If you’ve been feeling tired, irritable, depressed, cold, and maybe even a little short of breath lately, listen up: this post is for you! (especially if you’ve been writing it off).

I get blood work every year and recommend my clients request the same from their doctor or naturopath. Ask for a CBC with a metabolic panel, a lipid profile, iron/ferritin, vitamin D, thyroid panel, and hemoglobin A1C to start. I also request B vitamins and sex hormones. This gives you a good idea about your blood cell counts, blood sugar levels, organ function, signs of infection, possible deficiencies, and even clues about how to adjust your diet.

I recently had my yearly blood work and was shocked to see my severely low iron levels!

I had requested serum iron, ferritin (not pictured here but also low), and total iron binding capacity (TIBC). Serum iron measures the levels of iron in your blood, while ferritin measures the amount of stored iron. TIBC measures the amount of transferrin, a blood protein that transports iron from the gut to the cells that use it.

What does this mean? And more importantly, what is causing these low levels?

There are more than 400 types of anemia, which are divided into three basic groups: Anemia caused by blood loss, anemia caused by decreased or faulty red blood cell production, and anemia caused by destruction of red blood cells.

Iron deficiency anemia is the most common form, especially in children menstruating women. It means there is not enough iron in the blood (red blood cells).Your bone marrow needs iron to make hemoglobin, which is a protein molecule in the red blood cells that carries oxygen to tissues. The problem is it often goes undetected in people, as symptoms may be minor or vague. Many won’t know they have it until it shows on lab work.

Vitamin-deficiency anemia occurs when your diet lacks enough folate, vitamin B12 and other key nutrients. The body needs folate and vitamin B12 to produce enough healthy red blood cells.

Hemolytic anemia develops when the red blood cells are destroyed faster than the bone marrow can replace them. Hemolytic anemia can be inherited or develop later in life.

Sickle cell anemia is an inherited condition in which the body makes sickle-shaped red blood cells. These irregularly shaped red blood cells die prematurely, resulting in a chronic shortage of red blood cells.

Anemia may also occur as a result of chronic disease such as cancer, HIV/AIDS, rheumatoid arthritis, Crohn’s disease and other chronic inflammatory diseases.

Iron Deficiency Anemia: The Surprising Cause

I am experiencing iron deficiency anemia and will be focusing on it primarily in this post. I also had my vitamin B6 & B12 levels tested and both are over the optimal range (which is fine and good because I supplement with a B complex), so we knew it wasn’t vitamin deficiency anemia. Aside from iron deficiency, B vitamin deficiency is the other main cause of anemia I see in women in my practice.

Anemia is difficult to diagnose without a blood test because the symptoms can be pretty vague and may seem like other conditions (adrenal fatigue, depression, hypothyroidism). I’d been feeling more tired than usual (a main symptom) and incredibly irritable and depressed, 2 symptoms I wouldn’t have linked to anemia. But as soon as I began supplementing with iron, the symptoms immediately lifted (thank goodness).

Anemia Symptoms

• Feeling tired, fatigue
• Poor circulation
• Feeling cold
• Weakness
• Dizziness
• Pale skin
• Headache
• Rapid heartbeat or palpitations
• Shortness of breath
• Difficulty concentrating
• Brittle nails, hair loss

Blood Markers for Anemia

• Serum iron below 85
• Iron saturation below 20
• Low ferritin
• Low MCV (mean corpuscular volume), below 82.  MCV tells you how big your red blood cells are.  Low numbers mean small red blood cells, a sign of iron deficiency.
• Low mean corpuscular hemoglobin, MCH (below 27) and low MCHC (below 32).
• Low hemoglobin & hematocrit
• High TIBC

Most doctors, when they see low iron, will send you packing with iron pills. While this will make you feel better (soooo much better) and is necessary to bring up low levels, it’s not addressing the underlying cause. So, the big question:

What causes iron deficiency anemia?

• Dietary insufficiency: vegetarian or vegan diets, insufficient intake of iron-rich foods
• Heavy menstrual cycles
• Blood loss from internal bleeding (ulcers, GI bleeding)
• Pregnancy (iron needs increase)
• Inflammation in the digestive tract, preventing absorption of nutrients. Present in celiac or with other GI infections such as candida, parasites, SIBO, h pylori.
• Hypothyroidism
• Insufficient production of stomach acid, which prevents iron absorption

Diet is the first place to look, and obviously I have my diet pretty well curated. I eat plenty of leafy greens and supplement with B vitamins. It is true, however, that I’m not a huge fan of red meat. I prefer lighter proteins such as chicken and fish. Those do provide some iron, and I get plenty of protein and iron-rich foods. So what gives?

Anemia: The Surprising Cause

First off, my thyroid levels aren’t ideal. My TSH at this time was 3.5, and the ideal is around 1.5. I’ve been working on correcting my hypothyroidism, and this indicates I need some adjustments. Secondly, when your thyroid is sluggish, everything slows down, including digestion and production of HCl, stomach acid that helps you break down food for absorption. Lightbulb moment: I’d noticed increasingly nagging digestive symptoms such as a lot of belching and fullness after meals, an indication that digestion is slow and not moving through your intestinal track quickly enough. I ran a stool test on myself, and lo and behold: H pylori showed up, and that can be a huge cause of anemia.

So in my case, h pylori, sluggish thyroid, and poor stomach acid/digestive function (from the h pylori) were causing my anemia. I don’t have heavy periods, so I knew that wasn’t a cause. Low iron stores also slow the conversion of T4 to T3, the main thyroid hormone in your body, and that further worsens hypothyroidism.

If you think about it, you’re only as good as what you digest and absorb. You could have the perfect diet, but if you’re not breaking down and absorbing everything you’re eating, deficiencies will develop.

Did your doctor ever tell you poor digestion is a main cause of anemia? 

With intestinal inflammation, you won’t be absorbing nutrients from your food. What causes that inflammation?

• Dysbiosis (when your bad bacteria outweigh your good),
• candida overgrowth,
• parasites,
• h pylori,
• SIBO
• inflammatory foods such as gluten, dairy, sugar, processed food
• Antibiotic use
• Alcohol
• OTC drugs such as acid blockers and NSAIDs.

The resulting inflammation also affects HCl (stomach acid) production, meaning your ability to break down food is compromised, and the inflammation prevents nutrients from being properly absorbed.

How to Correct Iron Deficiency Anemia

• Diet: are you getting enough iron rich foods (liver, leafy greens/spinach, grass fed meat, beans/lentils, oysters?) Are you eating enough in general? Are you vegetarian/vegan? Maybe time to rethink that. Note that animal proteins contain the most absorbable forms of iron. Liver and oysters are the best sources of iron. Hmmmmm, no wonder I crave oysters.
• Take a digestive enzyme to help your body break down and absorb food. I started taking this one and all my nagging digestive symptoms disappeared.
• Take an iron supplement to bring your levels back up. Ferrous glycinate or iron bysglycinate are the best, most absorbable and non-constipating forms. Once your levels are back up, I like FloraVital liquid to keep them up. If you don’t like liver, you can take liver capsules.
• Get stool testing to see if there are GI issues causing inflammation and malabsorption. You can order your own labwork here. I use and highly recommend the GI MAP stool test.
• Address female hormone issues: if you are soaking a tampon every 2 hours or more often, you are bleeding too heavily. This can occur because of fibroids, hypothyroid, estrogen dominance, endometriosis, and more. Talk to your doctor.
• Eat vitamin C rich foods with your iron rich foods (or supplement) to increase absorption.
• Limit coffee or tea before an iron rich meal. Both can inhibit iron absorption.
• Get your thyroid tested. (you can order a thyroid panel here).

If you have iron deficient anemia, the cause may be more complex than just not getting enough iron in your diet. If you’re eating enough animal protein, you likely have some malabsorption issues present from digestive issues so you’re not absorbing all the nutrients in your food. Or you may not be secreting enough stomach acid to break down food. Request a stool test to check gut function (I use the GI MAP which you can order here), and take a look at your blood work to see if other deficiencies are present: B vitamins, hypothyroid. Nothing in the body malfunctions in isolation!

Resources

Hypothyroid & low iron

Mary Vance, NC

Mary Vance is a Certified Nutrition Consultant and author specializing in digestive health. She combines a science-based approach with natural therapies to rebalance the body. In addition to her 1:1 coaching, she offers courses to help you heal your gut and improve your health. Mary lives in San Francisco and Lake Tahoe in Northern California. Read more about her coaching practice here and her background here.