Iron Deficiency Anemia: Why Am I So Tired All the Time?

You wake up in the morning, but you still don't feel rested. Climbing the stairs or exercising leaves you out of breath. You notice your heart racing. Strands of hair collect in your brush, your nails break easily, and your skin looks pale… These symptoms could point to iron deficiency anemia.

I've been dealing with iron deficiency anemia for years, and I wanted to dedicate one of my first blog posts to it. I know many people are going through the same thing, or experiencing symptoms without realizing what's behind them. It can have a serious effect on your quality of life and, if left untreated, may lead to health problems later on. So I feel it's important to share how nutrition can support you. Medication and supplements, of course, are something to discuss with your doctor.

What does iron do?

Iron has many roles in the body, but one of the most important is that it's a key part of hemoglobin. Hemoglobin carries oxygen from the lungs to cells throughout the body. When iron is low, this process can be affected, and when the body's cells don't get enough oxygen, we may feel tired and weak.

You can have enough iron circulating in your blood while your iron stores are low or depleted. Ferritin is one of the tests used to assess those stores. If your ferritin is low, your doctor will look at it alongside your other results and may recommend an iron supplement.

Your hair and nails may be trying to tell you something

Iron deficiency anemia most often shows up as fatigue and low energy. Headaches, a racing heartbeat, pale skin and shortness of breath during physical activity can also occur. Hair loss or weakened hair, changes in the nails, restless legs and cravings for ice are other possible symptoms. In more advanced cases, the nails may curve outward into a shape known as “spoon nails.”

But hair loss or brittle nails don't always mean you have iron deficiency. Before starting an iron supplement based on symptoms alone, it's important to find out whether you're actually low in iron.

What causes iron deficiency?

An important part of treatment is finding the cause, not just replacing the iron that's low. If the cause isn't identified, your iron stores may drop again, and the cycle of treatment can start all over.

Around one in three women of reproductive age worldwide has anemia, and iron deficiency is its most common cause. It's much less common in men and postmenopausal women.

Menstrual bleeding is a major cause, but it isn't the only one. Iron deficiency anemia can also develop because of:

• Conditions that interfere with absorption in the gut, such as chronic intestinal inflammation or celiac disease
• Increased iron needs during pregnancy
• Low iron intake
• Hidden bleeding in the intestines or elsewhere in the digestive tract
• Certain genetic factors

Long-term use of medicines that reduce stomach acid, such as proton pump inhibitors (PPIs), a vegetarian or vegan diet, and frequent blood donation can also increase your risk. If any of these apply to you, pay attention to possible symptoms and keep up with your medical checkups. In men and postmenopausal women, possible hidden bleeding should be taken seriously and investigated.

What should you keep in mind when it comes to food?

Eating iron-rich foods can support treatment and help prevent iron deficiency from coming back. But if you have more severe iron deficiency anemia, your doctor may recommend an iron supplement.

A few words about iron-rich foods…

Meat, poultry and fish contain more iron, and the body absorbs this type of iron more easily. That's why animal foods often have a place in meal planning for iron deficiency anemia. But that doesn't mean plant sources of iron are unimportant. Lentils, chickpeas, beans, dark leafy greens and nuts are all valuable sources of iron, especially when you pair them with the right foods.

Vitamin C helps the body absorb iron from plant foods. One simple approach is to pair beans or greens with lemon, fresh peppers, tomatoes or strawberries. A salad alongside lentils, or a squeeze of lemon over your meal, is a good start.

Do I need to take vitamin C?

Having a vitamin C-rich food with a meal that contains iron may help with iron absorption, especially when the iron comes from plant foods. But research hasn't reached a consensus that everyone taking iron medication also needs a vitamin C tablet. It's best to leave the decision about adding a high-dose vitamin C supplement to your doctor, based on your iron levels and how treatment is going.

Calcium and iron don't always get along

Calcium can reduce iron absorption. If you have iron deficiency anemia, you may want to avoid having calcium-rich foods at the same time as iron-rich foods and leave a couple of hours between them.

One of the questions I hear most often from clients is: “Does that mean I shouldn't eat dishes where iron and calcium come together, like a cheeseburger or spinach lasagna?” If you don't have iron deficiency anemia, enjoy them. And even if you do, you can still enjoy them. My clients know I'm not a fan of unnecessary restrictions. Adding vitamin C-rich foods to your cheeseburger, like tomatoes, peppers or a side salad, may partly offset calcium's effect on iron absorption. And if you eat a balanced diet and get enough iron- and calcium-rich foods at different times during the day, one meal won't throw everything off.

Here's the part that matters: food is one thing, your supplement is another. Leave at least a couple of hours between your iron supplement and calcium-rich foods. Taking iron on an empty stomach is another option, as it may help your body absorb more of it.

“Iron supplements make me feel sick. I can't take them.”

This was one of the things I struggled with for years, too. The taste and smell can be really unpleasant. After checking with your doctor or pharmacist, you could try taking your supplement about an hour before bed. But for some people, taking it at night can cause reflux or heartburn.

If treatment isn't working well or the deficiency is severe, your doctor may consider giving iron through an IV. This needs to be done in a hospital or other appropriate medical setting, because although the risk is low, allergic reactions can occur.

You could also ask your doctor about liposomal iron supplements, a newer option made possible by advances in supplement technology. Some people who experience nausea, stomach pain or constipation with traditional iron supplements may tolerate liposomal iron better. That's what finally worked for me: the problems I'd dealt with for years went away after I switched to liposomal iron. It is usually more expensive, though, and research showing that it is clearly better than standard iron supplements is limited.

If nothing else works and iron still makes you feel sick, talk to your doctor about taking it with a meal. To help with absorption, avoid calcium-rich foods at that meal and include foods rich in vitamin C. Recent research also suggests that taking iron every other day may improve absorption and reduce digestive side effects. Ask your doctor whether that could be an option for you.

Iron supplements often make stools turn black or dark green, and can change their smell. If you become constipated, adding fiber and drinking plenty of water may help. Some people get diarrhea instead. These symptoms often ease over time. If they don't, talk to your doctor about whether a different medication might suit you better.

Do I have to give up tea and coffee?

Tea and coffee can reduce iron absorption. Leaving about two hours between meals and tea or coffee may help. As with calcium, try not to take your iron supplement at the same time as the tannins and polyphenols in tea and coffee. Wait at least two hours after taking your supplement before having tea or coffee.

One important point: caffeine isn't the substance in tea and coffee that reduces iron absorption. So don't assume that switching to decaf means your iron absorption won't be affected.

What if treatment isn't working?

Your body needs copper to use iron properly. If iron treatment isn't working, your doctor may consider checking for copper deficiency. Copper deficiency isn't common, especially in people who eat a balanced diet. But zinc can interfere with copper absorption in the intestines, so taking high doses of zinc for a long time without medical guidance can lead to copper deficiency.

So you could be eating plenty of iron, absorbing it fine, and still end up low, all because of an extra zinc supplement.

Stomach acid is another part of the picture. Iron needs to pass through the acidic environment of the stomach to be absorbed. If stomach acid is low, your body may not absorb enough iron from food, and more of it may pass out in your stool. If you take a PPI or antacid, you may have trouble absorbing iron.

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If your tests show iron deficiency and your doctor is overseeing your treatment, we can work together to adjust your daily meals. Let's talk during a free 20-minute consultation.

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