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
hello dr bariffa,
Thanks for your article.
As a child, teenager and young adult i have been very active, though my hemoglbin has always been very low between 7-8:50. and my BP has been very very low. At age 23 i was diagnosed with hypothyroidism, thinking back some of my symptoms had started around 16-17. Presently ‘m taking 300 mcg of synthyroid. from late 80’s to early 90s, i was feeling so low, fatigued,the best i could describe how horrible i felt ” how a sugarcane must feel after going through the juicer!”
In 1995 i came across a small book in which adr had said that if one has one auto -immune problem, the probability of multiple autoimmune problem increase. The book suggest B-12 deficiency, as i was feeling tingling sensation on my legs and , lost sensations in my left toe,plus was having terrible leg cramps.
i mentioned this to my dr and finally after 7 yrs, she listened to me and ordered some test, called me later and said that u have severe B 12 deficiency and suggested B 12 shots , which i have been taking since Dec 1995 and i felt a lot better, even the sensation in my toe came back
I felt better but not 100 percent….
around 6 yr back i was having mild stomach pain, my doctor was so confident that i had bleeding ulcer, so he put me through, upper and lower scope and both came out very clean and nice.
my husband , who is a pediatrician felt that the pain seemed more like gall stone and eventually, it was discovered that i had 3 stones.
i avoided oily food and was ok
Around a yr and half ago i again started having constant pain so was suggested operation, but as i mentioned my heamoglobin was around 7:50 , so i was told either i can have transfusion or take 12 treatment of iron infusion.
while taking the 2nd infusion my BP went very high. i mentioned this to the nurse and she called the doctor but he brushed it of saying that the iron infusion had nothing to do with my high BP. and arythemia
I came home and my husband looked it up in the medical books and it clearly said that though in 30% pts , it lower the BP , but in 12 % of pts it can make it go up, ut the hematologiost wouldn’t hear me out, finally i told him where to look and i guess i offended him. i went to a friend, who is a cardiologist, because of the arythemia, the surgeon wouldn’t do the surgery any way. the cardiologist suggest that i should have cardiccatherization to rule out blockage, which i did and there was no blockage. luckily i don’t have cholesterol problem.
finally coming to my recent problem….. about 2:30 months ago, i started feeling extremely fatigued , out of breath, BP went up and was weezing. I had never felt so listless ever.
went to see the cardiologist and he did EKG and said that your heart is working at 35% less out of 60 and if u were a little older , i would have admitted you right away.( my DOB is 13th jan “59).
I was in Atrial fibrillation, though since then i am back in sinus rythem but do feel out of breath and very tired, but not so tired as i as feeling 2-3 months ago. He put me on warffin 10 mg, cardizam 250, benecar20 mg and toporol.
within last one month i have had received 5 letters from the drug company saying that if u took iron in past yr u are at risk for iron overload and u are at risk for heart and liver failure and by the time these symtoms appear , its often too late etc, etc
Initially i ignored these letters , then my husband came across one and said may be u should go for liver functions and ferritin level.
please help… i had gone for ferritin level on the 8th of april and the lab messed up and forgot to do ferritin level, and when i asked my dr about it ” if the ferritin level was okay..he said yes it was fine, and today i found out that the lab had not even done level, so i wonder what he was looking at when he said that it was fine.
who do u trust?
i am very upset… i feel let down, can u please help?
thanks in advance,
c.sobti
May 28, 2008 @ 4:32 am
I live in the UK. I am 43 years old. I have been suffering with extreme fatigue, short term memory loss and lack of concentration. I just got my blood results and I was told that it was 5 - the norm being 3 - 20 (not sure what the measurements were). She told me I was fine but told me she thought I was depressed and has prescribed me pills for this. I really don’t feel depressed, just down at having no energy. I started taking 14mg iron supplement today as I really do feel that my iron is low. My periods are extremely heavy. Please could you advise on the best course of action. Thankyou
July 1, 2008 @ 2:50 pm
hi all,
i have been suffering low ferritin for over a year i am a 22 year old female who has also been diagnosed with CFS.
i am constantly tired and sleep most of the day, the fatigue leaves me lifeless some days. my ferritin has averaged at about 4 but when i collected my result 2day from hemotology was concluded at a 7. i may need a iron infusion i am waiting on a phonecall from hospital?
July 7, 2008 @ 4:17 pm
Hi, I’m looking for a case study for an article on iron-deficiency anaemia for a Boots publication. I need to find a 20-something female (not a mum) who has been to their GP and been told to take iron tablets. I would interview you over email and we’d need to run a picture of you. If you’re interested, please let me know asap! Thanks. claire.atherton@gmail.com
July 17, 2008 @ 3:19 pm
Oh….well I guess I’m in trouble. I got my blood test back yesterday with the test for Ferritin and I was quite shocked at the extent of my iron deficiency. So I went on the internet to do some searching.
It states on my report that 20-291 ug/l is the range, while I tested 3. It’s true that I felt very tired and lethargic about three or four years ago, and that I took iron tablets, but since then I’ve felt much better and not at all as tired as before. After reading your article, perhaps I should go and buy those iron supplements now and not wait until the weekend.
When I asked for other possible causes aside from blood loss for my severe iron deficiency, the doctor ignored me and insisted that I eat more red meat and that the cause was most definitely blood loss. I’m not a vegetarian, and I eat red meat at least twice a week, so I wanted more information, eg. would it be malabsorption or something else? But instead I was brushed off. Maybe the doctor was oversimplifying things?
July 30, 2008 @ 6:48 am
excellent information
August 2, 2008 @ 5:14 pm
excellent information.One of my responsibility is taking care of the anemic blood donors,especially menstuating female blood donors.Many of them have serum ferritin lower than 15 ng/ml,that mean their iron store equivalent to zero.Trying to raise up theiriron store,not merely hemoglobin,I wonder what would be the optimum level of serum ferritin for them,for optimum health.Would serum ferritin level between 50-100 ng/ml be the optimum for optimum health.As we know,if not all,high serum ferritin is not benefit for optimum health,especially for cardiac health.
August 2, 2008 @ 5:52 pm
Hi I have been exhausted for months, I work for a GP and also have a metal heart valve which means taking warfarin which seems to get blamed for most of my health worries, anyway he was on holiday and i saw the Locum, he tested not just my FBC but ferritin too, my Hb was 10 and my ferritin level is 3.4!no wonder I’m so exhausted, when I’m not working I’m sleeping, on iron therapy now but locum wants to look further at causes.
My advice is - its sometimes better to have a fresh perspective as my GP and boss had obviously become a little complacent and not given my earlier results the attention they deserved (in his defecnce he does has 1000s of patients and is generally a great GP) and assumed that the problem revolves around my warfarin therapy for my metal heart valve.
August 27, 2008 @ 12:35 pm
I have been low in iron for years and iron tabs always made me sick. Stumbled upon a great product called Spatone. 100% natural iron supplement. Worked miracles for me. I used to suffer from heart palpatations, depression and extreme tiredness and heavy periods. Thanks to Spatone i no longer have palpatations and my periods have been reduced to half a day! Iron levels were 3 and as of today they are at 24. Takes a while to build levels back up but try this product and stick with it. I have experienced no side effects and swear by this stuff. Ferritin levels still low was 3 now 6. Slowly moving up, trying to find out why they don’t move much. Any thoughts?
September 29, 2008 @ 10:17 am
Dear Dr. Briffa,
Hi, I am a female, just turned 50. I have been going to my GP regularly since Jan 08 with stomach problems - constant loose motions 6 times a day and low ferritin of 10. I am always totally exhausted. I get up in the morning, get my husband off to work, eat a meat rich breakfast, then go to sleep for several hours. I have no stamina during my waking hours. I run (Or try to!) a small farm and it is now becoming impossible. For the record my periods are quite light. I feel that I am not absorbing iron from my diet.
I am now paying to have a colonoscopy (it is criminal that I have to pay). Iron supplements make me constipated, as in I need colonic irrigation every week to empty my bowels. I am seeing my doctor again this afternoon. I don’t want alternative iron supplements, or iron injections. I desperately need a quicker fix. Am I within my rights after losing nearly all year to exhaustion, asking for a blood transfusion, and would this help. Any advice would be so appreciated.
September 29, 2008 @ 1:36 pm
just read your article what an eye opener.Last year feeling extremly tired midwives at work suggested having my blood taken to check my thyroid Went to see my gp who asked if i was feeling depressed at all or low i replyed i was feeling low and that was why i wanted my thyroid checked, she decided to do this and an FBC.checking my results at work i was shocked to see my HB was 8.4 depressed my foot more like knackered.Revisited my gp who gave me a prescription for iron supplements but wanted my ferritin level checked first this came back as 4.After a discussion with the gp she put it down to heavy periods even though i told her this was not a problem.Eventually my HB returned to 10.9.Then last week feeling tired again had my blood taken at work my HB has dropped to 10 again and have now had a letter wanting to discuss my mild anaemia.i have suffered with very sluggish bowel on and off for few years.any suggestions.
October 14, 2008 @ 4:15 am
I am a Crohn’s sufferer and so naturally my iron absorption is not great. Since having children I have always been slighty anaemic and have often suffered with exhaustion, I always put this down to bringing up a family and the Crohn’s disease. However my GP recently requested a full blood test and discovered that my Ferritin levels were 3.6!! My GP said he had never seen a count as low and that and that I must have been functioning on air! He prescribed Ferrous Sulphate tablets to be taken 3 times a day, but they do tend to upset my tum because of the Crohn’s disease ,So I am going to try a liquid supplement from the health shop. My levels are now at 16 which is an improvement, but no where near what they should be! I eat a fairly good diet and so I believe that it could be the medication I take, Mesren, for the Crohn’s disease that is partly responsible for my low Ferritin levels….any suggestions from anybody else who is a Crohns sufferer welcome!
October 16, 2008 @ 1:22 pm
My daughter has been going to school but feeling very sick & not getting better recently. Just found out her Ferritin level is 1. Have been reading everyone else’s comments and wondering how she has functioned as long as she has. Dr prescribed oral iron 3x per day but this could take forever to get to normal, and her schooling is really going to suffer. Just wondering if any of these iron supplements mentioned such as Floradix or Spatone are available anywhere in Canada or USA?? She needs something quicker than something that will take months to help her. Any help greatly appreciated.
October 24, 2008 @ 8:27 am
Hi, I have been diagnosed with CFS/ME and had a Ferritin level of 8, I was retested 3 months later, have been taking Iron suppliment and it has only gone up to 33 which is in the normal level but with the high level of Ferrous fumerate that I’m taking I was expecting a huge increase in my Iron level. My docter wants me to stop my tablets for 6 weeks and have another blood test, I eat normally actually very healthily, fruit, veg, meat, fish, have even taken to drinking Guiness to get Iron (recommended by my docter). What reason could there be for my body not to absore Iron? Any thoughts would be greatly appreciated as I do not want to go backwards with my health
November 3, 2008 @ 3:27 pm
Nancy, Ask your doctor about iron infusions, it is much faster, but expensive if your insurance won’t pay for it. Also, you will probably need to see a specialist in order to get it.
I was first diagnosed with anemia when I was 12 years old, before I even started menstrating. I have had trouble with fatigue, low mood, and bad memory most of my life. I wasn’t diagnosed with low ferritin until I was 37 and it was at 2. I still struggle because I hate taking pills. I’m so used to feeling bad I can’t imagine how it would feel to have a ferritin level of 50 (as suggested in one of the posts).
I found a blog at http://www.mothering.com/discussions/showthread.php?t=336058 that talked about getting Floradix at health food stores and The Vitamin Shoppe. It also mentioned something called “Iron and Herbs,” among others, and chlorophyll (???) I will have to do more research about these claims.
After checking the internet, I found out that you can ordern Floradix online through The Viamin Shoppe (vitaminshoppe.com).
I am not endorsing this product or Vitamin Shoppe, only going by what I have read on posts. Apparently it tastes better if you drink it with orange juice.
From experience I know that this is not something you can get rid of once and forget about, it is an ongoing routine that one must get in the habit of doing and to continually get blood work done. Try not to let insurance lapse otherwise it will be seen and a preexisting condition and your new insurance may not pay for the blood work (yes, again from experience).
Good luck!
November 10, 2008 @ 9:55 pm
Forgot to mention…
Vitamin C helps with the absorbtion of iron. My doc recommended taking my iron pills with orange juice. when I don’t have any I take a Vit C tablet.
Check with your doctor but taking folic acid, B6, and B12 may be good too. (all of which are in regular multivitamin tabs).
November 10, 2008 @ 10:38 pm