The Trouble with Iron: Iron Deficiency vs. Iron Overload

How much iron do you really need? And what are the dangers of too much or too little?

By Susan Ince

The Facts on Iron

In an old commercial now making the rounds on YouTube, a man trying to dance with his listless wife drags her around the floor like a rag doll, while a voice-over asks, "Tired because of iron-poor blood?" After taking Geritol, the wife dances into the room in a boa, and bends her husband backward into a kiss that’s reminiscent of Adrien Brody planting one on Halle Berry at the Oscars.

Over the years, the words Geritol and iron-poor blood have become American shorthand for middle-age fatigue. Many women, then, may be surprised to discover that iron depletion is far from being a given of life after 40. The landmark Nurses’ Health Study found that only about three percent of postmenopausal women are iron depleted — and those tend to be women who exercise more than average, take aspirin regularly, or have stopped menstruating relatively recently. In fact, the study found, more than three times as many postmenopausal women — almost 10 percent — have too much iron in their blood.

Consuming meat and alcohol often, taking iron supplements or birth control pills, and aging can all lead to increased iron stores in the body. Most at risk are the half-million women (mostly Caucasian) with hemochromatosis, a genetic tendency to absorb and hold on to large amounts of iron. Although the gene is present equally in men and women, most women don’t get symptoms until after they stop menstruating — a process that appears to protect against excess iron storage. Because hemochromatosis can lead to permanent damage to joints and certain organs, it’s important to detect and treat it early. That can be difficult, as some symptoms of too much iron are similar to those of anemia, or too little iron, and can also be mistaken for other conditions that hit women in menopause, such as osteoarthritis. In addition, many physicians think of hemochromatosis as a man’s disease because iron overload occurs more frequently in men.

Here’s how two women faced the iron issue in their own lives.

Too Much Iron

Paula Johnson, an avid sea kayaker, led an active life until her late 40s. Then her body started to betray her. By age 50, she felt as if she were 80. I’m too young to feel this old, she thought.

She downed three 12-ounce mugs of coffee every day to fight her fatigue, then came home from work and collapsed in front of the television. She experienced an irregular heartbeat. Fleeting pains in her knuckles worsened, and the pain in her wrists, shoulders, neck, and knees made just getting around her split-level home in Port Angeles, Washington, a challenge. Doctor after doctor found nothing physically wrong.

Finally, she laid out all her symptoms to a nurse practitioner, who ordered the right tests. They showed that Johnson was overloaded with iron. An average range of ferritin (a blood protein involved in iron storage) is 25 to 200 nanograms per milliliter; Johnson’s was 723. Genetic testing confirmed she had hemochromatosis.

An overload of iron keeps the organs and tissues of people with hemochromatosis from functioning properly, and the condition can eventually lead to diabetes, cirrhosis, and other life-threatening diseases.

Pumping Iron Out

When Johnson’s doctor asked how she thought they might treat this disease, she half-jokingly guessed, "By bloodletting?"

Bingo. It turns out that the most efficient way to reduce iron is to give blood — often. As the body replenishes iron-containing red blood cells, it borrows iron stored in the tissues. Repeating the process gradually reduces the iron level in the body.

Along with other treatments for problems brought on by high iron levels, Johnson’s therapy called for her to donate a pint of blood every week and reduce the iron in her diet. After four donations, her brain fog cleared and the pain in her hands eased enough that she could open jars and potato chip bags again. After giving eight pints, she no longer experienced the irregular heartbeat that had plagued her for six years. After 12 sessions, her level was so close to normal that her doctor said she could cut back on donating blood to once every couple of months, though her joint pain continues.

This past September, nine months after her diagnosis, Johnson returned to her beloved kayak, spending six days paddling and camping in British Columbia.

"To be able to go out with a group and spend those days on the water, being self-sufficient and feeling well enough to enjoy the adventure, was incredible," she reports.

Iron Deficient

When Carolyn Winslow, 47, describes what she experienced in 2006, you would swear you were talking with Paula Johnson.

"I didn’t have enough energy for someone my age. I tried taking yoga and Pilates classes, and they wore me out — all these people older than me would just walk out afterward, while I had to sit down and rest," says Winslow, a computer instructor from Mooresville, South Carolina.

Soon even daily activities were too taxing: walking up stairs, drying her hair, taking a shower. Like Johnson, she was feeling foggy mentally.

Unlike Johnson, Winslow was familiar with hemochromatosis — her brother had had it before he died of liver cancer, 10 years before. But tests revealed her to be seriously iron deficient: Her ferritin level was only 3 nanograms per milliliter.

Pumping Iron In

Iron-deficiency anemia is usually treated with a diet change and supplements, but Winslow’s specialist decided on a more aggressive approach: intravenous infusions, which would deliver iron faster and without the gastrointestinal side effects many suffer from while taking supplements.

Getting the level back up is important: As women age, they’re more likely to become frail and have cognitive problems if they’re iron deficient. And changes during perimenopause, such as heavier periods, can lead to a loss of iron. "I’ve heard more and more women say they lose a lot of blood during perimenopause," says Laura Murray-Kolb, PhD, of the Johns Hopkins Bloomberg School of Public Health. "A couple of women who had difficulties concentrating and remembering showed vast improvement once they started taking iron supplements."

Even anemic women need a checkup before turning to iron supplements. Some women whose test results show too little iron in the blood may actually have plenty of stored iron in other tissues, though their systems are trying to cut off the supply so it doesn’t nourish diseased cells or germs in the blood. "It’s a defense your body has so you won’t feed these invaders," says Cheryl Garrison, executive director of the Iron Disorders Institute. That mechanism makes it vital for a woman who is told she has anemia to dig deeper and be checked for stored iron before taking iron pills, she adds.

Should All Women Get Iron Tests?

"No one recommends that people without symptoms be tested," says Heidi Blanck, MS, PhD, of the Centers for Disease Control and Prevention. "But if you have the symptoms of iron deficiency or overload — and plenty of people do — ask your doctor to test you."

Iron and Heart Disease

There’s an ongoing medical debate about whether excess iron contributes to heart disease. Estrogen is usually credited with protecting women against heart disease prior to menopause. But about 25 years ago, researchers in the Framingham Heart Study noticed that the heart disease rate for women who had undergone hysterectomies — whether or not they still had their estrogen-producing ovaries — was identical to that of women who had gone through natural menopause.

That piqued experts’ curiosity, and today, some think it may actually be menstrual flow that protects the heart, by keeping iron levels down. One such expert is Jerome L. Sullivan, MD, PhD, of the University of Central Florida College of Medicine. He offers the following points as further support for the theory.

  • The Women’s Health Initiative showed that there was no heart benefit to women from taking estrogen. That makes sense if iron buildup, rather than lack of estrogen, increases the risk of heart disease.
  • Taking aspirin appears to benefit the heart, and taking aspirin daily causes enough bleeding from the gastrointestinal tract to lower a woman’s level of ferritin (a protein linked to iron storage) quite significantly over time.
  • Artery-clogging plaque contains much more iron than a healthy artery wall.
  • The blood vessels of frequent blood donors are healthier than those of occasional donors.

If Sullivan’s right, should heart-savvy women line up for the bloodmobile now? It’s not a bad idea to donate blood if you’re qualified. And don’t worry about anemia — each time you hit the blood bank, you’ll be monitored.

Get the Iron You Need

From Food

Women require about 18 milligrams of iron a day (27 when pregnant) until menopause, when the amount drops to about 8 milligrams.

Good sources of iron are lean red meats (such as beef, venison, and lamb), organ meats, oysters, clams, beans, whole grains, and cooked greens. (There are 13 milligrams of iron in 3.5 ounces of cooked chicken liver; a cup of kidney beans has 5.) In addition, many types of food naturally low in iron (such as breads and cereals that are not whole grain) are iron-fortified.

With a few exceptions, for every 20 milligrams of iron you consume, only one is absorbed into your bloodstream (unless you have hemochromatosis). Iron from animal sources is two to three times more absorbable than iron from plants or fortified foods. To boost iron absorption from plant sources, include fruit (such as citrus or papaya) or raw vegetables high in vitamin C (broccoli, brussels sprouts, green peppers, leafy greens) in the same meal. To lower iron absorption, pair iron-rich foods with those that contain calcium (dairy products), tannins (tea), and phytates (wheat bran and flaxseed).

From Supplements

Don’t assume you need an iron supplement, as overload is a possibility. Women over 40 should ask their doctors before taking a multivitamin that contains iron. But if you do need to take iron, here are some suggestions for good results.

  • Consider Proferrin (from Colorado Biolabs), made from easily absorbed heme iron (which is found only in meat, poultry, and fish). The risk of its causing digestive problems is low, so you can take it with or between meals. Vegetarians, beware: It’s made from the red blood cells of cows.
  • Try supplements made from non-heme iron (found in plant-based and iron-fortified foods). These include ferrous fumarate, ferrous sulfate, and ferric iron; they’re less expensive and more widely available than those made from heme iron. They can, however, cause gastrointestinal disturbance and constipation, although products designed to dissolve in the intestine rather than the stomach may have fewer side effects. Ferrous sulfate (sold as Feosol and Slow Fe) is the most easily absorbed non-heme iron.
  • Take iron between meals (preferably paired with some vitamin C) and at least two hours before or after other medications, as one may reduce the effectiveness of another.

Is Your Iron in Balance?

If you have too much iron, you may experience:

  • Swollen, stiff, or painful joints, especially the hips, knees, and ankles
  • Fatigue
  • Abdominal pain
  • Irregular heart rhythm
  • Diabetes
  • Infertility
  • Hair loss

If you have too little iron, you may experience:

  • Fatigue
  • Foggy thinking, memory loss
  • Headaches
  • Restless legs syndrome
  • Hair loss
  • Sensitivity to cold
  • Shortness of breath
  • Urge to eat ice

Originally published in MORE magazine, February 2008.

First Published Mon, 2009-04-06 18:24

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