Do you feel tired all the time? Are you lacking energy and losing your hair despite taking iron supplements religiously? You may be among the estimated one in three people who cannot absorb iron orally – and your gut microbiome could be to blame.
Dr Andrew Klein, a consultant anaesthetist at the Royal Papworth Hospital in Cambridge with a special interest in anaemia management and iron replacement therapy, explains: “Issues with iron absorption can be a consequence of having a sensitive, unhealthy or damaged gut microbiome. Through drinking too much alcohol, eating too many processed foods, not eating healthily, having certain conditions like IBS or the repeated use of antibiotics, the gut microbiome becomes damaged and doesn’t have enough absorptive surfaces – fronds and villi – to adequately absorb iron and other micronutrients like B vitamins.
“In most people with this issue, it makes absorption of iron supplements difficult, if not impossible,” he adds. “That said, there may also be some crossover between those who struggle to tolerate iron tablets and those who cannot absorb it efficiently from their food as well.”
The exhausting reality of living with iron deficiency
When Catherine Ford, 32, began to struggle with crippling tiredness that required her to take naps just to make it through the day, she knew something wasn’t right. “I’d sleep for nine or 10 hours every night but never felt rested,” the administrative worker from Cambridge says. “That obviously isn’t normal for a young person.”
Not long after, her hair began falling out in handfuls. “I was really scared,” she admits. “I was brushing my hair as usual after a shower one day and noticed loads of hair on the brush.” When she tied it into a ponytail she realised the volume was hugely reduced, and she soon noticed gaps in her parting and crown as well. “It felt awful – a young woman shouldn’t lose that much hair for no reason.”
The tiredness wasn’t new for Catherine. She had struggled with exhaustion for most of her adult life, often cancelling plans at the last minute because she felt too tired. However, her issues worsened earlier this year when she was travelling solo around Indonesia. “I had so many fun plans and things I wanted to do, but I just didn’t have any energy,” she says. “I ended up spending my days inside, worrying and researching what might be the problem.”
After Sarah Green, a drum teacher from Cambridge, gave birth to twins in 2017, a concerned nurse stopped her in the hospital hallway to suggest she had her iron levels checked. “‘You look ever so pale,’ she told me,” Sarah, 43, recalls. “And then she added, ‘you must be anaemic’.”
The encounter took Sarah by surprise as she had “always been quite pale and never thought anything of it.” She heeded the nurse’s advice and asked after the results of her latest blood test. However her haemoglobin levels appeared to be normal, so she ploughed on.
Despite having moments when she couldn’t cope and felt “pathetic”, Sarah dismissed her symptoms as part and parcel of new motherhood. “However, it got to the point where I was struggling to function and couldn’t climb a flight of stairs without feeling exhausted, so I went to my GP and asked for another blood test,” she says. A text from the surgery informed her that her iron levels were normal – no further action required.
The same pattern continued for a number of years. One morning, Sarah noticed the extra effort was showing on her smartwatch as she took her drum kit into school. “I remember just feeling exhausted, and my Fitbit had clocked it as 25 active minutes instead of the usual five because I was so out of breath,” Sarah says. “All I was doing was taking my equipment into school!”
It is a familiar story across the UK. Iron is an essential mineral for transporting oxygen throughout the body by making haemoglobin, a protein in red blood cells. We cannot produce it so must consume enough from the foods we eat. Common symptoms of an iron deficiency include tiredness, pale skin, heart palpitations and spells of dizziness.
Iron deficiency is a particular problem for women, who are more prone to the issue due to heavy periods and pregnancy. “Women have to absorb a lot more iron than men, so when their stomach is a little bit sensitive or unhealthy, then they just can’t get enough,” Dr Klein explains.
Whilst men need to absorb one or two milligrams of dietary iron from food per day, women need at least three or four. If their periods are heavy, this rises to five or six and, if they are pregnant, then 10 to 12 milligrams is the optimal amount. This means they often cannot keep up with what their body needs, especially if they eat a vegan or vegetarian diet, which contains less iron and in a form which is more difficult to absorb (non-heme iron).
Both Catherine and Sarah sought advice from their local GPs. Catherine’s doctor identified that her iron levels were low and prescribed her with “incredibly strong” liquid iron. She was given a few months’ supply, but quickly found that she couldn’t tolerate them and suffered from severe stomach ache and nausea. Meanwhile, Sarah asked her GP for another blood test but the appointment ended with the same text: Your test results were normal, no further action is required.
Acceptable, not optimal, iron levels
If your blood levels of serum ferritin (a protein that stores iron) are between 15 and 300 micrograms per litre, then you are likely to fall in the “normal” range. However, the ideal levels are actually between 200 to 250 for men and 50 to 100 for women, according to Dr Klein, who also runs Cambridge Iron and B12, a private clinic specialising in treating patients with iron and B12 deficiency. “It means there is a massive difference between living with low levels of iron that cause symptoms, and what the NHS actually classes as deficiency.”
After Sarah received the familiar text from her GP informing her no further action was required, she decided to login and check her results for the first time. “I saw that my ferritin level was 19, which was incredibly close to the bottom boundary,” she says. “It made me realise that even though my results were acceptable, they clearly weren’t optimal.”
With little support from her GP, Sarah decided to try boosting her iron levels herself. “I’m a meat eater and don’t avoid red meat so there wasn’t ever a sustained lack of iron in my diet,” she says. So instead of changing her diet, Sarah bought a packet of over-the-counter iron tablets. “After just a few days, I was experiencing severe stomach cramps and awful gastritis symptoms. It was so uncomfortable and I couldn’t continue,” she recalls.
‘Life-changing’ intravenous iron infusions
Both Sarah and Catherine discovered Dr Klein’s clinic after hearing him speaking about iron deficiency on a podcast. “By this point I felt really horrible,” Catherine says. “The hair loss was really scary, I had awful anxiety and heart palpitations, and a level of fatigue that I’d never experienced before.” Her serum ferritin level was 10 micrograms per litre, which Dr Klein classifies as a severe deficiency. “He told me I should have been treated years ago,” she recalls. “It felt validating after dealing with these problems for so long.”
Tests revealed that Catherine wasn’t absorbing oral iron, whilst Sarah’s gastritis symptoms suggested a similar problem, so Dr Klein prescribed intravenous infusions. These deliver iron directly into the patient’s vein to rapidly increase their levels. The effects of an iron infusion kick in after a few weeks, and can last for several years.
“Within a week, I had comments from my colleagues on how much healthier I looked,” Sarah recalls. “One asked if I’d been on holiday because my skin looked so tanned.” Sarah soon had the energy to cook dinner from scratch after work, rather crashing with exhaustion each evening.
It was a similar experience for Catherine. Within weeks, her hair started to regrow and her severe bouts of exhaustion vanished. “The infusion was so quick – only 20 minutes – and my symptoms were gone almost immediately,” she says.
While an iron infusion is the quick and obvious fix for those suffering with severe symptoms, they are incredibly expensive and, as such, rarely offered on the NHS.
“Iron deficiency is a massive health problem, especially for women who are trying to juggle work, their relationships and family with awful symptoms like exhaustion, anxiety and hair loss. It can be really dreadful,” Dr Klein says. However, the NHS simply cannot prioritise iron infusions for every woman who cannot absorb it orally as that would be a massive cost within its already stretched budget, he adds.
The infusions are expensive, costing between £300 and almost £1000, including consultation fees, at clinics across the UK, but Dr Klein says many of his patients are frustrated. “They feel unwell and have had to take time off work, and all of this is made worse by the fact they can’t absorb oral iron and it’s made them feel even more ill,” he explains.
That was certainly the case for Sarah and Catherine. “I’m incredibly grateful for what the NHS has done for me in the past, but what I’ve realised is that, whilst they will hopefully keep me alive, they won’t necessarily help me to thrive,” Sarah reflects. “Going to Dr Klein was the nuclear option, but I’m so glad I did it rather than waiting until I was ill enough for the NHS to agree there was actually a problem.”
Eight signs you might have an iron deficiency
Iron deficiency is a common condition where the body lacks sufficient iron to produce haemoglobin, the protein in red blood cells that carries oxygen to tissues. It is often caused by chronic blood loss, insufficient dietary intake or poor absorption.
If you do not have enough haemoglobin, then your organs and tissues won’t receive as much oxygen as they should, resulting in a range of symptoms. According to Dr Klein these include:
1. Feeling tired all the time.
2. Brain fog.
3. Hair falling out and thinning/balding patches.
4. Restless legs.
5. Aching legs, even after light exercise.
6. Feeling out of breath very easily and heart palpitations.
7. Brittle nails and dry skin.
8. Headaches.