or those unable to tolerate any oral iron should consult their doctor, as this approach may not be sufficient alone. This research is less relevant for women without anemia or those who tolerate supplements well.
Based on this study, measurable improvements in hemoglobin levels appeared within 21 days of combining the fortified snack with regular supplements. Most pregnant women would likely need to continue this approach throughout pregnancy for sustained benefits. Individual results will vary depending on baseline anemia severity, overall diet quality, and adherence to both the snack and supplements. Consult your healthcare provider about realistic timelines for your specific situation.
Frequently Asked Questions
Can I use food instead of iron pills during pregnancy to treat anemia?
Food alone is not sufficient to treat anemia in pregnancy. This research shows fortified foods work best when combined with iron supplements, not as a replacement. Talk to your doctor about using both approaches together, especially if supplements cause side effects.
What foods are high in iron that I can eat while pregnant?
Red meat, poultry, fish, beans, lentils, fortified cereals, and dark leafy greens like spinach are excellent iron sources. This study specifically tested spinach-fortified fish snacks, which combined two iron-rich foods. Pair iron-rich foods with vitamin C sources like citrus or tomatoes to improve absorption.
How long does it take for iron-rich foods to improve anemia in pregnancy?
This study showed measurable hemoglobin improvements within 21 days when combining fortified foods with supplements. Individual results vary based on anemia severity and how well your body absorbs iron. Your doctor can monitor progress through blood tests at prenatal visits.
Why do iron supplements cause stomach problems and can food help?
Iron supplements irritate the stomach lining, causing nausea and constipation. Food-based iron is gentler on the digestive system. This research suggests combining both approaches allows you to get adequate iron while potentially reducing supplement-related side effects.
Is this spinach fish snack available outside of Indonesia?
The specific fortified snack tested in this study was produced locally in Indonesia. However, the principle applies globally: combining iron-rich foods like fish and spinach with supplements may help. Ask your healthcare provider about similar fortified foods available in your region.
Want to Apply This Research?
- Log daily consumption of iron-rich foods (spinach, fortified fish products, red meat, beans) alongside iron supplement intake. Track hemoglobin levels at regular prenatal appointments and note any gastrointestinal side effects from supplements to identify patterns.
- Set daily reminders to consume one serving of iron-rich fortified food alongside your iron supplement at the same time each day. Use the app to log which foods you ate and any side effects experienced, helping you identify which combinations work best for your body.
- Track hemoglobin levels at each prenatal visit (typically monthly). Monitor for persistent nausea, constipation, or stomach upset from supplements. Log food intake weekly to ensure consistent consumption of iron-rich foods. Share this data with your healthcare provider to adjust your iron strategy if needed.
This research describes findings from a single 21-day study conducted in Indonesia with 60 participants. These results should not replace medical advice from your healthcare provider. Pregnant women with anemia should continue taking prescribed iron supplements and discuss any dietary changes with their doctor before implementation. Individual results vary based on health status, diet, and other factors. This article is for informational purposes only and does not constitute medical advice. Always consult your obstetrician or midwife before modifying your prenatal care routine.
This research translation is published by Gram Research, the science division of Gram, an AI-powered nutrition tracking app.