Iron deficiency: causes, symptoms, prevention and treatment.

Iron deficiency is the commonest nutritional deficiency in the world. It is estimated that about 10% of women and 1% of men in the USA are affected by iron (fe) deficiency. It is more prevalent among children who are living in the third world countries. Low levels of iron in the body causes serious consequences, such as anaemia, depressed immune function and hair loss.

Causes of iron deficiency.

Chronic blood loss is the most common cause. Iron is mainly found in the red blood cells (RBC). When we loss 1 ml of blood, we lose 1 mg of fe through it. Causes of chronic blood loss are;

  • Menstrual loss: Women lose between 30 - 80 ml blood each month during their periods. Some may lose more than that amount. Because of that women are more prone to have iron deficiency symptoms.
  • Haemorrhoids (piles): This is a common condition that affects more than a quarter of the adult population. Bleeding from the haemorrhoids is one of the main causes of  iron loss.
  • Hookworm infestation: This worms are found inside the intestine and suck our blood. This is the most common cause of fe deficiency among children, specially in the developing world.
  • Cancer: Cancers in the gastro-intestinal tract, such as stomach, colon and rectum are associated with chronic blood loss. Iron deficiency anaemia in a person over the age of 40 is an ominous sign, and should be taken seriously. Necessary  investigations should be done to find out or exclude cancer.
  • Inflammatory bowel disease: Ulcerative colitis and Crohn's disease cause bloody diarrhoea and chronic blood loss.
  • Analgesic use: Long term use of non steroidal anti-inflammatory drugs (NSAID) such as Ibuprofen may cause bleeding from the digestive tract.

One of the main cause of low iron level is inadequate intake of iron rich foods such as meat, liver and green leafy vegetables. Inadequate intake of these food results in depletion of iron stores in the body.

Other causes of low iron levels
  • Pregnancy, when iron requirement increases.
  • Rapid growth.
  • Inappropriate dieting.
  • Meal skipping.
  • Peptic ulcer disease.
  • Coeliac disease.
  • Too frequent blood donations.
  • Gastric bypass surgery.
  • Vegetarianism: Many vegetables contain significant amount of fe. However, absorption from vegetables is poor and  vitamin C is needed for the absorption of this iron.

Symptoms and signs of iron deficiency.

The most important sign is anaemia, which means reduced amount of haemoglobin in the blood. Haemoglobin carries oxygen from the lungs to other parts of the body. The oxygen is needed for the production of energy within the cells.

Iron deficiency anaemia is the major nutritional disorder in the world. About one in ten women in the USA are affected by this condition. Iron deficiency anaemia affects a large number of women and children in developing countries.

The World Health Organization estimated that over 30 per cent of the world's population is anaemic, majority of them are due to lack of iron in the body.

How iron deficiency causes anaemia.

Iron plays several important roles in our body. The main function is formation of haemoglobin, which carries oxygen from the lungs to other parts of the body.

Iron is a main component of the haemoglobin, which is a red coloured pigment found inside the red blood cells. Haemoglobin gives red colour to our blood. Four molecules of iron are found in one haemoglobin molecule. Oxygen is temporarily binds with these molecules and transported throughout the body.

Lack of iron in the body leads to reduced production of haemoglobin in the red blood cells. Low levels of haemoglobin in the blood is called anaemia.

Normal level of haemoglobin in the blood is 15 g/100 ml in men and 13 g/100 ml in women.

People with anaemia have following symptoms.
  • Tiredness and difficulty in doing physical activities.
  • Palpitations or awareness of heart beat.
  • Shortness of breath.
  • Dizziness.
  • Chest pain.
  • Pain in the legs while walking.
  • headache.
  • Ringing in the ears.
  • Pallor.
Other symptoms of lack of iron
  • Brittle and spoon shape nails.
  • Thin and brittle hair.
  • Hair loss, mainly in women
  • Soreness of the tongue.
  • Altered taste.
  • Eating strange items such as mud or ice. This condition is called pica.
  • Difficulty in swallowing.
  • Ulcers at the corners of the mouth.
  • Impaired immunity and increased susceptibility to infections.

Iron deficiency during pregnancy

Iron deficiency is common in pregnancy. You need more iron during pregnancy for several reasons. Firstly, extra iron is needed for your growing baby and the placenta, particularly in the second and third trimesters.

Secondly, the amount of blood in your body significantly increases during pregnancy. Therefore, more iron is needed for the production of haemoglobin in the blood.

Many women start their pregnancy with insufficient amount of iron in body stores. So, they are more prone to get iron deficiency anaemia, which is associated with low birth weight, premature delivery, and increased maternal and infant mortality rates.

Because of the above reasons, you need about double the amount of iron than normal women. Unfortunately, meeting this demand by diet alone is difficult, particularly in vegetarians.

Liver (beef, lamb, and chicken) has the highest amount of iron, however, it is not recommended to eat liver during pregnancy. Liver contains unsafe amount of vitamin A, and high dose of vitamin A may cause foetal malformations.

So, taking an iron supplement is a good option for many women during pregnancy. Remember! consult your health care provider before taking any supplements during pregnancy, because you may or may not need certain vitamins and minerals in extra amounts.

How iron deficiency is diagnosed

Estimation of haemoglobin (Hb%) in the blood is measured to diagnose anaemia. An Hb level of less than 13.5g/dl in men, and less than 12g/dl in women are indicatives of anaemia.

Measuring haematocrit is another test. This is the percentage of red blood cells (RBC) by volume in the blood. Normal ranges are 38-50 for males, and 35-45 for females.

These two tests can identify anaemia. However, further tests are needed to demonstrate low levels of iron in the body.

Blood picture is a test used to examine the morphology of blood cells. In iron deficiency, red blood cells are smaller and paler in colour than normal. This is called microcytic hypochromic anaemia.

Iron studies is the test to diagnose deficiency. The test consist of estimation of ferritin, transferrin saturation and iron levels. Ferritin and transferrin are  proteins that help transport and store iron in the body.

If the results indicate anaemia due to lack of iron, further tests may be needed to confirm the cause of deficiency. Upper GI endoscopy, colonoscopy, and ultra sound scan are commonly performed.

How to prevent iron deficiency.

Eating iron rich food is the best way of preventing anaemia. Foods of animal origin are the best sources. Red meat is the number one food that provide adequate amounts of haeme iron. Eating beef or lamb one or twice a week is a good way of preventing anaemia.

Liver of beef, lamb, and chicken contain large amounts of iron. However, eating too much liver is not recommended because of the risk of vitamin A toxicity.

Beans and green leafy vegetables are the good plant sources. Better examples are; spinach, tofu, lentils, kidney beans, lima beans, soy beans, and dates. However, iron from these food is poorly absorbed by our bodies. The absorption can be increased by adding vitamin C rich foods such as lemon, lime, and capsicum.

Absorption of iron in our diet may be inhibited by some substances. These iron absorption inhibitors are usually found in foods and drinks. Some medications also reduce the assimilation process of iron in the digestive system. Here is a list of inhibitors of iron absorption.
  • Tea and coffee
  • Chocolate
  • Soy products
  • Almond nuts
  • Brazil nuts
  • Large amounts of zinc in the diet
  • Large amounts of manganese
  • Calcium supplements
  • Antacids and other peptic ulcer medications
Tea, coffee and chocolate contain tannins that are chemical substances found in many plants. Tannin makes insoluble molecular complexes with non haeme iron, making it harder to digest.

Treatment of iron deficiency

Your doctor may recommend you to take iron supplements. In addition, he or she will also treat the underlying cause such as piles, peptic ulcer or menorrhoea.

When taking iron supplements consider following points.
  • Always take the correct dose. Iron overdose can be dangerous.
  • It is better to take it on an empty stomach. If you develop nausea, stomach upset or vomiting, take the pills with small amount of food.
  • You can take the tablets in divided doses to reduce the side effects. For example; taking one tablet in the morning and one in the afternoon is better than taking two at the same time.
  • Do not take iron with antacids or calcium supplements because they reduce the absorption of iron.
  • Avoid tea, coffee and milk at least two hours before and after taking the tablets, because these foods reduce the absorption of iron.
  • Take the tablets with plenty of water. Never swallow the tablets without water.
  • Always take while you are sitting or standing. Never swallow the pills while you are lying on the bed.
  • Vitamin C is an iron absorption enhancer. So, drinking orange juice may help increase the absorption of iron from the gut.
  • Do not chew, crush or split extended release tablets.
  • If you are using liquid form, shake well before use and measure the correct amount carefully.
  • Iron supplements have many side effects, most are minor ones. However they may cause allergic reactions. If you develop symptoms of allergy such as itching, rash, swelling, dizziness and difficult breathing, stop the medicine and seek immediate medical help.
  • Keep the iron and other medications away from children.
  • You may stop taking the iron supplement when your body's iron stores become full. Check you blood for iron and ferritin levels and ask your doctor when to stop.
In summary, deficiency of iron is an important illness. It can be due to inadequate dietary intake or excessive loss of iron from the body. However, serious health problems such as bowel cancer can be the cause, particularly after 40 years of age. So, always consult your doctor.