Managing Iron Levels: A Holistic Look at Clinical Indications

Iron is an essential nutrient needed by the body. Its main function is to produce healthy red blood cells and it is a major component of red blood cells.


When iron levels are not in an ideal range, we can see a variety of symptoms manifest. We often think that when iron is out of homeostatic range it is an automatic deficiency. While the statistics do favour this assumption, being mindful of iron overload in practice cannot be understated.

With this in mind, supplementation and food sources are not black and white and deserve careful attention when making protocols.


Low levels of Iron


Low iron levels can occur with insufficient intake of dietary iron, in the case of malabsorption pathologies such as celiac disease or when there is an increased need due to blood loss (peptic ulcer, heavy menstruation)


Early Symptoms: Fatigue, weakness, lack of energy, hair loss, dizziness, headaches, pale skin, tinnitus


Later stage symptoms: Chest pain, cold hands and feet, inflammation and tongue soreness, reduced immune function, heart and lung complications


Elevated levels of Iron


Iron overload is when iron accumulates in the body. An excess of iron has been shown to accumulate in tissues such as the lungs, liver and heart. When build up recaches a certain threshold, organ failure can result.


High Iron Promotes Dis-Ease and drives the pathological process of several diseases and disease states. There is substantial; evidence that iron overload may increases cancer cell proliferation and is one of myriad contributing factors to cancer progression.


Typically speaking, iron overload occurs because of a rare genetic condition, hemochromatosis. It can also result from excess supplementation, alcoholism and chronic liver disease. It is more common in males as they don’t release blood via a monthly menstrual cycle.


Early Symptoms: Joint pain, fatigue, weakness, hair loss, abdominal pain, loss of sex drive

Later Stage Symptoms: Organ failure, disease progression, cancer


The importance of lab testing


Symptoms of high iron and low iron can parallel each other, especially in two of the most common presentations: fatigue and hair loss. Supplementing with iron in the case of a preexisting iron overload can have severe consequences.


Assessing iron levels based on intake of iron can serve as a guideline but is by no means definitive given the wide range of factors that impact bioavailability.


It’s paramount to know baseline ferritin levels and monitor them if supplementation is being used to avoid iron overload, which is often overlooked in clinical settings.


Ferritin VS Hemoglobin


Ferritin: Storage form of iron. Only a fraction of ferritin gets circulated, but the amount in the blood is reflective of total iron stores.

Hemoglobin: Made from iron, hemoglobin is a protein that contains iron in the red blood cells that is responsible for transporting oxygen from the lungs to the tissues in the body.


Stages of Iron Deficiency


Iron deficiency is a gradual process, that has three distinct stages, ending with Iron Deficiency Anemia.


Stage 1: Storage Depletion


Inadequate iron is being taken in or absorbed. In this phase, the body is generally asymptomatic. There is enough iron to carry out physiological needs, but the iron isn’t being replaced at a sufficient rate. We start to see storage depletion and this is marked by a decrease in ferritin levels. If not caught here, storage will further deplete and progress to stage 2.


Clinical presentation: Low ferritin, normal serum iron


Stage 2: Mild Deficiency


The amount of circulating iron decreases. Symptoms are likely to start appearing here.


Clinical Presentation: Low ferritin, Low Transferrin or low total iron binding capacity (TIBC)

Stage 3: Iron Deficiency Anemia

When stores have been severely depleted and the body does not have enough iron to make hemoglobin and there is low circulating iron.


Clinical Presentation: Low Hemoglobin


Interpreting Lab Tests


Hemoglobin is not an accurate indicator of iron deficiency. By the time reduced hemoglobin levels show up on a blood test, the body has been iron deficient for a while. It is the last marker to discern if an individual has the last stage of iron deficiency, Iron Deficiency Anemia. For this reason, ferritin levels are a superior and more sensitive clinical marker to determine if extra support is needed.


Note: In times of high physiological stress, ferritin is an immune marker not an indication of iron status. If a client has an active infection, chronic underlying infections or substantial inflammation in the body, ferritin levels can be elevated while total iron is low. This is why it’s important to make protocols based in the marrying between lab result and am in-depth intake.


Heme vs Non-Heme Iron

Heme Iron is found in animal products. It’s derived from the hemoglobin and myoglobin and has a higher bioavailability than non-heme iron, which is found mainly in plant sources.


Heme iron isn’t influenced by the factors that impede the absorption of the plant-based non-heme iron such phytates, phosphates, tannates and oxalates. This is because heme iron is not chelated or impacted by the ligands found in plant sources.


Heme and non-heme iron are absorbed non-competitively. Heme iron absorbs directly into enterocytes through a different mechanism than non-heme iron. Once absorption has occurred, heme and non-heme iron have the same characteristics in the body.


Absorption rate of heme iron: 15-35%


Absorption rate of non-heme iron: 2-20%


Fun Fact: Heme iron converts to non-heme iron if meat is cooked too long at a high temperature.

Increasing Absorption of non-Heme iron:

  • Vitamin C

  • Proper stomach acid pH

  • Avoid taking with calcium supplements or high calcium foods

  • Not consuming with soy

  • Some evidence for fermented foods increasing absorption

  • Vitamin A and carotenoids

  • Avoid taking zinc and copper supplements with non-heme supplements or foods high in non-heme iron as they compete for absorption in the intestine.



Clinical Considerations for Increasing Iron Levels


If a client is presenting with low ferritin or has been diagnosed with anemia, supplementing is typically indicated.


In stage 1 deficiency, storage depletion, iron levels may be restored with dietary heme iron or correcting malabsorption issues.


When bringing iron levels back into homeostasis from stage 2 or 3, plant-based food sources don’t provide the therapeutic value that is needed.


Often times increasing heme iron is not sufficient to bring levels up in a timely manner to reduce client symptoms, and supplementation is needed.



Major Takeaways:


Assuming iron deficiency and supplementing can be harmful. Always ask for lab values and work with or refer to a clinician who is able to order lab tests. Interpret lab markers within the context of a comprehensive intake will help make sure you nail the protocol the first time.


Plant-based iron sources, provided digestion isn’t compromised can help maintain iron levels but non-heme iron from food sources is not therapeutic in nature and is not indicated attenuating anemia.


P s- have you downloaded our free resource “10 Questions that Should be on Your Intake But Probably Aren’t” Yet? You can get it here!


Author: Lisa Kowalyk, Co-Founder, Fiore Health








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