Iron Deficiency Anemia: Your options when it comes to prevention and care.

This article is not medical advice and should not be used to diagnose or prescribe.

Iron deficiency is the most common deficiency for women worldwide (1).

Iron deficiency affects 33% of non pregnant women, 40% of pregnant women and 42% of children around the globe (1). Despite global efforts to educate women and eradicate this health issue it is still prevalent (1). So what do you do if you think you have low iron? Read on to learn how you can check your iron stores and your options to increase them if you are low.

Why is iron important?

Iron is an essential mineral that has important functions such as DNA synthesis, oxygen transport and thyroid hormone production (2). You may have heard of iodine and how important it is for the thyroid. Iodine requires iron in order to be fully utilized (2). It is essential for thyroid hormone synthesis and metabolism (2). When your levels are too low you may feel fatigued, brain fog, inability to focus, low mood, low libido, low motivation, hair loss and reduction in overall capacity to deal with life (3, 4). The list goes on. As women we are incredible at finding deep reserves that can hide symptoms of a deficiency. Us Wonder Women still can have a full time job, workout, and look after our families with undiagnosed anemia. Of course once this is corrected everything else becomes a lot easier.

Types of Iron deficiency

Just briefly let's look at the types of iron deficiencies. If a deficiency comes up in your labs it may not just be iron that is low. It's important to check what kind of iron deficiency it might be so it can be treated correctly. Below is a short list of the various types of anemia.

Iron deficiency anemia: This is what this article will be focused on.
Microcytic anemia
Normocytic anemia
Macrocytic anemia
Iron deficiency without anemia: Also called latent iron deficiency. This is when your iron is too low for ‘You’ and you have symptoms such as fatigue but your blood results may still be in the normal range (5).
Anemia of Chronic Disease (5).

Testing

To see the full picture of your iron it's recommended to have your full blood count done (CBC) along with Ferritin (your iron stores), Transferrin, Transferrin saturation, serum iron and B12 (5).
In New Zealand requesting a full iron panel from your GP is subsidized. The Doctor’s appointment will cost you $30-$50. When it comes to anemia, blood tests are your best preventative treatment combined with a iron rich diet and supplementation. It can be hard to increase your iron stores once they are low, especially if you lose iron each month through menstruation. I recommend that if you are menstruating to check your iron twice yearly so that you can track to see if your iron levels are dipping and then work with a Naturopath to supplement appropriately so that they don’t get lower.

What is the optimal level?

The range for optimal iron (ferritin) on lab tests can vary (see the picture above). It can be hard to know whether you should be sitting at one end or the other or is somewhere in the middle healthy? For example if you are a woman between 20-29 years old you have a ferritin (Your iron stores) range between 20-170 ug/L. It's helpful to have someone look over your lab results to assess optimal levels compared to in range. Having a ferritin of 22 even though within range may be causing fatigue, concentration issues and a whole lot of other symptoms. The other markers such as b12 and transferrin saturation play a role too. If you are a menstruating woman the risk for iron deficiency increases due to the loss of blood every month (4).

Deficiency

The diagnostic range for iron deficiency anemia varies between guidelines and between laboratories within New Zealand (6). In general, the lower the hemoglobin level, the more likely there is to be a serious underlying deficiency, and the more urgent the need for investigation (6). If you lab tests are flagged by you GP and you are diagnosed with Iron Deficiency Anemia then there are two options through NZ subsidized healthcare.

Iron Infusion

Ferric carboxymaltose is the type of intravenous iron preparation that can be delivered as an infusion diluted in saline (a salt liquid) (6). To qualify to have this funded in New Zealand you must have diagnosed anemia and a hemoglobin lower than 120 g/L (6). If you don't have both of these but feel that supplementation is not right for you then you can request it unfunded from your GP. The cost of the iron vile for the infusion is around $252.60. Once you have the vile you book in with a practice nurse to have the infusion put in. This cost to have the infusion performed is about $70-$100. There are clinics all around New Zealand that specialize in iron infusions and care. They are a helpful place to call to understand your options.

What happens when I get an infusion and how long does it take?

A nurse will insert a IV into your preferred arm. The infusion can take about 15 minutes (6). The nurse requires you to stay afterwards for 30 minutes for observation (6).

Supplementation

Oral iron supplementation or dietary changes are still the first-line of treatment for many people in Public Health Care(6). There are 3 forms of iron available. Ferrous fumarate 200mg tablets (65 mg elemental iron), Ferrous sulphate 325mg (105 mg elemental iron) partially subsidized, and the same ferrous sulphate table is also available with 350mg of folic acid (partially subsidized)(6). However the form of iron in these supplements for some people will not result in a sufficient improvement in iron stores, or it will cause intolerable side affects, such as gastrointestinal symptoms, diarrhea or constipation (6). If there is a malabsorption issue then an infusion is recommended (5).

A note about normal or raised levels of ferritin.

Normal or raised ferritin levels do not exclude iron deficiency anemia (5). Iron stores can be elevated due to illness, supplementation, liver disease and inflammation (5). During an illness or inflammation, serum ferritin levels are increased to bind any free iron and prevent it being accessible to those bugs causing your infection (5). If you would expect your iron to be much lower than what it comes back as then it may pay to check again after a couple of weeks, once you have recovered from that flu or cold. If you have a condition that means you suffer from chronic inflammation then this can falsely elevate your iron levels too. I recommend support from a specialist or knowledgeable naturopathic practitioner to tease out if there is an iron deficiency or not.

Next steps

Please read my article on Infusions vs Supplementation, Smart Iron Supplementation and Naturopathic Recommendations for Iron Deficiencies to continue to learn about how you can improve your iron wellbeing.

Many barriers still exist for women accessing the right iron treatment options for them (3). The enduring burden of iron deficiency suggests that current strategies are limited in their accessibility and usability (3). A person's ability to pay for treatment options should not prevent them from accessing healthcare. And knowledge about iron deficiency and prevention needs to be more widely available. Knowledge is vital for women to feel empowered in their healthcare decisions. Moreover there is a need for iron supplements that are better absorbed and with fewer side effects to be subsidized. Too often I hear women say that stopped supplementing all together because the supplements caused them stomach pain, diarrhea or constipation. My hope is that this article is a start to providing information that may support you in understanding what options are available to you and recommendations for prevention in iron deficiency anemia. Remember prevention is your #1 strategy, start checking your levels early and don't stop just because they are in range.

References

1 World Health Organisation. (2022). Micronutrients. https://www.who.int/health-topics/micronutrients#tab=tab_1.

2. Ghiya, R., & Ahmad, S. (2019). SUN-591 Severe Iron-Deficiency Anemia Leading to Hypothyroidism. Journal of the Endocrine Society, 3(Suppl 1), SUN-591. https://doi.org/10.1210/js.2019-SUN-591 .

3. Benson, C. S., Shah, A., Stanworth, S. J., Frise, C. J., Spiby, H., Lax, S. J., ... & Klein, A. A. (2021). The effect of iron deficiency and anaemia on women’s health. Anaesthesia, 76, 84-95.

4. Nguyen M, Tadi P. Iron Supplementation. [Updated 2022 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557376/

5. Bpacnz. (2013). Anaemia on full blood count: investigating beyond the pale.://bpac.org.nz/BT/2013/September/investigating-anaemia.aspx.

6. Bpacnz. (2017). Intravenous ferric carboxymaltose: now available for the treatment of iron deficiency. https://bpac.org.nz/2017/iron.aspx#fig1.