September 2024 letter - iron and ferritin

I wanted to talk about iron and ferritin as “our iron levels” seems to be a very current issue which many of us think about. I always address the fact that whatever you want to heal or improve, including your iron levels, The first thing you need to look at, is your food and nutrition. Even when working in a GP practice, I was never a fan of the current thinking of always finding a diagnosis and then treat that diagnosis with medication or even supplements alone. It is always best to at least try to find the root cause of symptoms and do something about it. This is the same with iron. We need to try to find ways to correct iron levels naturally within our body.

Why is iron important? Iron in hemoglobin in the blood transports oxygen to all tissues all over the body. Iron is also needed in mitochondria in our cells for the cell respiration to happen. We also all know that liver contains a lot of iron. Iron in the liver is needed in excretion of waste products in the liver. Certain enzymes need iron to function properly to be able to excrete toxins from the body. Iron is also needed for collagen production for skin, muscles and bone health, as well as our immune functions.

Patients often worry about their iron levels if they feel tired and have low energy levels. You know, if you have been following me for a while that low energy can be linked to many other problems too, stress or insulin resistance for example, but iron deficiency anaemia is often a concern of many.

Ferritin is a protein produced in the liver. It stores iron. Low ferritin levels usually mean iron deficiency. We usually also check hemoglobin (Hb) as well as ferritin levels with a blood test, this is usually done in a GP surgery if for example iron deficiency anaemia is suspected. It is not always easy to interpret the results however.

Hb is checked in a common test called full blood count (FBC) which also looks at other cells in the blood including red cells. One of the important markers is MCV which measures the size of our red cells. MCV is a very important marker of iron deficiency anaemia as usually red cells are smaller than normal if there is not enough iron in the body. It is important to notice though that other micronutrients, for example deficiency in vitamin B12 and B9 also affect MCV and actually increase it, so it is not always easy to now if iron deficiency is present or could it be other deficiencies or both.

This is why sometimes transferrin saturation (TS) is also checked. This measures the amount if iron in the body as well as amount of transferrin, a protein which transports iron within the bloodstream. This protein is usually raised when there is too little iron. Transferrin is often low if there is deficiency of amino acids, protein, within the body, so this marker is not straight forwards either. As you can see, it is not always easy to find whether someone is suffering from iron deficiency, or whether there is also deficiency in something else.

If you are considering iron supplements, remember this important fact; too much iron is harmful and so it is important to not take any iron supplements if there is no deficiency. Unlike some vitamins such as vitamin B, our body cannot cope with excess amounts of iron, but it can be toxic.

Another important factor is to not only treat iron deficiency with supplement, but actually find out WHY there is deficiency in the body. Often the reason is not diet. Our diet might be the cause, for example if we follow a badly planned vegetarian or vegan diet as we know red meat is the best source of iron. Another, more common possibility of that there is a problem in absorbing the iron from the diet. Third important reason is loss of blood, for example heavy periods could be a reason for iron deficiency.

PROBLEMS WITH ABSORBING IRON

Very often low iron levels do not mean that we are getting too little iron from our diet. This very often is only a problem when following a vegan diet. If you eat meat, the problem is likely something else and so iron supplements might not help, especially if you don’t look at the root problem.

The most common problem is often found in the bowel. Iron might not be absorbed from the bowel that well or the body might be shutting down iron absorption as a protective mechanism. If iron deficiency anaemia is found, it is important to rule out a few obvious problems; usually these are IBD (such as Crohn’s), coeliac disease and H Pylori infection, depending on your symptoms. These can all affect absorption of iron even when causing only mild symptoms. Another problem is SIBO - small intestinal bacterial overgrowth which can affect our iron levels, and so can a very common, IBS. Calprotectin (a protein in stool) is often checked if bowel problems such as IBD is suspected.

OTHER PROBLEMS

If there are no bowel problems present causing problems in absorbing iron from food, the problem could be that the body “shuts down” absorption of iron and stores it instead. Ferritin is usually raised if this is the problem. There are few reasons for this to happen, with infection being the most common reason. In addition to H.Pylori, most other bacteria and virus need iron to survive. Activated immune response therefore closes down iron absorption. Chronic inflammation can also result in this reaction. Common causes behind chronic inflammation are insulin resistance/metabolic syndrome resulting in fatty liver for example. If there is infection or chronic inflammation behind iron deficiency, you often see changes in white cells in FBC also as they are activated in immune reactions. Also it is important to note that ferritin is then usually raised, not low.

If ferritin is raised, it is never a good sign. Iron then sits “in the store” and is not available for all those important functions it is meant for. Raised ferritin is always a sign of some kind of a problem. If ferritin is even a little low, but all other bloods are normal (Hb and MCV) and you feel well, then all is ok. Slightly low ferritin is ok.

There is also a condition called hemochromatosis. This is a genetic condition causing problems in iron metabolism. This requires follow up with a medical professional. Serious illness can show in raised ferritin levels. This is not a sign of raised iron levels, but other series problems in the body. Those problems with have already talked about; loss of blood, infections, chronic inflammation, insulin resistance/metabolic problems including type 2 diabetes, alcohol dependency and poor diet low in antioxidants.

When taking iron supplements, it is important to remember the importance of iron for microbes. Iron supplements are never started during infections for this reason. If iron supplements are started to correct low iron levels, bowel health needs to be monitored also as many people have problems with iron supplements. If you have IBS already, for example, it could be that the iron you are taking never ends up benefiting the body, but only the unwanted microbes in the colon, or small intestine and the problems caused by them get worse.

TOO MUCH IRON AND OXIDATIVE STRESS

Why is too much iron a problem? Iron oxidises easily and too much becomes harmful. Iron is a well known oxidant. In addition to infections, this oxidising which leads to oxidative stress, is a problem for the body which is why it is trying to protect itself against too much iron. Hence too much iron in the body increases ferritin levels, this excess iron needs to be stored away. Also if antioxidant defence is not working well within the body, it can be shown as raised ferritin levels. The root cause behind it is for example poor nutrition, poor diet, or problems in absorbing micronutrients in the presence of bowel problems.

We have all heard how vitamin C - a well known antioxidant increases the absorption of iron. In addition to vitamin C, other antioxidants, vitamins A, E and D, Co-enzyme Q10 and glutathione can also help this situation.

It is important to rule out ongoing problems with oxidative stress in the body. Oxidative stress is an imbalance between free radicals and antioxidants in your body. There are more free radicals present than can be kept in balance by antioxidants, and so the free radicals can damage many tissues in the body. In addition to raised ferritin, your GP or other health professional can also check your liver enzymes, ALT and GT. If especially GT is raised, it points towards problems in many antioxidants, including glutathione, either there is too little glutathione, or it is not working well. Urate might be another lab test that can be checked (even without gout). Raised rate is a marker for many problems, but also low antioxidant levels.

Increasing antioxidants often then reduces ferritin levels back to normal and improves all these other markers. You can see that tiredness or other symptoms are not therefore necessarily caused by low iron, but low levels of antioxidants in the body. It is extremely important to think about other causes for tiredness.

GLUTATHIONE

A few words about glutathione. Glutathione is an antioxidant produced in cells and is comprised largely of three amino acids: glutamine, glycine, and cysteine. Problems with this antioxidant causes problems with iron levels or absorption. Raised GT is a good marker of oxidising in the body. Glutathione levels in the body may be reduced by a number of factors, including poor nutrition, environmental toxins, and stress. Its levels also decline with age. Sugar and insulin resistance decline glutathione a lot and damages the mitochondria increasing problems with chronic diseases. Deficiency in selenium, magnesium and zinc can also decline production of glutathione.

Many foods increase glutathione production, including garlic, cabbage, broccoli, spinach, blueberry as well as turmeric, meat, sea food, eggs and unpasteurised milk. Prosessed milk is not beneficial so you could try cheese made with unpasteurised milk. Supplements are also useful, as many stimulate production of glutathione. These include NAC, ALA, Q10 and vitamin C, D and E. Make sure you are getting enough zinc and magnesium also. In general I would say low carb, real food is an effective diet which increases glutathione.

CORRECTING IRON DEFICIENCY

It is obviously important to find out the cause of iron deficiency, not only start iron supplements which will only work if there is an obvious cause such as heavy periods causing iron deficiency. It is vital to make sure you eat well, a healthy balanced diet with real food; and especially red meat and liver and/or other organs. You should also make sure you are getting enough vitamin C, A, E and D, and try Q10 and glutathione supplements. Discuss these with a knowledgeable GP or other health professionals.