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Why Iron Levels Remain Low

Iron is arguably the most important nutrient to our body’s functioning because it ’switches-on’ most body systems; very little is activated within the body without adequate iron. Iron storage (termed: ‘Ferritin’) is the accepted stable + most reliable indicator of the body’s true iron status.

At a 2006 International Hormone Conference, Dr. John Lee – Australia’s most progressive thyroid researcher – presented his findings that ferritin levels should ideally be at a ‘target’ level of 120-150 ug/L (halfway within the reference range of 20-300ug/L). His research confirmed this level is required to generate sufficient and quality mitochondrial ATP (adenosine tri-phosphate) for optimal metabolic and liver activity. Adequate ATP is essential in the production of Cytochrome P450 and the function of ‘phase II’ liver detoxification pathways.

Inadequate or depleted iron storage is the most prevalent nutritional deficiency in women of menstruating age. Iron is lost predominantly through menstruation each month, and if a woman’s periods are excessively heavy or frequent, she may drop her iron stores quite rapidly. Iron deficiency may also occur during pregnancy as a result of increased demands on the mother’s nutrient reserves by the developing infant.

Iron is central to healthy functioning of the human body because it’s the main constituent of haemoglobin – the oxygen-carrying protein inside red blood cells. Iron is also essential for many bio-chemical processes including the formation of many cytochrome iso-enzymes and certain respiratory enzymes.

A small but constant daily intake of iron is essential to maintain the quality & numbers in red blood cell production. Females 14-50 years of age require 15-18mg of iron per day, decreasing to about 8mg/day after menopause.

Early indicators of diminished iron levels are fatigue, dry skin and hair, or intolerance to cold. Scalp hair density will reduce; individual hair shafts become thinner in diameter, and (in brunettes) the natural hair colour may change to a reddish-brown.

Symptoms of fatigue and sensitivity to cold are both related to inadequate oxygen supply (due to decreased haemoglobin); vital for ATP & thermo-genesis (heat) production. The revealing pallor of iron deficient women is again due to low haemoglobin content in the blood.

Raising iron levels in a woman with iron deficiency anaemia can sometimes be a lengthy & ‘patience-testing’ process, for there are many factors to frustrate this undertaking. The main issues are:

  1. Blood Loss from bleeding ulcers, haemorrhoids, ulcerative colitis or other problems within the gastrointestinal or genitourinary tracts. When iron levels fail to rise with iron supplementation, the patient should be referred (by their GP/MD) to a Gastroenterologist for further investigation – and exclude any malignancy. Heavy, persistent menstruation with blood ‘clotting’ can be an indication of low iron (or thyroid disturbance) in pre-menopausal women.
  2. Helicobacter pylori(HpSA)infection is – except for blood loss – the most common cause of iron deficiency worldwide. H. pylori bacterium decreases the gut’s ability to absorb iron by inhibiting gastric acid secretion, damaging the stomach’s mucous layer, & underlying gastric cells. Establishing if there is a HpSA infection is usually verified by one or more of the following:
    1. Endoscopic biopsy
    2. Fasting C-14 breath test
    3. HpSA faecal (stool) antigen

Testing to identify (or eliminate) HpSA as an underlying cause should always be considered in chronic iron deficiency.

  1. Coeliac Disease/Gluten Intolerance occurs in the small intestines of pre-disposed people as a result of an inflammatory reaction to Gluten – the main protein of wheat, rye, barley and hops in beer. Over time the intestinal lining is obliterated, diminishing its capacity to absorb dietary nutrients – particularly iron. Coeliac serology should be mandatory when investigating the cause/s of iron deficiency.
  2. Intestinal Parasites & Disordered Gut Function: Blastocystis Hominis is a ‘natural’ inhabitant of the human gastrointestinal tract. However, when over-colonisation of this parasite occurs, it can cause chronic diarrhoea, fever, nausea and abdominal cramping. B. Hominis utilises iron from the host’s body to mature and replicate, thus depleting the person of iron for their body’s needs. Many chronic anaemia patients are found to be infested with this parasite.

Severe fermentative dysbiosis is an overgrowth of normal gut bacteria due to inadequate gastric acid and/or pancreatic enzyme production. Sufferers often exhibit multiple nutrient deficiencies including iron, B group vitamins, B12, zinc & magnesium.

  1. Competing Nutrients: When supplementing vitamins & minerals it’s important to know which nutrients aid or antagonise another’s absorption. Taking an iron supplement at the same time as the minerals zinc and copper (other than Picolinate forms), or calcium or chromium will inhibit the absorption of all. Excessive or prolonged supplementing of Vitamin B12, D or E can inhibit the absorption of iron. Vitamin B group excess is an increasing clinical issue for Practitioners as more people tend to self-diagnose and self-medicate. Commercial multi-vitamin companies heavily market their products as tiredness ‘cure-alls’ – and it’s not uncommon to see a patient taking 2-4 different brands of multivitamin B-complex all at once!

Cobalt is the essential element of Vitamin B12 (Cobalamin). Cobalt antagonises the absorption of Magnesium (Mg) when Cobalt is ingested in excessive amounts or for prolonged periods of time. Any resulting deficiency of Mg may cause cardiac arrhythmias (+ sudden death from heart attack) – particularly in the elderly or those with weakened/damaged hearts (Watts: 1995). Folic acid also increases the body’s metabolic need for Mg. Excessive Folic Acid ingestion resulting in elevated nutrient levels may cause diffuse hair loss (Rushton et al).

Fenugeek (Trigonella f-g) is a traditional herbal treatment taken for ‘hair health.’ US National Institutes for Health (NHI) states that Fenugeek is known to interfere with iron absorption and thyroid medication.

  1. Copper Deficiency may result in a refractory anaemia unrelieved by iron supplementation. A deficiencyof copper (Cu) hinders the deployment of iron by the red blood cells, resulting in the iron being accumulated (and unavailable) within the organs of the body. Because this stored iron cannot be utilised whilst the copper deficiency persists, symptoms of iron deficiency may present despite an actual iron sufficiency.

Elevated Copper has an action within the body similar to heavy metal toxicity (Baratosy: 2005) Copper in excess has a suppressing effect on zinc and iron absorption and interferes with thyroid function.

Elevated Copper exhibits in approximately 20-30% of women who take certain oral contraceptives or (synthetic) hormone replacement. Excess Cu also disrupts adrenal hormone production and sex hormone balance – by retaining and increasing Oestrogen. Oestrogen in turn retains Copper – thus driving up each other’s levels and destabilising the levels of their opposing hormone and nutrients.

  1. Underactive Thyroid function (Hypothyroidism) is an indirect cause of low iron as the active thyroid hormone T3 (Triiodothyronine) is essential for good gut function. Menorrhagia (heavy menstrual bleeding) and a disruption in menstrual cycling can be an indicator of thyroid gland disturbance in pre-menopausal women (Shames + Shames: 2005).
  2. Chronic Health Conditions such as Thalassaemia (B) trait which is an inherited red blood cell defect among (predominantly) Adriatic/Mediterranean people. Those with Thalassaemia can absorb and store iron – but the body cannot optimally utilise it.
  3. Heavy Metal Toxicity of lead, mercury or cadmium will inhibit iron absorption and utilisation. Heavy metal pollutant effects on the body is at last receiving greater investigative focus due to its underlying influence on chronic illness.
  4. Antacid Medication or tablets can bind to supplemented (non-dietary) iron inhibiting its absorption. Those who regularly use prescribed or self-administered antacids should advise their health practitioner if they’re found to be iron deficient requiring supplementation. Iron supplements should be taken at least one hour before or two hours after any antacid medication.
  5. Strenuous Exercise with a resultant heavy perspiring utilises iron, Vitamins B12, Folate and protein at an accelerated rate. A demanding exercise regime may also lead to decreased nutrient absorption as blood supply to the gastrointestinal tract is diverted to the muscles. Excessive exercise usually leads to increased perspiration/sweating, an can deplete zinc, magnesium, and often potassium. A good level of zinc is required for the stomach to produce hydrochloric acid (HCL) – HCL is essential for the absorption of iron, magnesium and ‘trace elements’ (Zinc, Selenium, Molybdenum, Manganese, Copper, Cobalt, Vanadium).

Athletes who are significantly deficient in iron or other nutrients should rest or only undertake light workouts and replenish with quality nutrient therapy.

  1. Types of Iron, Delivery + Combinations: its unclear why but some people better absorb and utilise certain forms of iron and not others. Supplementing with different types of iron or an iron ‘combination’ may yield better results. Iron Picolinate, Ferrous Fumarate, Iron Phosphate or Iron Amino Acid Chelate is iron variations to be considered. Oral iron supplementation should be at least 30 mg (equivalent elemental iron) per day. Vitamin C enhances the absorption of supplemental iron; green leafy vegetables with the absorption dietary iron from animal protein (lean red meat).

The common iron tablet prescribed by Doctors is commercially available Iron Sulphate tablets (with or without added Vitamin C). It contains one of the highest iron amounts of ‘elemental iron (105mg) – but an inorganic iron – more difficult for the body to breakdown, absorb and utilise, and sometimes quite irritating to the gut. Oral iron sulphate supplementation is a frequent cause of constipation, bloating and non-compliance in patients. Under the most optimal gut conditions it’s still believed just 10% of Iron Sulphate is absorbed by the body (Chan: 2010).

‘Ferronyl is carbonyl iron and has a much higher iron level (99% bioavailable) than ferrous salts, such as ferrous gluconate, ferrous sulphate or ferrous fumarate. ‘Ferronyl’ is effective and well tolerated according to ACNEM Compounding Pharmacist Harrison (2017).

As an additional adjunct iron to (iron) powder supplement protocol (or singularly in rare instance powder cannot be tolerated, this form of iron appears to improve iron levels which tend to resist elevating.

According to Chan (2012), amino acids are essential as a transporter and ‘cell messenger’ to deliver iron to the cells. Without adequate, quality amino acids the iron can be stored in the organs (as Ferritin) – but unavailable to the body – and a situation of ‘insufficient iron availability’ (1) may result.

Whilst iron injections (or transfusions) (2) are obviously necessary in life-saving or severe anaemia situations, they are not the optimal method of supplementation to raise one’s iron stores (3).

Inexpertly given iron injections can result in tissue abscesses or permanent staining to the skin. Additionally – when is given by injection, tissue iron levels within the body remain high whilst the iron is absorbed, disseminated to the organs for storage and ultimately utilised by the body.

During this time significant free radical (ROS) damage is believed to occur which can potentially predispose to malignancy in later life (Chan: 2010).

Iron is very oxidative with a very reactive potential that can cause physiological ‘shock’ to the body from the high amounts rapidly administered. This will often activate a Telogen Effluvium in susceptible people.

Human beings have evolved by having almost all nutrients absorbed and made available to the body from the gut. ‘We should strive to replicate’ such nutrient supply practices (Cannell: 2012).

  1. Compliance: diligence, patience and time are essential pre-requisites in re-building depleted iron stores. Patients will often take an iron supplement for 3-4 months only to find their iron levels are unchanged or even lower. This is due to low bone marrow iron that has compensated by taking iron from the muscles (termed ‘Myoglobin’).

When iron is being replenished through supplementation, the bone marrow ‘debt’ to the muscles and storage organs must first be repaid – hence iron storage (ferritin) levels remain static or even fall on the initial follow-up blood test. This is a temporary setback, and the person’s iron levels will eventually lift as they continue supplementing. It’s important for the Practitioner to reassure the patient, allay anxieties and encourage continued compliance.

  1. Chronic anaemia: occasionally patients may present with an acceptable iron studies signature where the ferritin is within ‘target’ range, but the Haemoglobin is revealing clinical anaemia. This can be due to underlying chronic disease which is suppressing bone marrow function. Chronic anaemia is habitually seen in patients with Thalassaemia or hyperthyroidism. They should always be referred (by their Doctor) to a Haematologist for further investigation and management. Raising Vitamin D levels to 150-200 nmol/L will help stimulate bone marrow activity (Van Zanden: 2017) (4).
  • ‘Poor Iron availability’ is an Iron Studies picture of adequate Ferritin levels but low Serum Iron, %Saturation, Transferrin (or high range TIBC).
  • **Iron transfusions are usually only undertaken within a hospital environment for reasons of patient safety.
  • Refer to article: The downsides of iron supplementation by injection or infusion.
  • ***Patients with hyperthyroidism must be Vitamin D supplemented conservatively (1000-5000 IU/daily maximum) to avoid exacerbating the hyperthyroid state.

Copyright Anthony Pearce 2007 (revised December 2019)


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