Iron Deficiency

Iron deficiency is the most common nutrient deficiency in the world. Iron deficiency occurs throughout the world from rural Africa to New Zealand and can happen to anyone. Iron deficiency can leave you feeling fatigued, breathless with exercise, irritable, affect the quality of your hair, skin and nails and is associated with a lower quality of life.

Why is iron deficiency so common? Iron deficiency occurs for many different reasons and the reasons can vary from country to country. In some countries traditional diets may contain a lot of unrefined starchy carbohydrates that are high in phytate (a compound in grains, legumes and seeds that binds to iron in the gut and means we absorb less of the iron in the food), or they rarely eat red meat (high in iron) or they may have less regular access to foods fortified with iron (e.g. refined cereals) or they have less regular access foods high in vitamin C (vitamin C increases the amount of iron we can absorb from food) or to they eat dairy products with iron rich foods (calcium reduces the amount of iron we can absorb from food). In New Zealand, iron deficiency is most common in pregnant women (baby needs iron to grow and uses up mother’s iron stores), menstruating women (due to regular blood loss) and especially women who eat low energy or highly restricted diets (low intake of iron containing foods), athletes (high turnover of red blood cells therefore increased iron needs) and people with chronic inflammatory diseases including inflammatory bowel disease (IBD). 

Why is iron deficiency common in IBD?

Iron deficiency affects 60 – 80% of people with IBD and iron deficiency anaemia is estimated to affect around 20% of New Zealanders with IBD. During an IBD flare the body reduces the amount of iron in the blood in response to the inflammation. If the inflammation continues, the iron deficiency will continue, and ongoing or repeated bouts of inflammation can result in more severe iron deficiency and development of iron deficiency anaemia.  

Iron deficiency is common with IBD for a number of reasons including: repeated or ongoing inflammation, blood loss due to bleeding in the gut and female menstruation, low intake of red meat, low intake of particular fruit or vegetables that contain iron and vitamin C and/or low intake of iron fortified breakfast cereals. Past studies have shown that people with iron deficiency and IBD have a diet containing less iron and vitamin C rich foods than people who aren’t iron deficient. Therefore, the simplest thing you can do to help maintain your iron levels, regardless of whether you have IBD or not, is to eat iron rich foods, together with foods high in vitamin C, more often.

Iron deficiency definitions

Iron deficiency– low iron stores. Diagnosed by a blood test which shows low serum iron and/or low serum ferritin. Note that inflammation increases serum ferritin so if your CRP is high then your ferritin will be higher too. 

Symptoms:fatigue, breathlessness, irritability

Iron deficiency anaemia– low number of red blood cells which transport iron around the body. Diagnosed by a low blood haemoglobin. The normal range for haemoglobin varies for men and women and by age.   

Symptoms:worsening fatigue, breathlessness, irritability, reduced ability to exercise, poor skin, hair and nails, feeling cold, poor appetite, weakened immune system are among some of the symptoms. Many of these symptoms may overlap with your IBD flare symptoms. 

Ask your GP or specialist for a twice yearly blood test which includes a CRP (marker of inflammation), full blood count, iron and ferritin. This is best done when your IBD is in remission (because it is more difficult to interpret your iron blood tests results if your CRP is high). This information can help you to monitor your iron status and, if needed, make any dietary changes before your iron stores become too low. Iron deficiency anaemia will not improve by only increasing your dietary iron intake.

How is iron deficiency treated?

Treatment of iron deficiency depends on the severity of the deficiency and whether anaemia (low haemoglobin) is present. For mild iron deficiency the first treatment is to optimise your intake of iron from food. Below are some ideas to optimize your iron intake from food. If the deficiency becomes more severe or does not improve your GP or specialist may prescribe an oral iron supplement. Iron deficiency anaemia is often treated with an oral iron supplement too but if the iron deficiency anaemia is more severe or does not respond to oral iron supplements you may need an intravenous iron infusion. Discuss your treatment options with your GP or specialist.

How can you optimise your iron intake?

You may, or may not, have heard the words haem iron and non-haem iron. Haem iron is the type of iron in animal foods. Red meat contains the most harm iron of any animal food. Haem iron is more bioavailable, which means that your body absorbs a greater amount of the iron in the food. Non-haem iron is present in plant foods. Non-haem iron is not as absorbed as efficiently by the body as haem iron but it is a very important source of dietary iron. The body absorbs more non-haem iron if it is eaten with foods high in vitamin C and not eaten with foods that contain a lot of calcium (e.g. dairy products or calcium fortified foods/drinks). Foods that contain vitamin C include citrus fruits, kiwifruit, capsicum, potatoes and kumara and tomatoes. Vitamin C is a water-soluble vitamin; this means vitamin C leaches out of foods and into the cooking water. To maximise the vitamin C in potatoes boil them whole with the skin on or use cooking methods that don’t use water, such as baking or roasting.

I find the following salad is a delicious and simple way to combine a range of iron and vitamin C rich plant foods in one dish. I hope you enjoy it too.

iron rich salad

Plant sources of iron are plentiful but, to optimise the amount of iron your body absorbs from plant foods, you need to eat them with vitamin C rich foods. This recipe is an example of how you can combine multiple iron containing plant foods (legumes, nuts, seeds, eggs, fruit and vegetables) with vitamin C rich plant foods (citrus and potatoes). Baking the potatoes whole reduces the amount of vitamin C lost during cooking. If you find potato skin too difficult to digest, or you are worried that it may aggravate a stricture (narrowing in the bowel), you can remove the skin or scoop out the soft middle of the potato after it has been cooked.  

This iron rich salad for two contains:

3 soft boil eggs 

4 handfuls of baby spinach

2 - 3 tablespoons of canned and rinsed chickpeas. Lightly toast in a pan with a splash of oil to bring out their flavour.

4 dried apricots sliced

1 - 2 handfuls of roasted, unsalted almonds roughly chopped

2 tablespoons of pumpkin seeds. Toasted in pan with chickpeas to bring out their flavour.

Dress with a vitamin C rich vinaigrette made with olive oil and orange or lemon juice. See previous blog for recipe.

Serve with baked potatoes. To make baked potatoes pop small to medium sizes potatoes drizzled with oil and a sprinkle of salt in the oven and bake for 30 - 40 minutes until they feel soft in the middle.

Serving this salad with potatoes further increases your vitamin C intake and makes it a nutritionally complete meal that contains carbohydrate (potato), protein (chickpeas, eggs, nuts and seeds), healthy fats (vinaigrette) and a variety of plant foods, vitamins and minerals!