The link between low iron levels and fatigue, and why this diagnosis is often missed
Today’s edition of the British Medical Journal contains an article which summarises guidance from the UK’s National Institute of Health and Clinical Excellence (NICE) on the management of chronic fatigue syndrome [1]. Let me start by saying I have special interest in this area, as quite a number of my patients present with ‘fatigue’ (often, long-lasting) for which no specific cause can be found.
My experience is that it is often able for individuals to regain much if not all of their lost energy using, usually, a range of approaches which may address more than one apparent cause. While the recommendations from NICE are better than nothing, my sense is that we prove to be of much use for a significant number of sufferers.
One of the reasons for this is that the recommendations do not embrace some issues that I find are common in CFS including compromised adrenal gland function. And even where a testing is advised, there are reasons why conventional interpretation of results may ‘miss’ something that is relevant clinically.
By way of example, I’m going to focus on NICE’s recommendation to measure ‘ferritin’ levels. Ferritin actually gives a pretty good measure of iron levels in the body. Low iron can cause anaemia (which can cause fatigue), but even if it doesn’t, on it’s own deficiency of this nutrient can cause fatigue. What is more, low iron (ferritin) is common in CFS sufferers, and restoring iron levels often leads to a significant improvement in energy and wellbeing.
NICE’s recommendations are that ferritin levels should be taken in children and young people only. Personally, I don’t agree with this, because in practice I see iron deficiency very commonly in vegetarians (of all ages) and women.
Next, I do think with iron levels it’s important to distinguish what is ‘normal’ from what is ‘optimal’. This week, I’ve been doing some work in Canada which has entailed, among other things, advising people on the results of their ‘medicals’. Ferritin levels are measured in women as a matter of course over here, and the normal range is quoted as 10 – 291 micrograms per litre of blood (mcg/L). Just seeing how wide this ‘normal’ range is set should set alarm bells a’ringing. Are we really saying that two individuals, one with 29 times the iron level of the other, are both ‘normal’.
You see, what is ‘normal’ is something determined by statistical techniques, not common sense, and is utterly arbitrary. Basically, the normal range for ferritin is set too wide. We know this partly from our experience in clinical practice, and partly because there is even some evidence that shows that individuals with iron levels well within the ‘normal’ range can still suffer as a result.
I suppose one of the reasons that I’m writing about this is that almost all the women I have seen this week has ferritin levels that I regard as far from optimal. And none of them had had this mentioned to them or had any advice given regarding this. The most memorable of these was a women who complained she lacked ‘stamina’. She turned in a ferritin of 4 (yes, four). And despite this being even lower than the ‘normal’ range, this seemed to have been ignored by her doctor. Personally, I think iron does not get enough attention, and yet I find it’s often critically important to those who are suffering from chronic fatigue or simply feel ‘below’ par.
The article pasted In below includes more information of the value of optimal iron levels with regard to brain function, and also offers some advice about iron supplementation.
References:
1. Baker R, et al. Diagnosis and management of chronic fatigue syndrome or myalgic encephalomyelitis (or encephalopathy): summary of NICE guidance. BMJ 2007;335:446-448
Metal fatigue - iron deficiency found to slow brain function in women - posted on 12 March 2007
While medical practice generally turns a blind eye to the value of nutrition in health, it has at least embraced the importance of certain specific nutrients including iron. Iron is important for the manufacture of haemoglobin – the protein in the red blood cells responsible for carrying oxygen around the body and delivering it to the tissues. Iron deficiency can lead to anaemia, which can lead to symptoms which include fatigue and low mood.
What is less well recognised about iron is that it participates in the reactions that generate energy within the body. It is possible for individuals to become iron deficient without becoming anaemic. However, iron deficiency in the absence of anaemia can still cause individuals to suffer symptoms such as fatigue and low mood. This is particularly common in women of child-bearing age, particularly as a result of loss of iron via menstrual blood each month.
The relationship between iron status, anaemia and mental function was recently studied in a group of 149 women aged 18-35 years. At the beginning of the study, women were classified as being either iron-sufficient, iron deficient and anaemic, or iron deficient in the absence of anaemia. All women were put through their paces with 8 tests of mental function.
At the beginning of the study, the iron-sufficient women performed better and completed the mental tasks more quickly than the iron deficient anaemic women. Cognitive performance and task completion results among the iron deficient non-anaemic women fell between the iron sufficient women and iron deficient anaemic women.
Women who were iron deficient were then treated with iron supplements for a period of 8 weeks. At the end of the study, a significant improvement in serum ferritin was associated with a 5-7 fold improvement in mental function. The authors of this study concluded, “Iron status is a significant factor in cognitive performance in women of reproductive age”. They went on to add that “…the severity of iron deficiency affects accuracy of cognitive function over a broad range of tasks”.
In medicine, we commonly check for anaemia. However, we much less commonly check for iron status. I do think it is important for individuals to be alert to the fact that iron deficiency in the absence of anaemia have adverse effects on health and wellbeing.
In my experience, the best test for iron levels in the body is what is known as the ’serum ferritin’. It is my experience is that ferritin levels of less than about 50 are generally associated with symptoms such as fatigue, low mental energy and low mood. As I said, women of child-rearing age are at risk of this. This is particularly true for vegetarians and vegans in my experience.
Those not wishing to stoke up on liver and red meat may wish to contemplate supplementation. Many iron supplements are not well absorbed, however. One that I find useful in practice is Floradix –a liquid form of iron that is available from most health food stores.
References:
1. Murray-Kolb LE, et al. Iron treatment normalizes cognitive functioning in young women Am J Clin Nutr, 2007;85(3): 778-787
Published August 31, 2007 . Filed under: Nutrients and Supplements, Specific conditions
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What a funny thing is serendipity. I gave blood for the first time in my 52 years about 2/3 months ago and for two weeks afterwards I dragged myself around feeling absolutely dreadful. When I went returned to the Blood Donor group this week I was advised it was probably to do with my iron levels and perhaps I should re-consider giving if it left me so completely exhausted. I have collected a number of little health blips, but with this reaction I could recollect I had done something different - I had given blood! I shall try the liquid supplement you recommend and monitor the results.
Thanks once again.
Carol Homer
August 31, 2007 @ 4:36 pm
Dr Briffa,
Excess iron is a problem for most men and post-menopausal women. I encourage men and non-menstruating women to donate blood if possible. I interpret a healthy ferritin (less heart and liver disease) to be about 50, which is the goal in individuals with hemachromatosis (or even less). Menstruating women may need additional iron but most of us do not. Would you agree?
Thanks, George
August 31, 2007 @ 4:49 pm
For years I had a low hematocrit, yet no doctor ever paid it any attention. Eventually, I was diagnosed with Chronic Fatigue Syndrome, still never a word about lacking iron. Last year I had double by-pass heart surgery, after three months I simply could not believe how devastating my exhaustion was. While mentioning this to the heart surgeons’ nurse, I was told “oh honey, all our heart patients are anaemic.” Clearly the exhaustion and depression patients suffer during the supposed recovery period were of little concern, she told me it would take 6 months to get my iron up. That is when I discovered Floradix on my own. Within a few short weeks my energy began to return without the least trace of constipation. It was well worth the expense. Thank you Dr. Briffa for mentioning it, sometimes such a simple thing makes an amazing difference. If only other physicians would stop listening to drug company hucksters and listen to what their patients are telling them.
August 31, 2007 @ 10:22 pm
I tried Floradix and it gave me bad diarrhoea. I tried taking a lesser amount than it suggested but that meant it went out of date before I’d had much.
How can you know if you need an iron supplement and can you suggest a non liquid one that’s effective?
Tiggy.
September 3, 2007 @ 10:13 pm
I am a female vegetarian and often feel very tired for no discernable reason (particularly when menstrating) so this article was fascinating. Could you offer advice on how to ensure someone gets enough iron without taking supplements? I already eat quite a lot of green vegetables and nuts so if i upped my intake of spinach and the like would that have the same effect as supplements, and, if so, what sort of amounts would I need to eat?
September 10, 2007 @ 10:52 am
hi, great to read your article. i,ve just been diagnosed with a ferritin level of 3. last year it was 4. as a nurse i understand the significance of this , however feel that to little attention is paid to iron levels / stores. very interesting article.
February 20, 2008 @ 9:18 pm
I have been feeling very tired and low for some time, I have been having tingling in my face and leg and have just had an MRI scan which I am awaiting results from. My fatigue is really getting me down now. I have just had a blood test and the level was 13 which is low I believe I just want to feel well. Please help.
March 10, 2008 @ 10:49 am
I had tingling in my face and legs and tests showed I had low calcium levels, my ferritin is below 3, my iron levels are also low, below 8.
I’m taking medication for this, but it’s slow going, although the calcium replacement worked within 24 hours and the tingling stopped.
March 12, 2008 @ 3:42 pm
So, Paula, sounds like you should have your calcium levels checked (I’m not aware of this tingling being a symptoms of low iron). More iron almost certainly would improve your energy levels (see above).
March 12, 2008 @ 3:49 pm
Karen
Thanks for that, re calcium. If you’re finding it slow going getting your iron levels up, you may think about switching to a more absorbable form of iron (if you haven’t already).
March 12, 2008 @ 3:51 pm
Very good article
April 3, 2008 @ 12:31 pm
I am 35 years old female, I am glad that I found this posting. In 2005, had an upper GI a year ago. Before the procedure I ha my blood/lab work done. On that follow up appointment they said my ferritin level was a 12. Becasue they were concern I agreed to a colonoscopy. That was fine. The GI dodctor said that I am low in iron due to heavy periods and I don’t eat enough iron. I am lucky that I don’t have high colesteral, I eat red meat, grains eat, green veggie etc… not to mention that I went on birthcontrol pills for my period.
I still always feel super tired, my memory is sporatic, I lose track of my thoughts like some one who is exhausted and over tired. I crash and sleep sometimes for 12-13 hours and wake up tired.
In the fall of 2007, I had to repeat the upper GI becasue my acid reflux medicine wasn’t working. They did more blood work. Didn’t hear anything again about it. I called followed up again . Recommended another a colonscopy after the holidays. I went to get the lab results - my ferritin was a 7 she was suggesting I had an absorption problem. She tested me for thryoid, and celiac disease which came back negitive.
My primary doctor referred me to a hemetologist and said he thinkings I may have a liver iron storage problem that I may be showing symptoms now? I can’t find information. I am a bit nervous. All the anemia sites say you need to find the cause to treat with a cure. Any thought??
April 9, 2008 @ 11:37 pm
I just recently had a CBC, Ferritin, B12 and Folate Levels checked. My ferritin level is at 29, which is within the normal range, but I feel especially bad (mainly with sore calf and arm muscles) right before I get my period. Could this be due to an iron situation. My other RBC are normal. Also, my B12 levels are 1460 (much higher than the normal range). I do regularly take the product Emergen-C which has 470% of the daily recommendation of B12.
Any thoughts?
Thanks,
Katie
April 22, 2008 @ 7:59 pm
Dear Dr Briffa,
these articles make so much sense of my experiences of fatigue which gets extreme during my period. At mid-cycle, my ferritin level was 5, so goodness knows what it drops to when I menstruate. I only had a test for iron because I asked for it and even then my GP was only concerned with anaemia which she didn’t think I had and I don’t. She and another GP in my practice prefered to prescribe anti-depressants instead for my period problems which I refused. Luckily, I had to see 3rd GP for the test results and he understood what this level meant and I’ve just started taking iron supplements. However, I did not ask what the normal range of ferritin levels are and these articles have helped me so much. Thank you. Incidentally the other GP wrote to me to say that my iron levels are “slightly low” as if it was nothing to do with how I am feeling !! Obviously she hasn’t read this research.
May 13, 2008 @ 5:39 am