Iron Supplementation

Medical Q&A [Moderated]
1

Hi Austin,

After seeing your recent post on iron being underrated I have the following question:

A few months back I started taking iron supplements due to experiencing the following anaemia-like symptoms:

  • Pale skin
  • Elevated heart rate
  • Heart palpitations
  • Swollen/sore tongue
  • Shortness of breath during exercise, even at levels such as walking upstairs
  • Ridged nails
  • Difficulty focusing

I am a 28 year old otherwise healthy and active male and have been on a vegan diet for around 4 years.

After ~ 8 weeks of taking the supplements I had a blood test (end of August) and the results were as follows:

  • Serum iron - 47 umol/L
  • Serum ferritin - 70.9 ug/L
  • Serum transferrin - 2.61 g/L
  • Saturation iron binding capacity - 79%

Because the serum iron and saturation iron binding capacity were above the normal range, I was asked to stop taking the supplements and repeat the test at a later date.

After stopping supplementation for ~ 6 weeks I had another test (mid October) and the results were:

  • Serum iron - 18 umol/L
  • Serum ferritin - 54 ug/L
  • Serum transferrin - 2.42 g/L
  • Saturation iron binding capacity - 33%

As these results are within normal range for the NHS I haven’t taken the supplements since. I am still experiencing the symptoms mentioned above, though the elevated heart rate, palpitations and shortness of breath are less frequent.

If you were treating a patient who had these blood test results, would you recommend they supplement with iron?

Thanks

2

No; I would not have recommended iron supplementation in the first place in a male patient, prior to blood testing to confirm iron deficiency based on a ferritin level. Note that serum iron is a much less useful test here.

The issue is that while the symptoms you report may be due to iron deficiency, they are not specific for it, meaning that they may be caused by many other issues that should be evaluated up-front as well, prior to supplementation.

This includes things like measuring a complete blood count, vitamin B12 level/methylmalonic acid (especially for someone on a vegan diet), thyroid function testing, and potentially several other things depending on your clinical evaluation.

3

Thanks for your response.

I know I shouldn’t have supplemented without evidence of deficiency, but I knew it was only for a few weeks before a test was completed. I wasn’t aware that it could have skewed results in such a short time period.

The first test was a full blood test which checked all of the things you mentioned. The second test was only a retest of iron as it was elevated and they wanted to check it was only high due to supplementation and not another cause.

B12 was similar to Iron in that I was supplementing for around 8 weeks prior to the first test.

I had the following results in the first test, among other results:

  • B12 - 975 ng/L
  • Thyroid function (Serum TSH) 1.5 mu/L
  • Haemoglobin - 162 g/L

With these results being normal (except elevated B12 due to supplementation), would your opinion change?

Thanks

4

I see. I would not pay much attention to serum iron measures here.

The ferritin dipping down to 54 after a few weeks off of supplementation is interesting. While not technically deficient at that level, it is lower than I’d expect for a 28 year old male. I’d be curious whether you felt notable improvements after supplementing up to the 70.9 level, which have worsened again since stopping supplementation.

To me, the bigger question is not just whether you need supplementation, but rather whether you require any further evaluation for the cause. While it may be related to your dietary intake, depending on how you have your vegan diet set up, this may not be an entirely safe assumption.

For example, celiac disease is a known and underdiagnosed cause of iron deficiency (due to malabsorption), which doesn’t always present with obvious gastrointestinal symptoms after gluten exposure. There are other potential causes of impaired iron absorption or occult iron/blood loss that often need to be evaluated when a patient has iron deficiency without an obvious source like heavy menstrual bleeding in women.

Again, you have not yet met formal “iron deficiency” criteria, which may make some of this difficult to access in the NHS until/unless you have documented deficiency. It’s unfortunately impossible to know in retrospect whether the supplementation you took masked any of this, or whether it’s unrelated, until repeat measurements are taken in the future.

1 Like
5

The heart related issues were the ones that I was mainly concerned about and they haven’t been as bad as they were around the time I started supplementing since. I still get the palpitations/flutters but not as frequently and the elevated heart rate seems to have improved. (I didn’t mention above that I continued B12 supplementation after the second test).

As for my diet, it isn’t as well planned as it should be being vegan and I don’t really eat any food sources rich in Iron, though I didn’t really before I was vegan. It was rare that I ate red meat.

I was referred for a blood test before I was vegan for symptoms like fatigue and cold hands and feet but never got it done due to fear of needles.

Earlier this year I found out I have a hiatus hernia. Could this affect the absorption of Iron?

You’re a legend for taking the time btw :+1:t3:

6

No problem, makes sense.

And no, a hiatal hernia would not impact nutrient absorption.