Aidan:
Hello and welcome to the Ideal Nutrition Podcast. My name is Aidan Muir, and I’m here with my co-host Torwen Eerkins. This is episode 239, where we’re going to talk about iron deficiency and the best ways to address it. We’re going to start by talking about common causes and which populations are at risk. I think the populations at risk are pretty well known. We know women who menstruate are a big one.
We also know any form of bleeding matters. For example, GI bleeding from inflammatory bowel disease. Pregnancy is another one, because iron needs get really high. Endurance athletes are also at risk, particularly runners. Hitting the pavement and the impact can play a role too. Another group includes people with reduced absorption.
For example, coeliac disease, if that’s not resolved. Going back to IBD, it can affect things from both angles. Some people may also have a high intake of inhibitors. That could be tea or coffee, or anything else.
Torwen:
Then there are the signs and symptoms of being iron deficient. People often come in complaining of tiredness. They also report headaches, dizziness, and weakness. If they exercise, they might notice poor exercise performance. They may also feel shortness of breath. In terms of testing for iron deficiency, the simplest way is a full blood count plus iron studies.
So, ferritin is the main marker of iron stores. When levels drop below 30 micrograms per litre in many adults, this suggests low iron. We also check transferrin and transferrin saturation. We check serum iron and TIBC too. That helps confirm iron deficiency and rules out other inflammation.
Aidan:
Absolutely. I’m surprisingly passionate about addressing this. It ties into why I’m a dietitian to start with. It kills me a little seeing someone being fatigued. And there could be an easy solution. I get that it might not seem easy sometimes. People may have tried things in the past that didn’t work. However, with the knowledge we have, there are many ways around it.
That’s why I see it as an easy solution. We’re going to start with supplements. We will also talk about food. However, we’re starting with supplements because they can move the needle most. That matters when addressing a deficiency quickly.
Torwen:
Most iron supplements come in two main forms. First are ferrous salts, which are Fe2+. An example is Ferrograd C. Second are ferric forms, such as iron polymaltose. An example is Maltofer. Those are the most common supplements we see. There is also the alternative of an iron infusion. That gives you intravenous iron. Still, the oral options are the common ones.
Aidan:
Absolutely. The common logic is to start with Ferrograd C over Maltofer. It’s well known to be quite effective. I spoke with our team, including you, about this. I’ve seen research and I can’t go back and find it. I don’t know the name of the study. It compared Ferrograd C to Maltofer. Ferrograd C massively outperformed, more than you would expect. I
don’t want to misquote the numbers because I couldn’t find the study. So it’s not in the show notes. From memory, it increased iron scores by over 100 percent. Maltofer was about 7 percent. I believe with a larger sample size, the gap wouldn’t be that big. Still, that’s a crazy big gap. It’s like, start with Ferrograd C. That’s often the move. The question is why we start with that. We do have another option. Why not just use the main one? It’s often based on side effects.
Ferrograd C is more likely to cause gastrointestinal symptoms. That includes constipation and sometimes nausea. Maltofer is less likely. This study found symptom frequency was similar. So Maltofer can still cause symptoms. However, severe symptoms were more likely with Ferrograd C. I don’t know if you have it on your list. We can talk about how to address symptoms.
Torwen:
Let’s chat about it. Side effects of iron supplementation are super common. Constipation, nausea, and dark stools are pretty normal. With constipation, there are a few things to consider. Start with increasing fluids and fibre. If it’s very bad, switch to a gentler form like Maltofer. For nausea, take it at night time. You could also take it with a smaller snack to help. We’ve also discussed taking iron every second day. That’s instead of taking it daily. The body produces hepcidin after a dose. Hepcidin temporarily blocks iron absorption for about 24 hours. It doesn’t block it completely. Still, there may be evidence supporting alternate-day dosing. If someone has extreme side effects, that could help. Nausea is often the bigger issue there.
Aidan:
Constipation can also push people to stop entirely. I’d rather people not be fatigued. If this is a common side effect, we should address it. There are many ways to do that. If you look up our content on constipation, you’ll find resources. You can address the symptom. Another way to think about it is less frequent dosing.
If Ferrograd C is much more effective, lower frequency might work. You could also potentially do a lower dosage. It’s not really recommended, but it’s an idea. In Australia, if an iron supplement sits below a cutoff, it can’t be marketed for deficiency. I don’t know the exact cutoff. It might be below 50 milligrams.
It could be 40 milligrams. The reason is that it doesn’t move the needle quickly enough. Still, you can use common sense. If it’s more tolerable, it’s better than nothing. There’s definitely stuff that can be done. Another area is alternative routes like liver or spleen supplements. What are your thoughts?
Torwen:
The amount of iron in those supplements can be low. I’ve heard clients say they have more energy on beef liver supplements that supposedly contain iron. If we look at food, organ meats can contain a fair bit of iron. In supplement form, it’s a small amount. I would usually go for a normal iron supplement.
Aidan:
Yeah, exactly. Often those supplements have one to three milligrams of iron. For context, Ferrograd C has 105 milligrams of elemental iron. Maltofer has 100 milligrams. One to three versus 105 is a huge difference. You can argue for food first as well. Liver supplements are nutrient rich for their size.
That could carry over to other forms of energy. I’m not opposed to people adding nutrient rich foods. However, there’s a gap for treating deficiency. I thought for a long time it wasn’t high enough. Then one day a client showed me one with 15 milligrams. That was an outlier. There are ones with 10 plus milligrams of heme iron. That’s the best absorbed form. Often they’re beef spleen and liver. It’s usually not just beef liver by itself.
Some of these might move the needle more. It’s still not gold standard for treating iron deficiency. However, some can be relevant. A key point is people report fewer symptoms. Food for thought, even at 10 milligrams, it’s one tenth of the dose. If you had one tenth of Ferrograd C, you probably wouldn’t get symptoms either. So I wouldn’t use symptoms alone as the reason to switch. There are other factors too.
Torwen:
One thing I want to add on there is that when supplementing for deficiency, higher doses may be needed. If iron is within range, and someone wants beef liver to maintain it, that’s different. Then I’m more open to adding it in.
Aidan:
Yeah, absolutely. There is a trend of getting deficient, supplementing, then stopping. Then people get deficient again. It becomes a cycle. There are ways around it. Dietary changes can help. Less frequent supplementation might also help. That could mean dropping back to twice a week. These approaches aren’t always common. With regular tests, you could find a way to keep levels steady. Let’s talk about dietary strategies.
Torwen:
If iron is low, it makes sense to look at the diet. Check how many iron rich foods are included. Then increase that where possible. There are two types of iron in food. There is heme and non-heme. Heme iron comes from animal sources. And heme iron is better absorbed. Lean red meat, liver, offal, poultry, sardines, and oily fish are great sources.
Non-heme iron is plant based. It’s less efficiently absorbed. That doesn’t mean the foods can’t be high in iron. It just means absorption is lower. Examples include lentils, chickpeas, and kidney beans. Baked beans can help as well. Tofu, tempeh, nuts and seeds can also contribute. Iron fortified cereals can help a lot. Dark leafy greens are also included.
Aidan:
With Leah previously co-hosting, she made a bunch of content on non-heme iron. Fortified products can also be very useful. There’s even some plant-based Milo products that are quite high. There are lots of ways to get there. Did you mention vitamin C?
Torwen:
Let’s chat about that. Vitamin C is one way to enhance absorption. It helps change iron into a form that absorbs more easily. It also keeps it soluble as it moves through the intestines. That’s important.
Aidan:
Earlier we mentioned tea and coffee. Tea contains tannins. Caffeine may also reduce absorption a little. I wouldn’t overthink it. These are small wins that may play a role. Some people go extreme with certain things. I had a 12 year old client with low iron. He was having over two litres of milk a day. The calcium was very high. It’s rare in that demographic for someone to have low iron, but it mattered. That’s another factor to keep in mind.
Torwen:
So, how much iron do you actually need? Let’s have a chat about it. For most adult women, it’s 18 milligrams a day. After 51, it drops to eight milligrams a day. Adult men also need eight milligrams a day. And like I mentioned at the start, pregnancy shoots through the roof at 27 milligrams a day. That’s a lot. And if you’re vegetarian or vegan, you may need to increase intake. That helps get the same absorbable iron.
Aidan:
To add some context on to that. If those numbers don’t mean anything, red meat helps with context. It’s one of the best sources of heme iron. To get 2.5 milligrams from red meat, you need about 100 grams. If you had 200 grams, you’d get about five milligrams. If my needs are eight milligrams, that’s pretty easy.
You can see why deficiency is less likely. Once you go up to 18 milligrams, it gets harder. If someone is deficient and adds red meat twice a week, it may not move the needle. Portions might not be large. If it’s 150 grams, that’s about 3.5 milligrams. That’s out of 18. It also needs to treat deficiency, not just maintain. And then you chuck pregnancy into the mix and it increases to 27 milligrams. That’s hard.
Torwen:
And that’s why iron fortified cereals can help. Iron fortified foods can help too. Even Milo can contribute. It brings you closer to maintaining around 18 milligrams daily. Anything else you want to add?
Aidan:
Happy to wrap up there.
Torwen:
Amazing. This has been episode 239 of the Ideal Nutrition Podcast. Where we covered the best ways to address iron deficiency. If someone you know would benefit, please send it to them. Otherwise, we’ll be back for the next episode. Thank you.