Iron is an essential mineral for human health, involved in critical pathways to mental and physical health, yet we often see suboptimal levels of available iron as well as stored iron. Iron is found in plant and animal sources of foods, cast iron cookware, environmental sources such as soil and water, and supplemental sources in vitamins.
In this blog post we will address the following topics to help empower you to ask your provider for labs you need, evaluate your labs, and better understand how your iron levels may be impacting your health positively or negatively.
- Symptoms of Low Iron
- Functions of Iron
- Normal vs Optimal Lab Values
- Forms of Supplemental Iron
- Reasons Why Iron-related Anemia May Exist or Persist
- Recipes & Strategies to Support Optimal Iron Levels
| Chronic fatigue | Weakness | Shortness of breath |
| Dizziness | Rapid Heartbeat | Irregular Heartbeat |
| Ringing in the ears | Poor sleep | Confusion |
| Memory loss | Numbness | Irritability |
| Sore Tongue | Loss of sex drive | Inability to focus |
| Restless legs syndrome | Malaise | Pallor of skin, eyelids, lips |
| Pica (eating ice, dirt) | Hypothyroid | Poor exercise recovery |
| Infertility | Body temperature issues | Poor wound healing |
| Impaired detoxification | Frequent infections | Mental health condition(s) |
Iron is critical for so many metabolic functions, it is nearly impossible to list them all, but here are a few critical ones:
- Oxygen transport and storage
- Energy metabolism & ATP production
- DNA synthesis & cell growth
- Brain function & neurotransmitter synthesis
- Immune function
- Detoxification & liver function
- Collagen & connective tissue formation
- Hormone synthesis & regulation
- Antioxidant & redox balance
- Temperature regulation & Cell differentiation
Adequate iron impacts not only metabolic functions but nervous system functions as well. How does adequate iron promote resilience, balance, empowerment, and an overall sense of well-being?
- Energy production allows us to intentionally activate the nervous system to be mobilized for exercise, play, meal prep, prepare healthy meals, work inside or outside the home & have enough energy for activities of intimacy and connection
- Oxygenation of tissues supports muscles when engaging in restorative activities such as yoga, Qi Gong, pilates, or walking in the woods, and restful sleep
- Adequate iron is required for mood, and low levels contribute to anxiety, depression and fatigue, imparting a sense of well-being necessary to find your purpose, engage in planning, proper nutrition, & emotional stability
In order to intentionally engage or disengage the nervous system, we must have a sense of safety and connection with others. This pulls us out of fight-or-flight and dissociated shut-down of the nervous system states and promotes resilience. Inadequate iron levels put the body in a crisis state, which is anything but safe, where we will struggle with resilience.
Ferritin is the most specific marker of iron deficiency, yet I find many providers only check an iron panel. With a Ferritin lab value, you have a sense of how much iron is stored in your body for use if needed. Ferritin is also what we call an “acute phase reactant,” meaning when it is abnormally or unexpectedly high, it could be a sign of iron overload due to conditions such as thalassemia, inflammation, liver disease, or alcohol abuse. The lab reference range is usually between 10 – 200 depending on the lab company. Aim for a value around 80. If your provider will not order a Ferritin lab, we can order it through Rupa Health for $12.
Iron measures the amount of iron in transit in the body. The iron is bound to transferrin protein in the blood to be transported. Lab values vary throughout the day, and from day to day, and is measured with other tests such as Total Iron Binding Capacity (TIBC) and Transferrin to get a complete picture of iron status. Labcorp reference interval is 38-169, with optimal values again around 80. Reference range for TIBC is 250-450 depending on the lab.
Testing.com provides the following information for the interpretation of iron along with Total Iron Binding Capacity (TIBC) and Transferrin – and I am a sucker for a good interpretation table!
| Condition | Iron Levels | Total Iron Binding Capacity / Transferrin |
| Iron Deficiency | Low | High |
| Hemochromatosis / Hemosiderosis | High | Low |
| Chronic Illness | Low | Low / Normal |
| Hemolytic Anemia | High | Normal / Low |
| Sideroblastic Anemia | Normal / High | Normal / Low |
| Iron Poisoning | High | Normal |
Iron Saturation is the measure of iron bound to transferrin protein in the blood. It is a mathematical calculation that identifies low iron saturation (<15%) which indicates iron deficiency anemia or high iron saturation (>50%) suggesting iron overload. Iron saturation levels fluctuate throughout the day and typically improve quickly with supplemental iron.
Iron supplementation can be in the form of an intravenous (IV), capsule, or liquid. Like other vitamin or mineral supplements, there are a variety of forms available and it can be difficult to choose the best option for yourself. Here is a rundown of the most common forms:
HIGH ABSORPTION
- Bisglycinate Chelated Iron – highly bioavailable, gentle on digestion, low risk of side effects, more expensive
- Commonly used brands are Designs for Health Ferrochel, Thorne Iron Bisglycinate NSF, Klaire Labs Iron Chelate, Orthomolecular Reacted Iron, Xymogen Iron Glycinate, Floradix Iron + Herbs (Fullscript.com)
- My Recommendation: Seeking Health Optimal Iron with Cofactors Copper, Vitamin C, Vitamin A, needed for the transport of iron (Fullscript.com)
MODERATE / HIGH ABSORPTION
- Ferrous Gluconate – gentler on the stomach than ferrous sulfate, moderately bioavailable, prone to mild side effects
- Commonly used brands are Floradix Liquid or Gaia Herbs PlantForce Liquid Iron (Fullscript.com)
MODERATE ABSORPTION
- Ferrous Sulfate – inexpensive, widely available, effective for severe deficiency, associated with digestive discomfort
- A common brand option is Nature Made 65mg Ferrous Sulfate (Local Retailer, Amazon)
LOW ABSORPTION
- Ferric Iron – primarily clinical applications, stable formulation, poor absorption compared to other forms, may be less effective for individuals with absorption issues and requires higher doses
- Unchelated Iron Salts – inexpensive, commonly in fortified foods, low absorption and not recommended as a supplement form, not well tolerated, must be taken with vitamin C
Iron administered via intravenous (IV) or injection is used in cases where a person has problems with absorption, or portions of their stomach or small intestines are removed. Infusions can take three to four hours and are conducted at a hospital or outpatient setting. The risk of an allergic reaction is high, and often antihistamines are administered before and after the infusion.
Side effects of iron infusions and injections can include:
- Nausea or vomiting
- Stomach Upset
- Bowel Changes
- Anaphylactic Shock
- Low Blood Pressure
- Fever
- Joint Pain
- Muscle Pain
- Swollen Lymph Nodes
- Chest, Back or Abdominal Pain
- Infection
- Rash/Hives
- Severe Itching
- Seizures
- Flushing
- Headache
- Inflammation of a Vein
- Shivering
- Chronic Pain at Injection Site
- Skin Staining
- Skin Atrophy
- Abscess
Low levels of hydrochloric acid (HCL), present in the stomach, can cause reduced iron absorption. Reasons for low HCL include stress, PPI medications, and age, primarily. It is not uncommon to need some Betaine HCL (shown to increase stomach acid) supplementation 648mg (NOW Brand) with meals containing protein to support overall digestion and increase the likelihood of absorption.
Oxalates impair the absorption of non-heme (plant-based) iron found in spinach, kale, beets, nuts, chocolate, tea, wheat bran, rhubarb, strawberries, and oregano, basil, and parsley culinary herbs. The presence of oxalates in spinach explains why the iron in spinach is not well absorbed.
Another food that contains a chemical that impairs absorption is eggs. Eggs contain a phosphoprotein called phosvitin that has an iron-binding capacity and may be responsible for the low bioavailability of iron in eggs. One boiled egg can reduce the absorption of iron in a meal by 28 percent.
Calcium-rich foods such as milk, yogurt, cheese, sardines, canned salmon, tofu, broccoli, almonds, figs, turnip greens, and rhubarb inhibit absorption of both non-heme and heme iron. Ironically we need lactoferrin from dairy to also help with the absorption of iron, and occasionally this is taken in supplement form. Women trying to prevent bone loss should take the citrate form of calcium (vs carbonate) along with vitamin K2, silica and vitamin D away from iron-rich foods or between meals. Calcium supplementation should not be taken without a DEXA scan indicating the need for calcium supplementation.
Phytates found in grains have an inhibitory effect on iron absorption and can reduce absorption by 50%.
High doses of zinc, an essential mineral found in meat, eggs, and seafood, can interfere with copper levels thereby interfering with the absorption and transportation of iron. Zinc and copper supplementation should not be taken without serum blood labs to calculate the copper to zinc ratio, which should be between 1 – 1.3 for optimal levels. Zinc testing via Rupa Health/Labcorp is inexpensive at around $15 and testing copper runs around $26 if your PCP is unable to order the labs.
Low levels of Omega-3s can impact nutrient absorption. We need these essential fats for the cellular lining to facilitate transport. Testing through an “Omega Check” or “Omega Profile” looks at not only the overall Omega-3 levels, but ratio of Omega-6 to Omega-3, Arachidonic Acid to EPA (one of the Omega-3s) as a marker of hidden inflammation, and evaluation of levels for each of the Omega-3s to better inform which Omega-3 supplement is needed. The average cost of an Omega Profile is $50 if out of pocket or covered by insurance through your PCP. Here is how your PCP would need to order the Omega Profile through Labcorp: When ordering use “MISC 009985” generic test code and next to that put “#823430 OmegaCheck” (omegacheck is all one word) – a CPT code is 82542 and one diagnosis code option is E63.0 but your doctor will decide which codes to use. This was hard to find because it is outsourced with Cleveland Labs but the draw is through LabCorp.
In adults, one of the most common reasons for iron-related anemia is blood loss from surgery, accidents, pregnancy needs, or heavy menstrual cycles in females. Other causes include chemotherapy and radiation, eating disorders, history of bariatric surgery, autoimmune diseases – particularly those impacting the small intestine, infection, bleeding disorders, alcohol abuse, drug use, medication interference, long-distance running or intense exercise, or inherited diseases. Kidney disease can cause chronic anemia because kidneys can’t produce enough erythropoietin (EPO) hormone that signals the body to make red blood cells (NIDDK).
Iron absorption from food can vary up to ten-fold depending on the bioavailability of iron. Eating high-quality red meat can replenish iron stores over time. Incorporating foods high in vitamin C, beta carotene, and vitamin D, enhances the transport of iron. Alcohol can enhance absorption of iron, however, no one is encouraged to consume alcohol as a means of increasing iron stores.
Foods high in iron include clams, fortified cereals, organ meats, soybeans, pumpkin seeds, blackstrap molasses, lentils, spinach, beef, kidney beans, sardines, chickpeas, duck, lamb, prune juice, shrimp, tomato puree, and beans. When I was pregnant with my first kiddo I C-R-A-V-E-D steak, beans and oranges – obviously I was low in iron! I needed the vitamin C from oranges to help with the absorption of iron from plant and animal sources. The body is so smart, it is amazing.
Vitamin C occurs naturally in vegetables and fruits and can increase the absorption of iron as much as four times. Fun fact – the highest source of vitamin C in food is not from citrus – it is guava! Sources of vitamin C include guava, red sweet pepper, kiwi fruit, orange, green pepper, grapefruit, vegetable juice cocktail, strawberries, brussels sprouts, cantaloupe, papaya, broccoli, sweet potato, tomato juice, cauliflower, pineapple, kale, and mango.
Beta carotene is a carotenoid that occurs naturally in plants. It converts to vitamin A (retinol) which is good for eye health, thyroid hormone function, immune system, and healthy skin. They are the yellow and red pigments in foods such as apricots, beets, broccoli, carrots, chard, cilantro, collards, grape leaves, kale, romaine lettuce, cantaloupe, red peppers (also high in vitamin C), spinach, sweet potato, tomatoes, and endive. Beta carotene enables the body to produce vitamin A. Research seems to suggest that plant sources of beta carotene may support the absorption of iron better than vitamin A, however, I did find research that vitamin A and beta carotene support the absorption of non-heme iron.
Some foods can impair the absorption of iron if consumed at the same time. Foods such as tea, coffee, dairy, fiber, and supplemental calcium should be taken between meals containing iron-rich foods.
The Framingham Heart Study looked at factors that increased iron stores among the elderly and found that those who consumed iron supplementation with fruit had higher iron stores – some as much as three times more. Eating fruit with honey or backstrap molasses with cereals can boost iron absorption.
So now that we know what we need, what to avoid, what are we going to eat? We’ve got you covered with a recipe bundle of foods that support adequate iron intake. We would love to see your recipe photos on facebook or Instagram @KaizenNutrWell. Let’s get cook’in!
References
Brigham, D., & Beard, J. (1996). Iron and thermoregulation: a review. Critical reviews in food science and nutrition, 36(8), 747–763. https://doi.org/10.1080/10408399609527748
Cappellini, M. D., Musallam, K. M., & Taher, A. T. (2020). Iron deficiency anaemia revisited. Journal of internal medicine, 287(2), 153–170. https://doi.org/10.1111/joim.13004
García-Casal, M. N., Layrisse, M., Solano, L., Barón, M. A., Arguello, F., Llovera, D., Ramírez, J., Leets, I., & Tropper, E. (1998). Vitamin A and beta-carotene can improve nonheme iron absorption from rice, wheat and corn by humans. The Journal of nutrition, 128(3), 646–650. https://doi.org/10.1093/jn/128.3.646
Garrison, C. D., Weinberg, E. D., & Skikne, B. (2009a). The Iron Disorders Institute guide to anemia. Cumberland House.
Köhrle J. (2023). Selenium, Iodine and Iron-Essential Trace Elements for Thyroid Hormone Synthesis and Metabolism. International journal of molecular sciences, 24(4), 3393. https://doi.org/10.3390/ijms24043393
Lane, D. J., Merlot, A. M., Huang, M. L., Bae, D. H., Jansson, P. J., Sahni, S., Kalinowski, D. S., & Richardson, D. R. (2015). Cellular iron uptake, trafficking and metabolism: Key molecules and mechanisms and their roles in disease. Biochimica et biophysica acta, 1853(5), 1130–1144. https://doi.org/10.1016/j.bbamcr.2015.01.021
Petraglia, F., & Dolmans, M. M. (2022). Iron deficiency anemia: Impact on women’s reproductive health. Fertility and sterility, 118(4), 605–606. https://doi.org/10.1016/j.fertnstert.2022.08.850
Świątczak, M., Młodziński, K., Sikorska, K., Raczak, A., Lipiński, P., & Daniłowicz-Szymanowicz, L. (2022). Chronic Fatigue Syndrome in Patients with Deteriorated Iron Metabolism. Diagnostics (Basel, Switzerland), 12(9), 2057. https://doi.org/10.3390/diagnostics12092057
U.S. Department of Health and Human Services. (n.d.). Office of dietary supplements – iron. NIH Office of Dietary Supplements. https://ods.od.nih.gov/factsheets/Iron-Consumer/#:~:text=Iron%20is%20a%20mineral%20that,that%20provides%20oxygen%20to%20muscles.
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