Functional Medicine/Strange Case of Low Iron


QUESTION: Hi Steven,

I have a very interesting case that I can't figure out what's happening.

I have a client who had low iron in January (I don't know her iron status before that). So she started taking iron supplementation, and when she was re-tested in June, her iron was actually even lower. So her doctor prescribed her an even higher dose of iron. So she had her iron levels re-tested last week, and her iron levels were even lower than before.

Any clue as to what's happening here?

ANSWER: Hey Igor:

This does seem like an unusual case and I need to know more details before I can help.

For example, do you know what form of iron she is taking?
What is the approximate age of the client?
What is her overall health status, such as approximate BMI and body fat percent?
What are her activity levels?
Does she have anemia? Does she have any digestive or health other conditions?
What are the specific iron levels/changes in her recent test results?

Id also like to know some information about lifestyle, such as dietary patterns.
Is she vegan or vegetarian?
Is she gaining, losing or have stable weight?
Does she follow a particular dietary pattern (low-fat-high carb, Paleo, high grains, Mediterranean, etc.)?
How is her alcohol usage?
Does she take a quality multivitamin and mineral supplement?

That information can offer insight as to possible influences.



---------- FOLLOW-UP ----------


Thanks a lot for your help. Here are the answers to your questions:

- Form or iron: at first, she was taking floradix iron supplement (that's from January to June). From June to now, her doctor gave her a liquid iron, of 300 mg. I'm not sure of the exact form.

- Age: 27

- Overall health status: pretty good. BMI is about 26. Body fat percent is probably in the mid-high 20s.

- Activity: Exercises 6 days per week. 3 days of strength training (just 1 sets of 6-7 exercises, at 10-12 reps), followed by interval training (6 intervals of 30 seconds, with a 90-second rest between intervals). On her non-strength training days, she goes for a 30-60 minute walk.

- No digestive or other health issues that she is aware of.

- On Nov. 25, her ferritin was 31 (before she was taking any iron). Then, on Jan. 22, her ferritin was 41. On June 28, her ferritin was 15.

- On Nov. 25, hemoglobin was 121, on Jan. 22, it was 125, on June 28 (after taking Floradix iron since January), it was 116, and last week (after taking a high-dose iron supplement), it was 108.

- She's not a vegan or vegetarian

- Weight is stable. Which is frustrating, because her entire goal is weight loss.

- She follows the "proper plate." Half of her plate is non-starchy veggies, a quarter of her plate is meat, fish or seafood, and the remaining quarter is starches.

- Alcohol use is minimal. Less than 1 glass per week.

- Yes, she's taking a good multi. Similar to Multigenics by Metagenics.

I'd love to hear your insights/thoughts.

ANSWER: Thanks for the info. One thing I should have caught is that you are both in Canada? So for the lab values, I need to know the reference ranges too (they vary per country and different testing labs also have different testing ranges and result averages).

Based on my initial review and some checking, she potentially looked low for ferritin but possibly within a low-normal range (are her results in ng/mL?), but dropped lower after the new supplement.

It looks possible/probable that she has a problem absorbing the new supplement efficiently and it's less effective. The Floridix is apparently combined with vitamins B and C to improve bioavailability. Indeed, vitamin C can help to improve vegetable (non-heme) forms of iron absorption. So it seems like the previous supplement worked better. Sometimes drugs or supplements are simply not a good fit for an individual. Also, has she had a serum iron test? That's our standard test in the US for most blood work.  

As she is in her late 20s, does she consider herself to have heavy menstruation? Women tend to lose significant iron during menstruation. And when was her last test done in relation to her period?

Also, has her exercise intensity either started or increased during the time her iron has dropped? If she is working up a good sweat, she is also losing iron through her sweat and her exercise. She might want to do the strength and interval training just 2X per week (like a Tuesday/Saturday schedule allowing 3 days between for recovery), and walk an extra day instead. Also, she might do better with slow-burn reps (slower pace and fewer reps, focusing on good form). Here is one site with information about activity and iron loss:

To me, it does seem like she might be pushing herself too hard, especially if she wasn't exercising on a regular bases previously. Her BMI and body fat are about average (women tend to have higher values). She should also realize that as she builds muscle, she can appear to gain weight but she will be losing body fat. So I never use BMI alone, athletes can look high when they have 5 or 10% body fat!

Her issues with iron levels are a signal that her routines need tweaking. She probably needs to increase her meat intake as well (heme iron in meats are the most bioavailable).


---------- FOLLOW-UP ----------


That's right, we're both in Canada. The units for ferritin are mcg/L. The reference range is 12-105.

She's only had a serum iron test in January, and the iron was 6 umol/L. The reference range is 6-27 umol/L.

In regards to the two questions of heavy menstruation, and when the test was done relative to her period, unfortunately I don't have the answers to those questions.

Her exercise intensity was actually pretty constant throughout the last 5 or so years.

In regards to body composition, yes, you're right. Although her weight is stable, her waist circumference is down nearly 4 inches, and skinfolds are much lower than they used to be.

Interesting thought about reducing the strength training, and upping her cardio. Might be worth a shot.

Thanks again for your advice!


Thanks for those additional details!

So yes, she is at the low range for iron and ferritin and her lowest was shortly after she started on the new iron supplement, tested just after she started taking it. I'd definitely suggest that she return to using the supplement as her values were more comfortable above the low value.

Glad to hear that she is losing some waist/tummy fat. That's always worth celebrating and should help to lower her systemic inflammation.

Tweaking her exercise and upping her protein by about 25% (especially beef, chicken, fish, shellfish and eggs), she should be able to get those iron and ferritin values back up to a better range in a few weeks. Here are some foods that are highest in heme-iron, the most bioavailable:

  Chicken liver
  Beef liver
  Beef (chuck roast, lean ground beef)
  Turkey leg

And if you were able to read that Dr. Briffa article, he mentioned how medical forms of iron are often not very absorbable toward the end!

I think she can improve quickly, and with upping her protein, she might not need as much of the supplement. We are all so unique, our challenge is to find the right balance that supports our maximum health!  

BTW, are you helping her with her weight issues?


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Steven Carney


I can answer questions that involve nutrition, fitness and weight loss issues. I'm also able to answer questions for chronic, lifestyle-driven conditions, such as high cholesterol/triglycerides, high BP/hypertension, atherosclerosis/heart disease, systemic inflammation, arthritis, high blood sugar, obesity, etc.


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