If you have been diagnosed with iron deficiency or iron deficiency anemia, chances are you been advised to use oral iron supplements, along with eating more foods rich in iron. Though there are several available at your pharmacy, resist the urge to just pick up any supplement because iron deficiency is not something you should try to treat on your own. Working with your doctor or pharmacist will allow you to get the right type and dose, and hopefully limit the undesired effects you may experience.
Not all iron supplements – or people for that matter – are the same; the one you should take depends on your specific needs. All iron supplements are effective (in terms of ability to increase hemoglobin and hematocrit) in a normal, healthy gut; however, the amount of elemental iron available for absorption by the body, the possibility of developing adverse effects, and more convenient dosing, are all important factors to consider when choosing an iron supplement.
It’s important to look at how much elemental iron (amount of iron that is available to be absorbed) is in each tablet/capsule. While absorption can be affected by various elements, in a normal healthy gut heme iron has a higher absorption rate than non-heme iron (25% versus 16.8% respectively). At the end of the day, the more iron that is readily available, the more that can be absorbed.
Oral Iron Preparations (Tablets/Capsules)*: Amount of Elemental Iron, Ranked Highest to Lowest
|Oral Iron||Strength per Capsule/Tablet||Elemental Iron per Capsule/Tablet||Heme Iron/Non-Heme Iron||Ionic/Non-Ionic|
|Polysaccharide-Iron Complex (eg. FeraMAX® 150)||150 mg||150 mg||Non-heme||Non-Ionic|
|Ferrous fumarate (eg. Palafer® & generics available)||300 mg||100 mg||Non-heme||Ionic|
|Ferrous sulphate (generics available)||300 mg||60 mg||Non-heme||Ionic|
|Ferrous sulphate dried sustained-release (eg. Slow-Fe®)||160 mg||50 mg||Non-heme||Ionic|
|Ferrous gluconate (generics available)||300 mg||35 mg||Non-heme||Ionic|
|Heme-Iron Polypeptide (eg. Proferrin®)||11 mg||11 mg||Heme||N/A|
*Anemia Guidelines for Family Medicine, 3rd Edition, 2014 (page 8)
The non-heme iron supplements listed above are either in ferrous (Fe2+, ionic) or ferric (Fe3+, non-ionic) forms. Iron salts, which are ionic, include ferrous fumarate (Palafer®) and ferrous sulfate (Slow Fe®). The only non-ionic option available in this market is a formulation called Polysaccharide-Iron Complex or PIC (FeraMAX®). To my knowledge, heme iron is not considered ionic nor non-ionic; Proferrin® is derived from bovine red blood cells.
Once prescribed, iron supplements are going to be used for a relatively long period of time, patients’ poor compliance is the primary reason for failure of therapy. Gastrointestinal (GI) side effects – stomach upset, abdominal distress, dark stool, and either constipation or diarrhea – are often the most common cause for temporary or permanent discontinuation. PIC and heme iron have both been noted to be easier on the digestive system and cause fewer GI side effects.
The British Columbia Ministry of Health Sciences outlines the incidence of side effects for the various oral iron preparations in their Guidelines and Protocols for Iron Deficiency:
Oral Iron Preparations (Tablets/Capsules): Incidence of Side Effects*, Ranked Least Incidence to Greatest Incidence
|Oral Iron||Incidence of Side Effects|
|Ferrous sulphate sustained-release||+|
*British Columbia Ministry of Health Services – Guidelines and Protocols: Iron Deficiency – Investigation and Management, 2010 http://www.bcguidelines.ca/pdf/iron_deficiency.pdf
Heme iron is also considered to be well tolerated. I will remind my vegetarian and vegan friends; however, that heme iron polypeptide is derived from animal proteins (bovine source).
As mentioned above, some supplements may offer more convenient dosing, which can be important depending on your lifestyle. Your doctor or pharmacist will assist you in determining the dosing regimen that best suits your needs, and hopefully reduces possible side effects as well.
Oral Iron Preparations (Tablets/Capsules): Adult Dose*, Ranked Most Convenient to Least Convenient
|Oral Iron||Adult Dosing|
|Polysaccharide-iron complex (150 mg of elemental iron)||1 capsule once a day|
|Ferrous fumarate (100 mg of elemental iron)||1 tablet 2-3 times a day|
|Heme iron polypeptide (11 mg of elemental iron)||1 capsule 2-3 times a day|
|Ferrous sulphate (60 mg of elemental iron)||1 tablet 2-3 times a day|
|Ferrous gluconate (35 mg of elemental iron)||1-3 tablets 2-3 times a day|
*Anemia Guidelines for Family Medicine, 3rd Edition, 2014 (page 11)
Choosing the right iron supplement depends on each patient’s individual needs. I always recommend speaking with your doctor or pharmacist for proper diagnosis and to assist in ensuring you get the right iron supplement for you.
Learn about iron preparations for children →
Think you are iron deficient? Check your symptoms here →
This article was last updated on 11.14.2014
Content and advice provided on The Iron Maiden is for information purposes only and should not serve as a substitute for a licensed health care provider, who is knowledgeable about an individual’s unique health care needs
34 thoughts on “Supplementation Options for Adults”
Good article however I am unclear about a few things;
The above table refers to Ionic and non-ionic iron. What is the relevance/benefits one vs the other?
What is the difference between the strength and elemental iron?
I have looked up all the above mentioned brands and you have talked about iron salts and PICs. What is your opinion on Heme Iron (Proferrin). Seems like it is the only Heme Iron available.
Thank you for the response.
Great Question Rajat, and a chance to expand beyond the limitations of the blog.
First, ionic vs. non-ionic essentially relates to how the iron supplement is composed – When we look at ionic forms, once ingested they require the acid in your stomach to dissolve the iron. In the presence of medications to decrease the acid in your stomach (eg. H2 inhibitors and PPIs), this can even further inhibit iron absorption. On the other hand, when we look at non-ionic forms, they are considered to be more stable; although they will be converted into an ionic form in order to be absorbed in the intestine, the iron does not interact with food in the stomach which, in turn, does not inhibit absorption.
Second, “strength” refers to the size (mg) of each tablet/pill. What is really important is to look at how much elemental iron is in each tablet/pill, which is the amount of iron that is available to be absorbed. We also need to look at factors that affect absorption such as: the quality of the absorptive surface (which may be affected by Celiac disease or Inflammatory Bowel Disease), the quantity of the absorptive surface (which may decrease due to bariatric surgery or other surgical procedures), and finally the time the iron is in contact with the absorptive surface (motility).
Now, in a normal healthy gut, heme iron has a higher absorption rate than non-heme iron (like the ferrous salts and PICs). I will also note that the source of heme iron is animal based, which may be a consideration for some patients.
Taking all of these factors into account, it’s pretty easy math to understand that if you have more iron ready for absorption, more will be absorbed.
Choosing the right iron supplement depends on each patient’s individual needs – I always recommend speaking with your doctor or pharmacist for proper diagnosis and to assist in ensuring you get the right iron supplement for you.
Why do they and you seem to recommend Heme-Iron Polypeptide above Ferrous fumarate. I see that it can be absorbed better, but not quite twice as well (25% vs. 16.7%), and since the doses are so much lower (11mb vs.100mg), won’t you end up absorbing more iron from the Ferrous fumarate? As long as you don’t have GI problems with it.
And the Heme-Iron Polypeptide we found, Proferrin brand, costs $50/month at full dosage, making it much more expensive, I think.
Thank you so much for asking a question I am sure so many are thinking!
You’re so right – in a normal, surgically unaltered gut, all the available iron supplements perform about the same. In this case, the choices then reflect other considerations. Please check out my Guide to Choosing the Right Iron Supplement.
Ease of dosing is a consideration – Maintenance doses of iron salts are up to three times a day on an empty stomach; FeraMAX is one capsule per day and Proferrin is twice daily, both can be taken with or without food. On a side note, with any iron supplement, one should also consider avoiding iron absorption inhibitors to ensure you’re getting the most out of your iron supplement.
Side effects are a consideration – Iron salts typically cause numerous side effects including heart burn, nausea, abdominal cramping, constipation and black tarry stools (unabsorbed iron). I’ve seen that these side effects are significantly decreased (if not eliminated) with Heme and polysaccharide irons. Scott, although you do not experience GI issues, it is important to note that if you take any medication that lowers the acidity in your stomach (Proton Pump Inhibitors, H2 Inhibitors, Aluminum Salt Antacids) the iron absorption will be compromised.
Cost is also a consideration – Scott, you brought up cost… While the heme and polysaccharide irons do tend to be more expensive, if you do the math you’ll find that this cost is not very extreme; the cost per tablet (as per the recommended daily dose) across available oral irons is approximately the same.
Thank you for your questions!
I have to take three iron pills a day for life due to my disease of HHT which means I pay over $90.00 a month for Profferin. I can’t take the cheaper iron supplements due to side effects. Drug companies won’t cover Profferin due to the high cost including the Ontario old age drug plan. I find it very disheartening that they want people to suffer because of a drugs cost.
I am sorry to learn of your chronic health issue, our health has a very valuable role in our quality of life!
I have two suggestions for you:
(1) Your physician may be able to get coverage through your public plan by writing a letter explaining why the heme polypeptide (Proferrin) is the only oral iron supplement that you can take
(2) You could try contacting the manufacturer of Proferrin and ask if they have a “Compassionate Release of Drug” program. Many drug companies do have such programs to help people like yourself. Be prepared that this may involve releasing personal information such as your income, etc. After this assessment, the manufacturer may be able to cover all or a percentage of the drug cost.
I hope this information is useful as I agree that the cost of non-salt iron supplements are almost prohibitive to those on a fixed income, however a “cheaper” iron supplement that does not work for you is a greater waste of scarce funds.
Good Luck I hope these suggestions work for you!
What’s the difference between an ionic and a non-ionic form of iron? Which is better absorbed?
What a great question! Ionic vs Non-Ionic essentially relates to how the iron formulation is composed.
When we look at ionic forms, once they are ingested, they require the acid in your stomach to dissolve the iron; this is why I often say that ionic irons need to be converted to the type of iron our body likes to absorb. In the presence of medications to decrease the acid in your stomach (such as H2 inhibitors or PPIs) this can even further inhibit iron absorption. When we look at non-ionic forms, they are considered to be more stable and I often say that this iron is the kind our body likes to readily absorb. Although it will be converted into an ionic form in order to be absorbed in the intestine, the iron does not interact with food in the stomach, which in turn does not inhibit absorption.
In a normal digestive tract, both forms of supplements are equally effective if taken under optimal conditions (ionic irons on an empty stomach with vitamin C etc.). What this means is that if you have a normal digestive tract, you may want to consider factors other than absorb-ability, such as: convenience, cost, and/or side effects (tolerability). You can see a comparison of the different iron supplements here. These considerations should always be explored with your health care professional or pharmacist who better understands you and your health care needs.
Hello! QUESTION: I have a low Ferritin (9) and low Hemoglobin (112) and high RDW (14.7) and low MCH (26.5) – I took FeraMax 150 daily for 6 weeks. I had no increase in my Ferritin. Before: 9, After 9. Why? I have Celiac but according to all my research that should only affect absorption if I am untreated, but I’ve been gluten free for 4 years. So, why am I not absorbing? Of course you can’t know, but what are the possibilities? I have a non-interested dud of a doctor and not many good doctor options (lots of doctors but very few acceptation new patients). I need information so I can figure this out on my own. I am SO TIRED. For so long. I am pretty desperate. I’m truing to keep a good attitude but I’ve been tired for so long I’m just worn out from the fatigue and frustration. It was only recently that I even figured out that my iron was low, before that I didn’t have a clue what was wring. Help! (also the FeraMax had tons of terrible side-effects)
A ferritin level of 9 must be significantly impacting your quality of life!
You can try to increase the bioavailability of FeraMAX by opening the capsule. Based on my clinical experience, it is difficult (if not impossible) to normalize one’s ferritin level with oral iron supplementation alone once it’s dropped below 20. You may want to ask your health care provider about intravenous iron.
I can empathize with Kate. I am 24 years old and have had to attend university part-time because I have just been too tired to concentrate on school work. My current ferritin level is 3 and my current haemoglobin level is 112. I have had fluctuating levels for over 4 years, never going above level 22 (might I mention, at a very slow rate). I am becoming EXTREMELY frustrated with family doctors not listening; they do not believe that low ferritin can cause the symptoms that you describe. I even saw a haematologist and he said that intravenous iron is too risky. Do you have an email at which I can contact you? I have a long story and was hoping that I could explain it to you and to also ask you which doctor you might recommend seeing so that my family doctor can make a referral to him/her. Thanks!
I will send you my contact information via email.
I am curious as to what your terrible side effects were with the FeraMax? I have been taking it as well and wondering if it is now causing some concerning issues I am having.
I hope you are finding your energy levels increasing 🙂
Is it safe to crack open the feramax tabs and pour on food? Also, my doc. says my iron is 9 and low, is that very low? I feel just awful but am also overweight and have other health problems.
Absolutely it is safe to open the FeraMAX capsule and add it to a warm liquid or soft food. While it will darken the colour of your warm beverage or food it will not stain your teeth like the liquid format of iron salts. It is also odourless and tasteless.
I advise my clients to dump it in their morning coffee, since it is already the type of iron our body absorbs; the caffeine will not inhibit it’s conversion. Some of my clients prefer to use the paediatric powder format of FeraMAX (FeraMAX Powder) which can be dissolved in cold liquids or mixed into foods. It is grape/raspberry flavoured (for kids) and tastes similarly.
Based on my experience with patients, it is difficult (if not impossible) to raise ferritin levels that are below 20 with oral iron supplements alone; IV iron may be necessary in your case – please speak to your Physician about this.
Best of luck!
The article is good but a few important things are missing. the heme iron is definitely good in terms of absorption but its expensive and studies has shown that it does not necessarily increase your iron levels too fast as compared to any ferrous salt.
Secondly, for polysaccharide iron complex, its true that it has high elemental iron and lower stomach side effects as compared to ferrous fumarate but the actual absorption is far lower than ferrous fumarate, because it is a ferric salt and it has to be converted to ferrous salt before body can absorb it. So, simply high elemental iron does not tell the whole picture and the companies market it and we get in the trap.
I was diagnosed with low ferritin last summer. It was at 13. All of this fall, I tried a Life Brand from Shoppers, Eurofer, and Feramax. The life brand and Eurofer bloated me up and seemed to fog up my brain. Feramax eliminated the gastrointestinal issues but made me anxious. So, I stopped taking them. I just had my blood retested and my ferritin level had dropped to 9. The doctor and pharmacist recommended Proferrin. I tried 1/2 a capsule and it gave me a really unpleasant anxiety attack although it did seem to clear my mind. I would like to try to continue with Proferrin but I don’t understand why it and Feramax created anxiety attacks? Any idea why?
Sounds like you have been having quite a struggle with iron deficiency. You are correct that Polysaccharide Iron Complex Supplements like Fermax and Heme Polypeptide Iron like Proferrin eliminate the gastrointestinal symptoms. Regarding your question about anxiety however, I know of no such averse side effects with either of these formulations. Is it possible that it is a coincidental effect (some other issue either environmental, other medication, symptom of the iron deficiency) rather than a causal effect?
I am sorry I don’t have a more concrete answer for you. I do encourage you to speak with your health care provider about it and to request testing to determine why you are iron deficient and receive definitive treatment for your deficiency.
I have a ferretin of 12 and have put on iron polysaccharide complex once daily with follow up bloodwork in 3 months. I take a PPI daily (Prevacid 30mg qAM), a multivitamin, and the iron with vitamin C daily (I space them apart to take on an empty/mostly empty stomach). I have tried various iron tablets and liquid over the years and all have reliably resulted in black coloured stool, except with the PIC. Does this indicate the iron supplement is not working? Should I switch to another supplement, and if so, which is a good option given the likely low acid environment from the daily PPI?
Thanks for your question. When tell me that most of the supplements you have taken in the past gave you a black stool you confirmed that a majority of these irons were likely iron salts or vegetable source irons. Iron salts and vegetable source irons must be converted to the type of iron our body absorbs. Only 8% of the elemental iron in these preparations get converted for absorption the remainder is eliminated through the colon as a very caustic black sticky stool everyone associates with iron supplementation. It is also what is responsible for a great deal of the gastrointestinal side effects associated with oral iron supplementation. The reason why your stool is not black with the PIC is that it is being better absorbed.
Unfortunately with a ferritin less than 20 it will be very difficult if not impossible to increase your iron stores (ferritin level) wit al iron alone.
Hi Leona. I’m so glad I found your site!
I’m a 45 year old male and very passionate and frequent blood donor (every 8 weeks – maximum frequency allowed in the US). A recent wellness check with my doctor found that my Ferritin is 15 (low), UIBC is 410 (high), TIBC is 468 (high), Iron serum is 58 (normal) and Iron saturation is 12 (low). Those numbers point to iron deficiency, although I don’t have any other symptoms like what you list on your site (http://theironmaiden.ca/think-you-might-be-iron-deficient-check-your-symptoms/)
The doctor suggested that I take Ferrous Sulfate 325mg once per day, which is roughly 65mg of elemental iron. Based on your info above (and other info on your site), I’m considering instead to take PIC 150mg once per day because it maximizes absorption, has fewest side effects, and I don’t have to worry about taking on an empty stomach or interactions with specific foods (Do I have that right??). Of course, taking PIC 150mg is more than double the elemental iron than Ferrous Sulfate 325mg.
Based on my situation described above and the benefits of PIC vs. Ferrous Sulfate, do you think that using PIC is a good idea for me? Any other thoughts?
(Feel free to post a reply there or reply via email.)
First, on behalf of the benefactors of your commitment to blood donation, I want to say thank you. Unless you have ever been in the position of needing a blood transfusion you truly have no idea how big a gift it is.
Second, congratulations on doing your research and taking an active role in your health and wellbeing. Yes, I do believe PIC would be a better, more convenient, option for all the reasons you have listed.
I am surprised that you are not symptomatic with a ferritin of 15. Using my common lab values normal ferritin is 20-300, but patients can be symptomatic at values less than 50. The triad of iron deficiency (irritability, chronic fatigue and difficulty concentrating) is often ignored or attributed to other causes. With a ferritin of 15 it may be difficult to restore your iron levels using oral iron alone, but you must start somewhere.
Triad of Symptoms
Iron deficiency in absence of anemia is a big problem within the “frequent donor” program. My blog has published an article related to this issue: http://wp.me/p6qvc6-6k. Within this article is a two-week “post donation ” iron repletion program, describing dosages for the most common oral iron supplements.
Here in Canada, Canadian Blood Services, have acknowledged that iron deficiency can exist in absence of anemia. They are moving away from the pre-donation, capillary hemoglobin test to a test of the donors iron.
Thank you for your question.
For those trying to raise their ferritin by oral supplementation alone – it can be done. I have, several times. (I know, I need to find a way to keep it there). But last time tested at 7 – I started taking iron 3x/day. Typically Ferrous sulphate with cranberry juice when I rolled out of bed, followed by breakfast 1.5 hrs later. Proferrin or another ferrous sulphate mid-day. And again before bed with vitamin C. After two months, I reduced to 2x/day for another 4 months or so, at which time I tested at 33.
This gives me so much hope. Thank you Jay for your detailed account of how you raised your ferritin levels. Thank you too iron maiden for this great resource! I’m pouring through everything.
Thanks for such a great, informative website!
I was diagnosed with low iron last summer (level 2) and started taking Fermax daily, as well as the pill. After three months, I was at level 8 and then at level 23 six months after that. I was told to continue taking iron until I got menopause (I’m 43). I recently read that taking more than 30 mg of iron long term can cause other problems (reduced absorption of copper and zinc). Should I be taking a different supplement?
Long term use of high dose iron may affect abortion of other trace elements, this is true, especially if you are not iron deficient nor anemic related to that iron deficiency.
You have nothing to worry about. While a ferritin of 23 is “normal” you are likely still symptomatic (chronic fatigue, irritability, difficulty concentrating) with symptoms we tend to incorporate as our “new norm”.
20% of all Canadian women are iron deficient. It is the most prevalent, under diagnosed, and under treated dietary deficiency in the world. A majority of females with iron deficiency also have dysfunctional monthly bleeding issues.
Once in menopause, the source of your blood and iron loss will be negated, however; I would not abandon oral iron replacement therapy until your ferritin level is over 50 and your iron panel (serum iron, TIBC, % Transferrin Saturation) is within normal range.
In a normal, non-surgically altered gut, there is no real difference between the effectiveness of oral iron supplements. Lifestyle and side effects may contribute to noncompliance. I recommend switching to an iron format that is easier to absorb and has significantly fewer side effects like a polysaccharide iron complex or heme polypeptide iron supplement.
Feel good, keep advocating for yourself.
HI! I have a hemoglobin of 10.2 and ferritin of 5! I have unfortunately lived like this for years, my doctor, I just don’t even know what he was thinking. I’ve been tested several times since 2011 and the highest I got was ferritin of 9. After he told me to take a single iron suppliment daily. He seemed ok with 9 and I went off the supplements, wrongly assuming it would go up. Of course it did not. Now I’m back to 5. I imagine I’ve had this for a very very long time and have always thought I was just a very lazy person. Was feeling poorly, went to urgent care and they were quite shocked by my numbers and acted like it was serious. Would a person at 5 ferritin be very inactive? Now I’ve started 2 ferrous gluconate 3x a day, and I went to the Dr for another reason and he thought that was too much and causing my stomach distress and nausea. Now 2 pills 2x a day, but I’m still sick to my stomach, nauseous, stomach pains, dizzy. I just ordered the heme iron polypeptide, but it’s only 11mg, is that enough 3x a DAY? I’m praying it helps with the gastrointestinal issues, I’m miserable! Thanks for all the great information! Jaycee
New doctor in the works!
I read your comment and am embarrassed for my health care colleagues. The fact that you have been left to suffer from debilitating symptoms of iron deficiency including the most severe related to anemia is very sad.
Iron deficiency is the most under diagnosed and under treated deficiencies in the world. The effect of treating iron deficiency appropriately can be life changing.
I have had patients who were placed on antidepressants for symptoms that could be attributed directly to iron deficiency, were on them for years before coming to me. Diagnosed early with stage one or stage two iron deficiency, once treated, had them feeling better than they had in a long time.
20% of all Canadian women (and up to 50% of pregnant Canadian women) are iron deficient.
So now let’s talk about you and how you are going to start feeling better. Ferrous Gluconate is an iron salt. When taken under optimal conditions only 8% is converted for absorption. What isn’t converted causes what I fondly refer to as “gut rot” (symptoms commonly associated with oral iron supplements)
One Ferrous Gluconate three times a day would be hard enough on your digestive tract but 2? You, my dear, are far more compliant than any of my patients would be, and frankly, I wouldn’t blame anyone for being non-compliant with a regime that caused such extreme side effects.
I am proud of you for doing your research and finding heme polypeptide iron supplements. Gastrointestinal side effects from this type of iron are significantly reduced, if not eliminated. It is already the type of iron our body absorbs so all 11 mg are available for absorption. So yes, the 11 mg capsule is enough elemental iron. It is safe to take 2 caplets twice a day. You can increase its bioavailability and subsequent absorption by crushing it. (**NOTE IT IS NOT SAFE TO CRUSH ANY OTHER ORAL IRON SUPPLEMENT)
Finally Jaycee, you need to ask your doctor for a referral to a benign clinical hematologist to prescribe a course of IV iron. Once your ferritin is below 20 it is difficult, if not impossible, to replete iron stores with oral iron alone. All your oral iron is doing right now is supporting your hemoglobin.
Let’s get you back on the road to wellness! Please let us know how your journey is going.
Hi! Thank you for the response. I forced the issue and had a single iron infusion, which after a month gave me 12.6 hemo and 182 ferritin! But I don’t know if it will stay that way or lower. I am getting a Mirena IUD, which I hope will illuminate iron loss. Thank you so much for your site! Also, word to the nervous! IV Iron infusion was a breeze! I worried for nothing!
I was diagnosed with low ferritin and my doctor recommended a Vancouver based brand which I have found to be tolerable.
Various doses, I use the highest 150mg elemental iron
$100 vegetarian capsules costs about $50
Capsules also contain: glycine, copper, 5-MTHF, methylcobalamin, vitamin C, zinc
What can you suggest of the iron supplement that doesnt bother on your stomach I had a BAD reaction or side effects of the ferrous sulphate, I really need some help or advice on this matter.
Have you tried polysaccharide iron complexes like FeraMAX or heme polypeptide iron supplements — both known to significantly reduce if not eliminate “gut” side effects?
I urge you to speak with your primary healthcare provider as s/he knows you and your health history a great deal better than I. I would recommend printing and completing the symptoms checker and the article on the progression of iron deficiency. Take these to your appointment and let your healthcare provider know you want to play an active role in your health and wellbeing. Your healthcare provider is the expert in medicine and you are the expert in you.
I hope this is helpful and good luck with the self-advocacy.