Iron: Causes of Deficiency and Nutritional Treatment

What is Iron and Why is it Vital?

Iron is one of the most important minerals essential for life, and is the most abundant trace mineral in the human body. Iron plays a crucial role in producing hemoglobin, the protein found in red blood cells responsible for transporting oxygen from the lungs to all parts of the body.

Iron deficiency is the most common nutritional deficiency worldwide, affecting over two billion people. Women of childbearing age, pregnant women, and children are most at risk.

Vital Functions of Iron:

• Hemoglobin Production: Transports oxygen through blood to all body cells
• Myoglobin Production: Protein that stores oxygen in muscles
• Energy Production: Essential for cellular respiration and ATP production
• Immune Functions: Important for immune cell function
• DNA Synthesis: Necessary for cell division and growth
• Brain Functions: Supports cognitive development and neurotransmitters
• Skin, Hair, and Nail Health: Essential for their growth and strength
• Body Temperature Regulation: Helps in thermoregulation

Types of Iron in Food

Understanding the difference between iron types is essential to improve absorption:

1. Heme Iron:

• Found in animal sources (meat, poultry, fish)
• Absorbed with high efficiency (15-35%)
• Absorption unaffected by other dietary factors
• Most bioavailable form

2. Non-Heme Iron:

• Found in plant sources (legumes, grains, vegetables)
• Lower absorption (2-20%)
• Absorption affected by enhancing and inhibiting factors
• Only source for vegetarians

Important Note: A varied diet combining both types is best to ensure adequate absorption.

Symptoms of Iron Deficiency and Anemia

Iron deficiency progresses through gradual stages, from depleted stores to overt anemia. Symptoms vary by deficiency severity.

Early Stage (Iron Store Depletion):

• Fatigue and Exhaustion: Most common symptom, constant feeling of low energy
• General Weakness: Difficulty performing daily activities
• Difficulty Concentrating: Memory and attention weakness
• Cold Extremities: Always cold hands and feet
• Frequent Headaches: Especially when stressed

Intermediate Stage (Iron Deficiency Without Anemia):

• Pale Skin and Mucous Membranes: Especially face, lips, gums, and inside lower eyelid
• Shortness of Breath: Especially during exertion
• Dizziness and Vertigo: Due to lack of oxygen in brain
• Heart Palpitations: Fast or irregular heartbeats
• Hair Loss: Noticeably more than usual
• Weak and Brittle Nails: Break easily, may become concave (spoon-shaped)

Advanced Stage (Iron Deficiency Anemia):

• Severe Fatigue: Inability to perform basic activities
• Obvious Pallor: Severe whiteness in skin and eyes
• Chest Pain: Due to lack of oxygen in heart
• Rapid Heartbeat: Heart attempting to compensate for oxygen lack
• Tongue Inflammation: Smooth, swollen, and painful tongue
• Cracks at Mouth Corners: (Angular cheilitis)
• Abnormal Cravings: Desire to eat non-food items (ice, starch, dirt) - condition called Pica
• Restless Legs Syndrome: Uncomfortable sensation in legs with urge to move them
• Weakened Immunity: Frequent infections

Symptoms in Children:

• Delayed growth and development
• Poor school performance
• Behavioral problems
• Delayed motor skills
• Increased infections

Causes of Iron Deficiency

1. Inadequate Dietary Intake:

The most common cause, especially in:

• Iron-Poor Diet: Low intake of iron-rich sources
• Vegetarians and Vegans: Relying only on poorly absorbed non-heme iron
• Strict Weight-Loss Diets: Calorie restriction leads to nutrient deficiencies
• Malnutrition: Especially in developing countries
• Infants and Children: Diet heavily dependent on milk without adequate iron sources

2. Increased Requirements:

• Pregnancy and Lactation: Increased needs to support fetus and milk production
• Rapid Growth Periods: Infancy, childhood, adolescence
• Athletes: Iron loss through sweat and red blood cell destruction

3. Blood Loss (Most Common Cause in Adults):

In Women:

• Heavy Menstruation: Primary cause of iron deficiency in women of childbearing age
• Uterine Fibroids: Cause heavy bleeding
• Endometriosis: May cause internal bleeding

In Everyone:

• Gastrointestinal Bleeding: Ulcers, hemorrhoids, colon cancer, colitis
• Chronic Use of Aspirin or NSAIDs: Can cause intestinal bleeding
• Frequent Blood Donation: Without adequate replacement
• Surgeries: Significant blood loss
• Intestinal Parasites: Hookworms absorb blood

4. Absorption Problems:

• Celiac Disease: Gluten intolerance damages intestinal lining
• Crohn's Disease and Ulcerative Colitis: Chronic intestinal inflammation
• Stomach and Intestinal Surgery: Removal of part of stomach or intestines (especially duodenum)
• H. pylori Infection: Reduces iron absorption
• GERD: Especially when taking proton pump inhibitors

5. Medications Affecting Iron Absorption:

• Proton pump inhibitors (omeprazole, lansoprazole)
• Antacids
• High-dose calcium supplements
• Some antibiotics

6. Chronic Medical Conditions:

• Chronic Kidney Disease: Reduces erythropoietin production (hormone stimulating red blood cell production)
• Cancer: Especially blood and gastrointestinal cancers
• Hypothyroidism: Slows metabolism
• Chronic Inflammatory Diseases: Reduce use of stored iron

Diagnosis and Testing

Accurate diagnosis requires several blood tests:

Basic Tests:

• Complete Blood Count (CBC): Measures hemoglobin level and red blood cell size
• Ferritin: Measures iron stores in body - most sensitive test
• Serum Iron: Amount of circulating iron
• Total Iron-Binding Capacity (TIBC): Blood's capacity to transport iron
• Transferrin Saturation: Ratio of iron bound to transport protein

Interpreting Results:

Normal Hemoglobin:

• Men: 13.5-17.5 g/dL
• Women: 12-15.5 g/dL
• Pregnant women: 11-14 g/dL
• Children: varies by age

Normal Ferritin:

• Men: 24-336 ng/mL
• Women: 11-307 ng/mL
• Depleted stores: less than 15 ng/mL
• Optimal: 40-60 ng/mL (for symptom prevention)

Additional Tests to Determine Cause:

• Fecal occult blood test (to detect gastrointestinal bleeding)
• Colonoscopy or gastroscopy (if internal bleeding suspected)
• Celiac disease tests
• Menstrual cycle evaluation in women

Iron-Rich Food Sources

1. Heme Iron Sources (High Absorption):Red Meat (Richest Sources):

• Beef: 2.6 mg per 100 grams
• Lamb: 1.9 mg per 100 grams
• Buffalo Meat: 3.4 mg per 100 grams
• Beef Liver: 6.5 mg per 100 grams
• Chicken Liver: 11 mg per 100 grams
• Kidneys: 5.5 mg per 100 grams
• Spleen: 28 mg per 100 grams (highest source!)

Note: Liver is very rich in vitamin A, should be consumed in moderation especially during pregnancy.Poultry:

• Dark Chicken Meat: 1.3 mg per 100 grams
• Dark Turkey Meat: 2.0 mg per 100 grams
• Oysters: 28 mg per 100 grams
• Mussels: 6.7 mg per 100 grams
• Sardines: 2.9 mg per 100 grams
• Tuna: 1.3 mg per 100 grams
• Shrimp: 1.8 mg per 100 grams

2. Non-Heme Iron Sources (Lower Absorption):Legumes:

• Lentils (Cooked): 3.3 mg per 100 grams
• Chickpeas: 2.9 mg per 100 grams
• Kidney Beans: 2.9 mg per 100 grams
• Black Beans: 2.1 mg per 100 grams
• Soybeans: 5.1 mg per 100 grams
• Spinach (Cooked): 3.6 mg per 100 grams
• Swiss Chard: 2.3 mg per 100 grams
• Kale: 1.5 mg per 100 grams
• Arugula: 1.5 mg per 100 grams
• Oats: 4.7 mg per 100 grams
• Quinoa: 4.6 mg per 100 grams
• Fortified Breakfast Cereals: may contain 4-18 mg
• Whole Wheat Bread: 2.5 mg per 100 grams
• Pumpkin Seeds: 8.8 mg per 100 grams
• Sesame Seeds: 14.6 mg per 100 grams
• Hemp Seeds: 9.6 mg per 100 grams
• Cashews: 6.7 mg per 100 grams
• Almonds: 3.7 mg per 100 grams
• Eggs (Yolk): 2.7 mg per 100 grams
• Dark Chocolate (70-85%): 11.9 mg per 100 grams
• Blackstrap Molasses: 4.7 mg per tablespoon
• Tofu: 5.4 mg per 100 grams
• Dried Fruits (apricots, raisins): 2-3 mg per 100 grams

Enhancing Iron Absorption

Absorption Enhancers:

1. Vitamin C (Ascorbic Acid) - Strongest Enhancer:

• Increases non-heme iron absorption by up to 300%
• Consuming 25-100 mg with meal makes significant difference
• Excellent sources: Red pepper, oranges, lemons, kiwi, strawberries, broccoli, tomatoes
• Practical tip: Add lemon juice to spinach salad, or eat an orange with legume meal

2. Animal Proteins:

• Contain "Meat Factor" that enhances non-heme iron absorption
• Adding small amount of meat to plant meal increases absorption

3. Organic Acids:

• Citric, malic, and lactic acids improve absorption
• Found in fruits, vegetables, and fermented foods

Absorption Inhibitors (Avoid with Iron-Rich Meals):

1. Tea and Coffee:

• Contain tannins that bind iron and prevent absorption
• Coffee reduces absorption by 39%, tea by 64%
• Solution: Wait one to two hours before or after meal

2. Calcium:

• Competes with iron for absorption
• Dairy products, calcium supplements
• Solution: Don't consume milk or calcium supplements with iron-rich meals

3. Phytates (Phytic Acid):

• Found in whole grains, legumes, nuts, seeds
• Binds iron and reduces absorption by up to 50%
• Solution: Soak legumes and grains before cooking, ferment, or toast them to reduce phytates

4. Polyphenols:

• Antioxidants found in tea, coffee, wine, and some fruits and vegetables
• Bind iron and reduce absorption

5. Oxalates:

• Found in spinach, rhubarb, beets, chocolate
• Bind iron and reduce absorption
• Note: Spinach is iron-rich but oxalates reduce absorption - add vitamin C to improve it

6. High-Dose Zinc:

• Competes with iron for absorption
• Separate iron and zinc supplements by two hours

Iron Supplements

When Do You Need Supplements?

• Test-proven anemia
• Low iron stores (ferritin less than 15 ng/mL)
• Pregnancy and lactation (under medical supervision)
• Heavy menstruation
• Acute or chronic bleeding
• Vegetarians with deficiency symptoms
• Malabsorption diseases

Types of Iron Supplements:1. Ferrous Sulfate:

• Most common and cheapest
• Good absorption (20% elemental iron)
• May cause stomach upset
• Common dose: 325 mg (65 mg elemental iron)
• Gentler on stomach
• 12% elemental iron
• Good absorption
• 33% elemental iron (highest concentration)
• Excellent absorption
• May cause constipation
• Stomach-gentle form (Chelated)
• Excellent absorption and fewer side effects
• More expensive
• Best choice for sensitive stomachs
• Lower absorption than ferrous
• Used in special cases
• For severe cases or oral iron intolerance
• Given under medical supervision in hospital

Recommended Doses:

Daily Requirements (Prevention):

• Adult men: 8 mg
• Women (19-50 years): 18 mg
• Women (50+ years): 8 mg
• Pregnant women: 27 mg
• Lactating women: 9-10 mg
• Children: 7-10 mg depending on age
• Infants (7-12 months): 11 mg

Therapeutic Doses (For Anemia):

• Adults: 100-200 mg elemental iron daily
• Children: 3-6 mg/kg body weight daily
• Divide dose into 2-3 times daily to improve tolerance
• Treatment continues 3-6 months to replenish stores even after correcting anemia

Tips for Taking Iron Supplements:

• On Empty Stomach: For optimal absorption (one hour before or two hours after food)
• With Vitamin C: Take with orange juice or vitamin C supplement
• Avoid Dairy Products: Don't take with milk or yogurt
• No Tea or Coffee: Wait two hours before or after
• If Stomach Upset Occurs: Take with light meal
• Swallow Tablet Whole: Don't chew it
• Consistency: Don't stop when symptoms improve, complete prescribed duration

Side Effects of Supplements

Common Side Effects:

• Stomach Upset: Nausea, pain, discomfort
• Constipation: Most common (30-50% of users)
• Diarrhea: Less common
• Dark or Black Stool: Completely normal, no need to worry
• Metallic Taste: In mouth

How to Reduce Side Effects:

• Start with low dose and increase gradually
• Take with food (even if it slightly reduces absorption)
• Choose gentler form on stomach (bisglycinate)
• Drink adequate water and fiber for constipation
• Divide dose into multiple times

When to Consult Doctor Immediately?

• Severe abdominal pain
• Bloody vomit
• Bloody or tarry stool
• Allergic reactions (rash, itching, swelling, breathing difficulty)

Risks of Iron Excess

Too much iron can be harmful:

Acute Poisoning:

• Occurs when taking high dose at once (especially in children)
• Symptoms: vomiting, diarrhea, abdominal pain, shock
• Emergency requiring immediate medical intervention

Chronic Overload (Hemochromatosis):

• Iron accumulation in organs (liver, heart, pancreas)
• May lead to cirrhosis, heart failure, diabetes
• Common in people with genetic predisposition

Safe Upper Limit:

• Adults: 45 mg daily from food and supplements
• Don't exceed prescribed dose without medical supervision

Practical Tips from Dr. Mai Obeid

1. Cook in Iron Cookware: Increases iron content in food, especially acidic foods
2. "Iron-Loaded" Meal: Red meat + leafy greens + orange juice = perfect meal
3. For Vegetarians: Soak legumes 12 hours, add vitamin C to each meal, vary sources
4. Tea and Coffee Timing: Wait two hours after main meal
5. Retest: After 3 months of treatment to evaluate improvement
6. Find the Cause: Treating deficiency is important, but knowing and treating cause is more important
7. For Women with Heavy Periods: Consult doctor about treatment, may need regular supplements
8. Pregnancy: Start iron supplements early (with folic acid) to avoid anemia
9. Monitor Children: Ensure they get adequate amount, especially after weaning
10. Patience: Symptom improvement takes 2-4 weeks, store correction 3-6 months

Dietary Plan to Increase Iron

Full Day Example:

Breakfast:

• Iron-fortified breakfast cereal with almond milk
• Fresh orange juice (vitamin C)
• Boiled egg

Snack:

• Handful of dried apricots
• Handful of pumpkin seeds

Lunch:

• Grilled beef steak (excellent heme iron source)
• Spinach salad with red pepper and lemon juice (iron + vitamin C)
• Cooked quinoa

Snack:

• Dark chocolate (small piece)
• Kiwi

Dinner:

• Grilled chicken
• Cooked lentils with tomatoes
• Steamed broccoli

Two Hours After Dinner:

• Herbal tea (without tannins)

Prevention of Iron Deficiency

• Varied diet rich in iron sources
• Enhance absorption with vitamin C
• Avoid inhibitors with iron-rich meals
• Regular testing for at-risk groups
• Treat any bleeding or causative medical conditions
• Preventive supplements for pregnant women and high-risk groups

Conclusion

Iron is an essential mineral for life, and its deficiency is one of the most common nutritional problems. The good news is it's treatable and preventable through thoughtful diet, improved absorption, and supplements when needed.

Remember prevention is easier than treatment. Pay attention to deficiency symptoms, especially if you're in at-risk groups. Early diagnosis and proper treatment prevent serious health complications.

Your health starts with what you put on your plate. Invest in iron-rich diet, and consult a nutritionist or your doctor for personalized plan that suits your needs.