This happened: I had an iron deficiency for years, perhaps decades before I finally figured it out how to effectively treat it. Iron deficiency treatment is far from perfect and there are many myths about food sources and supplements of iron.
Why would a nutritionist not know how to recognize their own iron deficiency?! In hindsight, I should have known. I should have been more proactive. However, deficiency can be so subtle, it is challenging to read by symptoms alone.
If it can happen to me, it might happen to you, especially if you are female and of reproductive age.
To my credit, iron is NOT screened and followed up in most doctor’s offices. I did find a great doctor who did check my ferritin, the storage form of iron. More on this later.
Here, I will tell you how to ask the right questions and find out if you need to get your iron checked out as well. I will also explore how much and how long you need to take iron to keep your levels where they need to be.
Iron Deficiency Symptoms
Symptoms of iron deficiency can be more than fatigue. You may not feel fatigued at all! I didn’t.
I felt weakness and even muscle pain. Why? Iron is involved in making myoglobin, which carries oxygen in muscles. Iron has many roles besides carrying oxygen, including repair of DNA and more [R].
Importantly, you can be low in iron and have completely normal-looking blood work. You can even feel perfectly fine, but in retrospect, you may identify with some of these.
Symptoms of deficiency can include one or more of the following:
- Weakness or gradual reduction in muscle strength
- Cold hands and feet
- Susceptibility to infection
- Brittle or spooned nails
- Swollen or sore tongue
- Anxious feelings
- Rapid heartbeats or irregular heartbeats
- Shortness of breath
10 Iron Deficiency Treatment Myths
The following iron deficiency myths are listed by how common the myth is according to my observation.
Myth 1. I eat a balanced diet, so I get all the iron I need.
Not necessarily true. The foods richest in iron are rarely eaten anymore, such as the liver. Whale meat, anyone? It has 72 grams of iron. Organ meats have the highest amounts of iron. This makes our current food sources, in comparison, look super-low.
Some foods appear to have a bunch of iron, such as fortified cereals. In reality, the type of iron added to cereals can be very poorly absorbed [R].
Even if you think you eat a balanced diet, you need to check in with your doctor about getting a blood ferritin level.
Myth 2. Spinach and Red Meat are Great Sources of Iron
This is also false. Spinach has a small amount of iron and the iron in spinach is poorly absorbed. Spinach is healthy for many other reasons and may give you energy because it is rich in magnesium and other nutrients, but not iron.
Red meat, like steak, falls way behind the liver as a rich source of iron.
If you are a female of reproductive age, have had children, have a “normal to heavy flow” for a period, you probably are NOT getting enough iron in your diet, even if you eat meat.
Plant sources of iron, also known as non-heme iron, absorbs at about 11% at most and under ideal conditions. Absorption can be almost zero if it plant iron is present with anti-nutrients or other minerals like calcium [R].
Since 1/4 lb cooked spinach has 3.5 grams of iron, you would only absorb about 0.35 grams at most, but probably less; this is not even 2% of your daily needs.
In contrast, the iron in seafood and meats are absorbed much more readily, but it still isn’t a sure bet.
Absorption of iron is a tightly regulated system in our body, and genes affect how much you will or won’t absorb as well [R].
In the average person, animal-source or heme iron is absorbed 2-3 times as much as from vegetables or plants. That is still only 20-30% absorption. In contrast, in people with iron-overload disorders, 80-100% of the heme, or animal form of iron is absorbed.
If you are looking for a vegetarian source of iron, chocolate and spices happen to be much higher in iron than spinach. So is spirulina and chlorella.
Food Sources of Iron [R]:
- Spices 80-100 mg
- Duck liver 30 mg
- Spirulina 30 mg
- Duck Liver 30 mg
- Unsweetened chocolate 16 mg
- Chlorella 6.3 mg
- Beef liver 5 mg
- Spinach 3.5 mg (0.35 mg absorbed, max)
- Beef steak 1.4 mg (0.4 absorbed, max)
Myth 3. I take a multivitamin; I am fine.
Many multivitamins DON’T have iron. This is by design, because some people are harmed by more or supplemental iron. Don’t start taking iron unless guided by your healthcare provider.
Many of the supplements on the market also may not have enough iron to help replace iron losses from higher amounts of bleeding or certain medical disorders.
I know I personally need to take additional iron to help meet my needs.
Interestingly, fermented foods, due to their acid content, and the fact that they break down anti-nutrients, may also enhance iron absorption.
Myth 4. Medicines Don’t Affect My Iron Absorption
If you take stomach medicines or have low stomach acid, you won’t be absorbing iron well or at all.
Iron needs stomach acid to absorb into your body.
These stomach medicines include anything that reduces your stomach acid, such as those used for heartburn or reflux.
Calcium supplements, whether used for indigestion or other reasons, also reduce iron absorption.
Bile acid sequestrants sometimes used to lower cholesterol, also reduce iron absorption.
Myth 5. Anemia means I am low in iron
You can be low in red blood cells for a lot of reasons. Iron deficiency is just one of them. You can also be low in B12 and/or folate. Or you can be low in all of the above.
Anemia can be a sign of a more ominous condition, such as kidney failure, cancer and more. You can get anemia from chronic inflammation or blood diseases.
Make sure that you explore the cause of your anemia with your doctor. You can have too high of iron levels and still be anemic.
Myth 6. I cook in a cast iron skillet, I get all the iron I need
I have been cooking with a cast iron skillet indefinitely and I’m still low in iron without supplements.
A LITTLE bit of research suggests that cooking with an iron skillet may help reduce anemia. However, this research did not measure the storage form of iron in the blood called ferritin [R].
From personal experience, I wouldn’t rely on iron skillets alone.
Plus, other people in your household may hold on to more iron than they need, putting that at risk for too much. They also should check their ferritin levels. If you all run normal or low-normal, use this great piece of cookware!
The best route is to check levels and supplement if needed.
Myth 7. Anemia means I have a poor diet
Anemia can mean a poor diet, but this is not always true. If you have losses of iron due to bleeding you can get anemic.
Other reasons for anemia that are not related to a poor diet:
- Labor and delivery
- Heavy periods
- Autoimmune diseases
- Gluten intolerance
- Dairy intolerance
- Food allergies
- Kidney diseases
- Certain cancers
- Cancer treatment
Myth 8. I am vegetarian, I must need extra iron
This is not always true. Vegetarians are at higher risk for deficiency due to the fact that less iron is absorbed from plants. However, vegetarians who pay close attention to their diet intake and aren’t of child-bearing age may be fine.
Other vegetarians, especially men, are probably adequate in iron.
A vegetarian diet may be very beneficial for a person with a disorder called hemochromatosis.
However, if a vegetarian has any of the risk factors listed above, they certainly may need supplemental iron.
Myth 9. I took iron supplements for a few days. I am fine.
If you continue to have heavy periods or lose blood for any reason, this is false.
If you lose about 1 cup of blood during a period, you lose 100-125 mg of iron. That’s a bushel of spinach and a barrel of red meat!
Although a cup of blood loss is not the average “flow” period, it certainly is not outside the realm of possibility for many women. Others lose more than this. Bottom line: periods can make it impossible to catch up in the iron.
If you poorly absorb iron, this is also false.
This is why you need your healthcare provider to guide you on how much iron to take, the type and how long.
You need to get your ferritin and CBC checked regularly if you are taking iron.
Myth 10. All iron supplements are created equal
This is false.
Some absorb better than others and some are much easier on your stomach than others. Finding the one that is right for you is going to be dependent on the dose you need and how much stomach upset you are willing to tolerate.
A chelated iron called iron bisglycinate is the best because it is pretty easy on the stomach. Clinical studies find it easier on the stomach than ferrous sulfate.
That said, if you are pinching pennies, ferrous sulfate is the cheapest and absorbed very well.
Chelated irons, in general, are easier on the stomach and comparable for absorption rates to ferrous sulfate.
However, I became intolerant of iron chelates too! I have switched over to whole food iron sources, such as supplemental liver and spleen from grass-fed, hormone free animals.
For me, ferrous sulfate is a bit rough on the stomach. If it is rough on the stomach, it is much less likely I will “remember” to take it. Ultimately, the best value for health is the one you are likely to “remember” to take.
What Reduces Iron Absorption?
All iron supplement types are going to be affected by what and how much you eat. The list of things in foods that reduce iron absorption is a mile long. These include phytates, polyphenols and more.
If you need iron, it is best to take it regardless of all these factors. Iron deficiency increases your absorption anyway. The body is pretty smart.
What Enhances Iron Absorption?
The list of things that enhance its absorption is short. Acids, including vitamin C, but also acids from the fermentation of foods. Also malic acid (think apples) [R].
To be extra sure your vitamin C is helping, take 40 mg for every 3 mg of iron [R].
Who is at risk for iron excess?
Perhaps even more dangerous than low iron is high iron levels. A condition called hemochromatosis, or iron overload disorder is risky for health. It can damage the liver, the heart and more. It creates inflammation in the body.
Knowing where you stand with iron is very important for overall health.
Final Thoughts About Iron
Any nutrient can slip through the cracks. Empower yourself by learning the right questions to ask.
We become complacent too easily. If your doctor doesn’t ask about your periods, describe them at your appointment. This will help them rule out a deficiency. They can’t know unless you tell them.
Did you know that when you go to the doctor for a routine checkup, ferritin is almost NEVER included in this checkup? This is true for almost every nutrient. Ask your doctor or healthcare provider to check ferritin.
Iron deficiency symptoms are subtle and can take years to really present themselves. The slow decline may not ever be obvious to you or me. Be proactive.
Heidi Moretti, MS, RD is The Healthy RD. A registered dietitian for 20 years, has a passion for functional nutrition and natural medicine. Has researched supplements and plants as medicine throughout her career. Loves helping people gain function and vitality by tackling the root causes of illness.