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).
- Feeling tired, fatigue
- Poor circulation
- Feeling cold
- Pale skin
- 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.
- 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,
- h pylori,
- inflammatory foods such as gluten, dairy, sugar, processed food
- Antibiotic use
- 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!
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.
Thanks for this article; I have had low iron for a long time and go to the doctor every now and then to receive infusions. He says that my body is just not good at holding onto iron. I’m interested to find out how often you take the Floravital liquid to maintain your iron levels?
It depends on your levels. Usually twice daily around 10ml.
Due to swallowing issues I drink liquid meal suppliments & very little solid foods. My iron is low w/ saturation level of 8%. Just started iron pills. Shouldn’t the meal supplements be enough?
Without knowing what’s in your meal supplements, I can’t say. You likely need a multi-vitamin/mineral, vitamin D, and probiotic also.
I’m an 18 year old male with symptoms exactly as yours were except I can’t relax before bed and I’m always dealing with anxiety. I don’t sleep for days sometimes and even when I do sleep I never feel rested. My testosterone is 103 ng/dl and I have done a ton of blood work everything is the same as yours was. Do you think bacteria, fungus or parasites could bbs to blame? Thank you for any help I am greatful for it.
MCHC helps to estimate the hemoglobin content, abnormal value of the MCHC need to correct the hemoglobin content of the blood.
Hello, do you have any suggestions for raising ferritin without taking iron? I have alpha thalassaemia minor and my iron is normal, but my ferritin is very low. I can’t take iron unless I’m actually deficient as it builds up in vital organs. I take 1mg of folate daily together with vitamin C and B12, all prescribed. However, I have dreadfully thin hair which continues to shed, pale skin, issues with focus and concentration, brittle nails etc. The full works basically. I see a haematologist once a year. He just shrugged and said sorry, can’t do anything. I’ve obviously been like this all my life. I expected an improvement after a hysterectomy last october but nothing has changed. Ferritin went up by about 7 points and is now around 35. Any suggestions you could make would be gratefully received. Thank you.
Please include the link between iron deficiency and hemoglobinopathies. In general, inherited blood traits don’t usually lead to iron deficiency anemia. For example, I have hemoglobin C trait and alpha thalassemia and I have iron-deficiency anemia. Also a bone marrow biopsy will provide very detailed lab results. My biopsy results included the blood markers listed above; and, in addition, hypochromasia, microcytosis, anisocytosis, target Cells and tear drop cells. Take care!
I don’t know it all, but a lot. Your post is informative for those partly like me who have little knowledge about the life’s debilitating anemia. After many years of anemia, it came down to multiple myeloma suspicion. Hematologist’s appointment will get to the truth of my condition and propose a cure. I’m 70.
I wish no one ever gets to that point because it’s also depressing when you have a balanced diet, vitamins and liquid iron (MALTOFER) no coffee, black tea, alcohol, or drugs, but as much as possible outdoor exercise, and natural remedies for better sleep. (Valerian, oils like lavender).
I keep my head high, and fight the enemy.
I was wondering about your lab numbers for anemia. You said low hematocrit is an indicator, but mine is high, but my MCHC is low and my red cell distribution is high. Do these still indicate anemia?
Carrie, this might be consistent with an MTHFR mutation (affects body’s ability to detox and absorb B vitamins), but I’m not sure.
I am vegan and suffer from endometriosis, low ferrous iron, low sex drive, low progesterone, and no energy. What foods would you recommend adding in? You mention a vegan diet may not be the wisest choice? (Fyi I don’t eat much processed food. I eat very clean whole unprocessed food). Thank you for any input!!!
Hi Marla, if you have those deficiencies you definitely need to make changes to your diet, and/or you may also have gut dysfunction that may be preventing you from absorbing nutrients. If you are a vegan, you MUST take supplemental B and iron (likely zinc also) as it’s nearly impossible to get B and zinc from a vegan diet. I would recommend working with a nutritionist to help you design a diet that works for you.
Hi Mary! Your article has been very enlightening. My symptoms started with itching and hives, and anxiety/panic attacks; which sent me to a dermatologist (with no answers) that led me to an allergist. The allergist determined my symptoms were not from allergies but possibly an autoimmune disorder. He then ordered bloodwork, which showed : iron level of 14, transferrin 310, iron saturation 5, ferritin 5, total bilirubin.3, bilirubin direct <0.1, alkaline phosphatase 95, AST 16, ALT(SGPT) 18, albumin 4.3, total protein 7.7, MCH 26.4, RDW 17.4
In turn the allergist sent me back to pcp to get my iron up. He had previously put me on Effexor 37.5mg for my anxiety and I have been taking an Allegra everyday to keep my itching and hives under control, and now having to take ferrous sulfate (iron) 325mg 3 times a day. Along with a stool softener.
Along with the prescription brought me to a GI doctor. She performed a colonoscopy which showed an inflamed small intestine and she did take 3 biopsy’s. The pictures of my colon also looked yellow in color instead of a pinkish/redish color??? I’m currently awaiting my follow up from the GI, but she said that if the biopsies came back normal then she is going to perform some more testing to help find out the root to all of this. I’m almost positive my next step is an endoscopy. She did say that if she can’t find me answers from a GI perspective, then my next step is to see a rheumatologist.
I would love some insight as to what you think!
Melony, I would recommend a stool test. I use the DSL GI MAP which you can order yourself here: https://store.directlabs.com/rs/Mvan
It will give you info about possible bacterial issues that cause leaky gut and malabsorption that can cause deficiencies. The health of the skin closely mirrors the health of the gut. You might also try a low histamine diet. The symptoms you mention are connected to histamine intolerance (another issue rooted in gut imbalance).
I would bet every one of you is riddled with heavy metals/contaminants.
I had horrific anemia which was probably brought on by sibo, h pylori, lyme.
But my BIG problem was my horrifying levels of heavy metals and super low mineral levels which.
I had NO selenium which helps with heavy metal detox. I had NONE. My mercury level was astronomical. Mercury binds up selenium. And of course i m vegan ish.
These stupid bugs would never have gotten such a grip on me had my heavy metals not been so high. Somehow they use these things to thrive.
Its all about asking the right questions.
Be well and thanks for the wonderful article
I have had two GI MAP tests – they do not show yeast, but I do think Candida is an issue (fungal toenails, yeast infections, chronic eyelid inflammation). Will taking the iron supplement just feed the candida? I have low RBC and RDW. Thank you.
ERM, the GI MAP does not do a good job of picking up yeast. If you have symptoms (which you do) + low SIgA, treat for yeast. Yes, iron does feed candida. Ideally you need a protocol to get rid of the yeast. If you don’t have low iron or ferritin on blood work, you can use liquid chlorophyll. Check out my candida masterclass: https://www.maryvancenc.com/kick-candida-masterclass/