Iron Deficiency Anaemia is described as the most common form of anaemia. Inadequate levels of the essential mineral Iron in the body, lead to a decreased production of haemoglobin. This in turn leads to a reduced production of red blood cell (RBC), resulting in Iron Deficiency Anaemia. Symptoms are then related to the extent of the reduction in RBC.
Iron Deficiency Anaemia symptoms explained
Iron Deficiency Anaemia can present with many signs and symptoms and are explained below:
Weakness
Fatigue
Irritability and mood swings
Headache
Exercise intolerance
Cravings for non-food items (Pica)
Pallor
Shortness of breath
Restless legs syndrome
Poor digestion (either by low gastric acid causing iron deficiency, or iron deficiency causing low gastric acid)
Hair loss
Reduced thyroid function (Hypothyroidism) as iron is needed for thyroid function
Impaired immune function
Depression
Infertility
Dizziness
Decreased mental and motor function
Severe iron deficiency may result in Tachycardia (elevated heart rate) from the lack of oxygen as RBC are required to supply haemoglobin, which is in turn required for oxygen delivery to the body
Specific Signs and Symptoms of Iron Deficiency Anaemia:
Brittle or spoon-shaped nails (Koilonychia)
Swollen or sore tongue
Cracks or ulcers at the sides of the mouth
Unusual non-food cravings (pica) - for items like ice and dirt
Laboratory Testing for Iron Deficiency
Laboratory test results will provide the differential diagnosis for iron deficiency anaemia. If Iron-Deficiency Anaemia is suspected a Full Blood Count (FBC) and Iron Studies will be performed.
A. Full Blood Count (FBC):
Full Blood Count (FBC) will show a reduced RBC count, and reduced haemoglobin (Hb)
Reduced size of RBC or mean corpuscular volume (MCV) Reduced oxygen carrying haemoglobin concentration or MCHC
Reduced haematocrit (Hct)
RBC may show anisocytosis (different sizes), and an increased red cell distribution width (RDW) highlighting RBC at various stages of development or past iron treatment
RBC reflect microcytic (small), hypochromic (pale) anaemia which is the advanced diagnostic findings of iron deficiency anaemia
Platelet levels will begin to rise
B. Iron studies:
Iron Deficiency Anaemia | Iron levels | Transferrin | TIBC | % Saturation | Ferritin |
Results | Low | High | High | Low | Low |
Table showing the different markers for detecting Iron Deficiency Anaemia
C. Ferritin testing:
The intracellular iron storage, Ferritin, is the gold standard testing and will show low Ferritin levels. However, Ferritin levels may be falsely raised in inflammation, lead poisoning and malignancy.
D. Other Pathology Tests:
Coeliac testing
H. pylori investigation
Inflammatory Bowel Disease screening
Gastric Parietal Cell Antibody screening
Faecal occult blood studies
C-reactive protein testing for inflammation
ESR will be elevated due to anaemia
Thyroid Function Tests (see Fun Fact below)
Progression of Iron Deficiency in Pathology testing:
Stage 1: Characterized by decreased bone marrow iron stores. Haemoglobin (Hb) and serum iron remain normal, but the serum ferritin level falls to < 20 ng/ml. The compensatory increase in iron absorption causes an increase in iron-binding capacity (transferrin level).
Stage 2: Erythropoiesis (Red Blood Cell production) is impaired. Although the transferrin level is increased, the serum iron level decreases and transferrin saturation decreases.
Stage 3: Anaemia with normal-appearing RBCs and indices develops.
Stage 4: RBC microcytosis and then hypochromia develop.
Stage 5: Iron deficiency affects tissues, resulting in symptoms and signs.
Causes of Iron Deficiency
Causes of Iron Deficiency Anaemia can be grouped into the following classifications as either an Increased Iron Need, Decreased Iron Availability, or Refractory Iron Deficiency.
1. Increased Iron Need:
Iron loss through RBC loss (menorrhagia, gastrointestinal bleeding, GI tract cancer, peptic ulcers, haemorrhoids, post-partum, ulcerative colitis)
Higher iron demands at various stages of life like pregnancy for foetal development, lactation, young children, and teenagers, extreme exercise where increased erythropoiesis is required
2. Decreased Iron Availability:
Low intake of iron (malnutrition, vegetarian diet)
Poor absorption of iron (inflammation, obesity, Coeliac disease from a defective mucosal barrier, or low stomach HCl.
Ingesting competitors that chelate iron such as calcium, lead, cobalt, phytates, tannins, phenolics.
Ingesting predators like H.pylori that can cause refractory iron deficiency anaemia, parasites and worms in the GIT.
Achlorhydria from gastric parietal cell dysfunction.
Medications that alter gastric pH can also decrease iron absorption - these include antacids, proton pump inhibitors, and H2 blockers (Zantac).
3. Refractory Iron Deficiency Anaemia (IRIDA) and Inflammation:
Hepcidin is the central regulator of Iron haemostasis. Hepcidin deficiency causes iron overload, while Hepcidin excess is associated with iron-refractory iron deficiency anaemia which is resistant to improvement, inflammation and chronic kidney disease.
Oral iron supplemetation upregulates Hepcidin. Hepcidin then limits the absorption of high-dose oral iron supplementation, as the body recognises high dose iron as inflammatory.
If there is inflammation, iron will be removed from the blood and taken back to the liver, so it's not available. This is a protective mechanism. If for example we have parasites and they are consuming our iron, then our body in that inflammatory state attempts to starve the parasite of iron.
Iron is then stored in the liver as Ferritin, so adequate Ferritin levels can also be indicative of the inflammation which has caused the iron to be stored. (see Hepcidin discussion below).
There is now an understanding that there are opposing aspects of iron absorption. The need for many physiological processes versus the threat it poses by encouraging and ‘feeding’ pathogen growth like parasites for example.
Existing data suggests that hepcidin balances the need for iron, against the threat of pathogen growth and infection.
Therapeutic goals
Treatment involves resolving and improving your iron deficiency, and importantly, understanding, and addressing the underlying aetiology.
In people with chronic inflammatory conditions, response to oral iron therapy may be limited by the hepcidin-mediated decreased absorption. As such the objective is to reduce the cause of inflammation first.
While medically important to correct iron deficiency, there is increasing evidence that boluses of iron work against the body’s developed haemostasis mechanism. Hepcidin restricts iron availability due potentially to the presence of pathogenic bacteria in the GIT. Hence the need to understand the aetiology, and to not let iron deficiency get so low that an iron infusion is necessary.
Fun Fact 1: Iron is needed for clotting. If you have low iron and are a menstruating female, the fact that you have low iron could be why you have heavy menstrual periods - and not the other way around!
Treatment goals are aimed at:
Understanding the reason behind the anaemia, and improve through diet, corrective actions and supplementation
Understanding your diet - do you have low protein intake?
Understand circumstances (pregnancy, lactation, exercise), or known current diseases (ulcers etc) or any relevant history (colon cancer etc).
Is there medication use?
Determine if it is:
Chronic blood loss from menstruation via a menstruation summary or charts
GI bleeding (via faecal occult blood testing)
Obtain an understanding of bowel movements and have a Complete Microbiome Mapping from stool sample to understand pathogen presence (H. pylori, worms, parasites) that may be competing for iron needs.
Undertake Coeliac testing to determine if gluten in the diet is destroying the absorption capability of iron, or reason behind poor absorption of iron
Understanding your intake of iron for intestinal absorption
Administering supplemental iron (if required), and providing therapeutic strategies for the gut to improve poor absorption, reduce inflammation, and enhance iron levels and ferritin stores.
Do you chew food properly to stimulate gastric secretion of HCl, and digestive enzymes to break down food so you can absorb the nutrients?
Fun Fact2: Anaemia could be showing that you have thyroid concerns, as the thyroid gland controls all metabolism, including the lifecycle of RBC, and your digestion and absorption of nutrients.
Food Inclusions
Iron containing foods such as heme and non-heme foods
Heme sources – Liver, Oysters, Organic Red Meat
Non-heme sources - Legumes, whole grains, nuts, seeds, green leafy vegetables
Vitamin C taken at same time as non-heme foods to improve absorption
Herbal treatments that kill bacteria and parasites in GIT that feed off consumed dietary iron e.g., berberine, garlic
Foods that reduce inflammation to eliminate the hepcidin iron blockade process in the body to allow iron absorption at lower iron levels. This includes eating a diverse variety of colours from naturally occurring fruit and vegetables.
Food Exclusions
Gluten free diet if positive for Coeliac disease due to inflammatory effects on small intestinal microvilli. Even if testing shows you are negative, an inflammatory state on a heavy bread diet may result in high hepcidin levels that prevent iron absorption.
Remove tannins, polyphenols from tea, coffee, cocoa, wine, some spices, dairy, eggs, phytates in legumes, grains, rice, soy protein as they will chelate (bind). As a minimum consume away from iron foods or supplements
Separating taking of other supplements like calcium, magnesium, and zinc at different times of the day to iron supplementation as they chelate (bind) iron and prevent absorption
Dairy as it inhibits absorption of iron
Take iron supplements away from pharmaceutical medications due to chelating effects
Remove uncooked plant foods as oxalates compete with iron
Remove NSAID use, like Nurofen
Specific Dietary focus
Increase Gastric HCl by chewing foods better to ensure food is broken down to allow the absorption of nutrients
Decrease inflammatory foods like gluten, dairy, and sugar to reduce inflammation and hence hepcidin levels that prevent iron absorption
Specific Nutrients
Iron
Lactoferrin as assistance to iron absorption
Vitamin C to assist with iron absorption in non-heme foods
Garlic and Berberine for their antibacterial effects, removing competitive chelators
Broccoli for its antibacterial and antiviral effects, removing competitive chelators
Green tea inhibits the adhesive affects of H. pylori, is anti-bacterial and is also a powerful antioxidant
Red wine in moderation. Resveratrol is anti-bacterial
Liquorice for treating peptic ulcers and inhibiting colonisation of H. pylori
Manuka honey for anti-bacterial effects, removing competitive chelators
Probiotics to increase beneficial bacteria and compete with potential pathogenic bacteria that may be utilising iron. Members of the Lactobacillaceae and Bifidobacteriaceae families that have no requirement or a very low requirement for iron are the most beneficial
Get Vitamin D from the sun to lower Hepcidin levels
Anti-inflammatory herbs to lower hepcidin levels
Zinc
Fun fact 3: Low Ferritin can actually be a sign of Zinc Deficiency! Additionally, iron deficiency can cause zinc deficiency.
Fun fact 4: High Ferritin can simply be a sign of inflammation which is not desired.
Lifestyle Modifications
Lose weight if applicable, as obese people have greater systemic inflammation and circulating hepcidin levels and subsequent inability to absorb iron
Home-prepared meals versus highly processed inflammatory foods to reduce inflammation
Give up smoking, recreational drugs, minimise drinking alcohol if applicable for reducing inflammation
Spread-out coffee and tea consumption throughout the day if applicable, and consume away from food
Ensure chelating dietary choices are taken away from iron supplementation or iron containing foods
As Iron-deficiency anaemia can cause shortness of breath, tiredness and dizziness, exercise should be undertaken slowly.
Hopefully you've realised that iron deficiency is not as straight forward as supplementing with iron. Determining the causes is a huge component to identifying the right strategy.
If you would like to discuss your personal circumstances, or have your pathology results reviewed in line with your current situation, feel free to make a booking with me on the bookings tab on my website.
Sign Up for Further Educational Material
If you would like to make sure you don't miss a Blog update from me, or would like to receive more information in the form of upcoming e-Books and Online courses, then please subscribe to my mailing list at the bottom of the Blog front page.
References:
Cappellini M, Musallam K, Taher A (2019) ‘Iron deficiency anaemia revisited’ Journal of Internal Medicine Vol 287, Issue 2 pp153-170
Goddard, A, McIntyre, A, Scott, B (2000) ‘Guidelines for the management of iron deficiency anaemia’ BMJ Journals Gut Vol 46, Issue suppl 4
Higdon J, Drake V (2011) An Evidenced-Based Approach to Vitamins and Minerals, Linus Pauling Institute, Thieme
Iron Deficiency, Clinical Practice Guidelines, accessed 4th July 2021
Iron Deficiency Anemia, The Calgary Guide to Understanding Disease, accessed 4th July 2021
Iron, Nutrition Australia, accessed 4th July 2021
Ning S, Zeller M, (2019) ‘Management of iron deficiency’ Haematology, ASH Education Program (1): 315-322
Physicians Committee for Responsible Medicine (2021) ‘Nutrition Guide for Clinicians – Iron Deficiency Anaemia’ accessed 4th July 2021
Red Cell Indices, Lab Tests Online AU, accessed July 4th 2021
Treating Anaemia and Managing Iron, National Blood Authority, accessed 4th July 2021
Trickey, R, (2011), Women, Hormones & the Menstrual Cycle (3rd Ed.). Trickey Enterprises
Walker, A et al (2004), ‘Hepcidin: what every gastroenterologist should know’ Gut 53 (624-627)
ARTICLE/CONTENT DISCLAIMER
The information provided in this blog/article/handout is for your personal or other non-commercial, educational purposes. It should not be considered as medical or professional advice. We recommend you consult with a GP or other healthcare professional before taking or omitting to take any action based on this blog/article/handout. While the author uses best endeavours to provide accurate and true content, the author makes no guarantees or promises and assumes no liability regarding the accuracy, reliability or completeness of the information presented. The information, opinions, and recommendations presented in this blog/article/handout are for general information only and any reliance on the information provided in this blog/article/handout is done at your own risk. Any third-party materials or content of any third-party site referenced in this blog/article/handout do not necessarily reflect the author’s opinion, standards or policies and the author does not assume any liability for them whatsoever.
,