When Iron Deficiency Isn't About Iron.
Iron deficiency anemia (IDA) is a prevalent diagnosis in the US. The condition is characterized by a lack of healthy red blood cells (RBCs). RBCs (specifically the hemoglobin within RBCs) carry oxygen throughout the body to various tissues and organs and bring back carbon dioxide to be expelled from the lungs. This process is essential for adequate physiological function and iron is required to make hemoglobin.
When our body tissues lack oxygen, we may feel weak or tired. We may have difficulty concentrating or experience headaches or heartbeat irregularities. Other signs include a pale tongue or pale conjunctiva. IDA can result in mood disturbances and delay cognitive development in children.
Iron deficiency anemia is typically diagnosed using blood work such as a Complete Blood Count (CBC). (1)
A CBC done for iron deficiency anemia will include measures of:
Hemoglobin: hemoglobin is a protein that carries oxygen within the red blood cells and this marker measures how much of this protein is in the blood.
Mean corpuscular volume (MCV): measures the size of red blood cells. RBC's varying from large to small or a lot of small RBCs may suggest anemia.
Red Blood Cell count or RBC: measures the number of red blood cells in the blood.
Hematocrit: percentage of blood that contains red blood cells.
Mean corpuscular hemoglobin (MCH): a measure of the amount of hemoglobin inside a red blood cell.
Red Cell Distribution Width: measures the variation of volume and size of red blood cells.
Typically iron deficiency anemia is treated with supplemental iron. But assessing IDA with the above criteria may not provide a complete accounting for the cause of anemia. Iron requires nutrients known as cofactors to get its job done. It is important to assess the adequacy of these cofactors or nutrients to determine whether they are playing a role in an anemia diagnosis. Determining whether sufficient amounts are included in the diet or if medication may be depleting these nutrients is an important part of this assessment.
Cofactors for Iron:
Vitamin C: Iron comes in two forms. Heme and non-heme. Heme iron is found mainly in animal products. Non-Heme can be found in plants, grains, nuts, and seeds. Heme is more absorbable than non-heme and therefore does not require vitamin C to facilitate absorption. But non-heme iron requires vitamin C to be assimilated properly. So if a person's diet is deficient in vitamin C, they may be getting adequate iron in their diet, but they may not be absorbing it and are therefore unable to use it efficiently. An iron supplement to improve anemia, in this case, would not be helpful because the person is already consuming enough. Increasing Vitamin C would be necessary. Increasing vitamin C-rich foods in meals with non-heme iron can improve iron absorption.
Foods rich in vitamin C include: bell peppers, strawberries, broccoli, Brussel sprouts, and citrus fruits are great sources of Vitamin C.
Medications that can deplete vitamin C: Aspirin and non-steroidal anti-inflammatory medications (Ibuprofen) can deplete vitamin C.
Click below for a video on the relationship between vitamin C and iron.
B6 (Pyridoxine): Vitamin B6 is used by the body to make hemoglobin. So if you are getting enough iron in the diet but are deficient in B6, this may affect the production of hemoglobin, which would disrupt the red blood cells' ability to get oxygen to the body. Iron supplementation would likely not be effective in this scenario. You would need to increase B6.
Foods rich in B6 include: beef, pork, salmon, eggs, sweet potato, avocado, and chickpeas.
Medications that can deplete B6 include: steroids, antibiotics, asthma medications, oral birth control, and some cardiovascular medications.
For more on B6 and its role in hemoglobin synthesis click below!
Zinc:
The relationship between zinc and iron is a complex one. Much like B6, zinc is required for the synthesis of hemoglobin and red blood cell development. If deficient in zinc, a person can become anemic. But there is some evidence to suggest that zinc and iron may have a competitive relationship during absorption. So while zinc is essential to prevent anemia, the two may be best consumed separately when supplementing with therapeutic doses. Consuming zinc and iron together in food is ok. (2)
Foods rich in zinc include animal products, shellfish, eggs, dairy, legumes, and nuts and seeds.
Medications that can deplete zinc include: diuretics and antihypertensives.
Copper:
Copper is carried through the bloodstream by a protein called ceruloplasmin. Ceruloplasmin is necessary to liberate iron from ferritin, the protein in which it is stored. Once iron is released, it can contribute to the development of heme in red blood cells. If copper is low, ceruloplasmin activity is disrupted, iron liberation is inhibited, and this can result in anemia. For this reason, it is important to assess copper as part of the possible causes of anemia. (3)
Foods rich in copper include: animal products, shellfish, seeds and nuts, spinach, asparagus, avocado, and chocolate.
Medications that deplete copper include: Penicillin and antacids. High-dose zinc supplementation may lead to copper deficiency.
For more on copper’s relationship to iron and a discussion on copper toxicity click below!
Vitamin A
Like copper, vitamin A is also involved in moving iron from storage in ferritin to be used in the body, and there is evidence supporting vitamin A supplementation can improve hemoglobin numbers.
Foods rich in vitamin A include: eggs, carrots, sweet potatoes, spinach, and broccoli.
Medications that deplete vitamin A include: antibiotics and some cardiac medications.
Absorption Issues:
In addition to the influence of supportive nutrients on iron, issues with absorption may also contribute to anemia. Even if we consume adequate amounts of iron but have issues assimilating it into the body, iron cannot do its job.
Many things can cause iron absorption issues. Digestive conditions such as celiac, IBS, and Chron's disease or a Heliobacter Pylori (H Pylori) infection. A history of gastric bypass. Certain prescription medications such as antibiotics, cardiac medications, proton pump inhibitors, and antacids. And nutritional supplements such as Calcium, Manganese and Vitamin E.
Considering the many factors that can contribute to a diagnosis of anemia, the following lab markers may provide a more accurate picture than just a CBC alone. (4).
Serum Ferritin: measures the amount of iron that is stored in the body
Transferrin: a measure of the protein that transports iron throughout the body
Serum Iron: the concentration of iron in the blood
Total Iron Binding Capacity (TIBC): measures the amount of iron in the blood that is available for binding to proteins.
If the above labs are normal, showing an adequate amount of iron, adequate storage, and sufficient transport proteins in the body, this may indicate that one of the cofactors mentioned above is contributing to anemia.
We discussed that symptoms of iron deficiency anemia can often include difficulty concentrating. It is no coincidence that it is often found that children with autism and ADHD are either iron deficient and/or struggling with many of the other nutrient deficiencies mentioned. (5)Hashimoto's is another condition in which iron deficiency anemia is common. Often this is due to the frequency of celiac disease among those with Hashimoto's interfering with iron absorption.
Think you or your child might be dealing with anemia or nutrient depletions? Schedule a Discovery Call with Jade or Shawna to discuss how you can develop a plan to heal and thrive!
References
Complete blood count (cbc). (2020). Retrieved March 12, 2021, from https://labtestsonline.org/tests/complete-blood-count-cbc#:~:text=The%20complete%20blood%20count%20(CBC,as%20infections%2C%20anemia%20and%20leukemia
Soliman, J., & Amer, A. (2019, January 02). Association of zinc deficiency with iron deficiency anemia and its SYMPTOMS: Results from a case-control study. Retrieved March 12, 2021, from https://www.cureus.com/articles/16553-association-of-zinc-deficiency-with-iron-deficiency-anemia-and-its-symptoms-results-from-a-case-control-study
Collins, J., Prohaska, J., & Knutson, M. (2010, March). Metabolic crossroads of iron and copper. Retrieved March 12, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3690345/
Iron tests. (2019). Retrieved March 12, 2021, from https://labtestsonline.org/tests/iron-tests
Bener, A., Kamal, M., Bener, H., & Bhugra, D. (2014, September). Higher prevalence of iron deficiency as strong predictor of attention deficit hyperactivity disorder in children. Retrieved March 12, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4212392/