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Iron
by Jack Norris, RD | Last updated: May 2013

Contents
Summary Iron Deficiency and Anemia Meat Iron vs. Plant Iron Table 1: Iron Amounts in Plant Foods Iron Deficiency in Vegetarians Low Iron Stores: Not Necessarily Unhealthy Hemochromatosis Celiac Disease Proton Pump Inhibitors Recommendations References

Summary
If you think your iron stores might be low, you can increase iron absorption by: Adding a source of vitamin C at meals. Avoiding tea and coffee at meals. Increasing legume (peanuts, beans, lentils, peas) intake. Cooking foods (especially water based acidic foods like tomato sauce) in cast iron skillets. If you think you might have iron deficiency anemia, see a doctor to find out. Supplements are available for people diagnosed with deficiency.

Functions of Iron
The major functions of iron are: Energy Production The majority of iron in the body is involved in energy production. The largest fraction is found in the hemoglobin of red blood cells and is necessary for oxygen transport throughout the body. Iron also serves as part of myoglobin for oxygen supply to muscle. Iron is involved in the electron transport system, is part of an important energy-producing enzyme, NADH dehydrogenase. Immunity Iron has pro-oxidation properties used by the immune system to destroy bacteria. Required for DNA synthesis

Iron Deficiency
Iron deficiency is the most common nutrient deficiency in the U.S. There are two stages:

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Iron deficiency anemia (IDA) - typically measured by a hemoglobin of less than 120 g/l Many iron deficiency symptoms are related to tissue oxygen deprivation: fatigue, rapid heart rate, palpitations, rapid breathing on exertion, and increased lactic acid production. IDA symptoms include pale skin, brittle fingernails, (koilonychia (spoon-shaped fingernails where the outer edges are raised), weakness, loss of appetite, apathy, hair loss. impaired immunity, angular stomatitis (irritation and fissuring in the corners of the lips), glossitis (inflammation of the tongue), chronic gastritis, pica, and abnormal temperature regulation. Many of these are symptoms of other nutritional deficiencies and diseases and therefore only a medical doctor can properly diagnose IDA. It is relatively inexpensive to have your iron levels tested by a doctor. Iron is transported throughout the body as part of the transferrin protein and is stored as ferritin. The earliest stage of iron deficiency occurs when stores are depleted, characterized by a drop in serum ferritin levels and an increase in total iron binding capacity (incomplete saturation of transferrin). Serum ferritin levels below 12 g/l are associated with complete depletion of storage iron. At this stage, normal red blood cell formation is impaired, but not enough to cause a measurable anemia. IDA is characterized by small red blood cells due to a lack of hemoglobin. Low values for hemoglobin concentration in blood, red blood cell count, hematocrit (the percentage, by volume, of red blood cells in whole blood), mean corpuscular volume (the size of the average red blood cell), and erythrocyte hemoglobin concentration are all potentially indicative of IDA. Because iron deficiency is not the only cause of anemia, multiple measures of iron status should be taken to determine if an anemia is truly from iron deficiency. The Centers for Disease Control (CDC) defines iron deficiency as abnormal values for any two of these parameters: serum ferritin, transferrin saturation, and free erythrocyte protoporphyrin. The CDC defines iron deficiency anemia as iron deficiency with a low hemoglobin value. Some health professionals believe in "sub-clinical iron deficiency" in which someone has blood measurements in the normal range but is still having symptoms of ID or IDA. According to the National Academy of Sciences, "The bulk of experimental and epidemiological evidence in humans suggests that functional consequences of iron deficiency (related both to anemia and tissue concentration) occur only when iron deficiency is of a severity sufficient to cause a measurable decrease in hemoglobin concentration ( 1)." However, other iron experts suggest that some people have a higher-than-average normal hemoglobin level and can suffer from IDA even though their hemoglobin is in the (presumably lower end of the) normal range. Iron is prevalent in a wide variety of plant foods, especially beans and grains. In fact, vegans' iron intakes are as high or higher than non-vegetarians. Table 1 shows the iron content of some plant foods as well as the Dietary Reference Intakes for iron. In meat, 65% of iron is bound to the heme molecule (from hemoglobin and myoglobin), which is relatively easily absorbed. The rest of the iron in meat and all iron in plants is nonheme iron (3). Non-heme iron requires being released from food components by hydrochloric acid and the digestive enzyme pepsin in the stomach (3). Non-heme iron also needs to be shuttled from the digestive tract into the bloodstream by a protein called transferrin. The phytates, found in legumes and grains, and polyphenols (including tannins found in coffee and green tea, black tea, and some herbal teas), can inhibit the absorption of plant iron. On the other hand, vitamin C is a strong enough enhancer of plant

Table 1. Iron in Plant Foods Food Broccoli Spinach Kale Collard greens Swiss chard Sweet potato Tomatoes Preparation 1/2 C chopped 1/2 C chopped 1/2 C chopped 1/2 C chopped 1/2 C chopped 1/2 C 1/2 C Serving boiled boiled boiled boiled boiled baked, w/skin cooked mg 0.52 3.2 0.59 1.1 2 0.7 0.82

Oatmeal Rice (white, long-grain, unenriched) Rice (white, long-grain, enriched) Bread whole wheat

1/2 C 1/2 C 1/2 C 1 slice

cooked cooked cooked

1 0.7 1.4 0.68

Tempeh Tofu Soymilk

3 oz 3 oz 1C

cooked

1.5 0.8 1.0 - 1.5

Edamame Kidney beans

1/2 C 1/2 C boiled

1.8 2.6

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iron and can overcome the inhibitors in plant foods. One study found that various doses of phytate reduced iron absorption by 10 to 50%. But adding 50 mg of vitamin C counteracted the phytate, and adding 150 mg of vitamin C increased iron absorption to almost 30%. Similarly, in the presence of a large dose of tannic acid, 100 mg of vitamin C increased iron absorption from 2 to 8% (13). In another study, vegetarian children with IDA and low vitamin C intakes in India were given 100 mg of vitamin C at both lunch and dinner for 60 days. They saw a drastic improvement in their anemia, with most making a full recovery (2). Researchers used 500 mg of vitamin C twice daily after meals to increase hemoglobin and serum ferritin in Indian vegetarians. They concluded that vitamin C was more effective at increasing iron status than iron supplements (12).

Pinto beans Garbanzo beans Peas green Lentils

1/2 C 1/2 C 1/2 C 1/2 C

boiled boiled boiled boiled

1.8 2.4 1.2 3.3

Hummus Peanut butter Tahini

2T 2T 2T

0.7 0.6 .7 - 2.6

Walnuts

1/4 C chopped 1/4 C 1/4 C 1/4 C roasted dry roasted dry roasted

0.85

Almonds Pistachios Sunflower seeds

1.3 1.2 1.2

Dried figs Raisins

1/2 C 1/2 C

dried, raw

1.5 1.4

Grape Nuts Total, whole grain

1/2 C 1/2 C

16 8

Molasses

2T

3.8

The foods highest in vitamin C per typical serving are orange juice and grapefruit juice (80 mg per cup), oranges (50 mg per small orange), broccoli (50 mg per 1/2 cup cooked, chopped), strawberries (85 mg per 1 cup of whole berries), and grapefruit (40-50 mg per 1/2 fruit). Vitamin C is also found in other green leafy vegetables (kale, collards, Swiss chard, Brussels sprouts), bell peppers (yellow, red, and green), and cauliflower. Polyphenols, which include tannic acid, can inhibit iron absorption, and are found in coffee, cocoa, and black, green and many herbal teas. You should avoid these foods at meals if you are trying to increase iron absorption (14). One study showed that, over four weeks, green and black tea lowered iron levels primarily in people with serum ferritin levels less than 20 g/l (15). Calcium supplements can also inhibit iron absorption if taken with meals. Cooking foods in cast iron pans can increase iron consumption. A 2007 study in Brazil showed that cooking tomato sauce in an iron skillet increases the amount of iron in the sauce and also increased iron status among teen-aged and young adult lacto-ovo vegetarians (9 ). The authors considered it important for the food cooked to be both acidic and water-based, such as tomato sauce. The amino acid, L-lysine, plays a part in the absorption of iron and zinc. Among plant foods, L-lysine is only found in high amounts in legumes (peanuts, beans, lentils, peas), and a vegan who doesn't eat many legumes could find themselves falling short on lysine.

Taken from the USDA National Nutrient Database or food labels.

Iron Deficiency in Vegetarians

The American Dietetic Association's Position Paper on Vegetarian Diets says, "Incidence of iron deficiency anemia among vegetarians is similar to that of nonvegetarians. Although vegetarian adults have lower iron stores than nonvegetarians, their serum ferritin levels are usually within the normal range (8)." This statement is based on cross-sectional studies and, to my knowledge, the iron status of vegetarians or vegans on self-selected diets has never been followed through time. A 2004 study from Germany (11) found that 40% of premenopausal vegan and near-vegan women had low iron stores, which was four times the national average. The authors recommended that premenopausal women on a vegan diet should have their iron status monitored and should consider taking iron supplements in case of marginal status. I have met many ex-vegetarian women (and a few men) who claimed to become anemic after becoming vegetarian. In most cases, they did not have a doctor diagnose them but assumed they were anemic because

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they were tired. This could be due to numerous things, such as not eating enough calories or protein, eating too many high-sugar foods, and possibly not getting enough sleep. However, I have heard it enough to think there is a real possibility that some women have a hard time with the lower iron absorption of plant foods, especially when first becoming vegetarian. Iron absorption may be more of a problem when people first become vegetarian because long-term studies of vegetarian women have not shown high dropout rates. These studies usually require that someone has been vegetarian for at least a year and anyone who gets IDA within the first few months of becoming vegetarian would not be included in such a study. Physiologically, it makes some sense that the problem would tend to show up right away or not at all, for the following reason: The body secretes transferrin into the digestive tract when iron stores are low in order to increase absorption of iron into the blood. If someone has been a meat-eater all her life, her body has not had a need to manufacture as much transferrin as she might need as a vegetarian. This might cause a quick drop in iron absorption once she becomes a vegetarian. Someone's body may or may not become more efficient at producing transferrin over time, but if she becomes anemic right away she will likely quit the diet and not give her body the chance. More evidence of this theory is that I have not heard of any children who were vegan from birth (and otherwise well-nourished and living in a developed country) who developed IDA. Because vegan infants have no prior history of depending on heme iron, they start their lives efficiently absorbing non-heme iron and retain this ability throughout life.

Low Iron Stores: Not Necessarily Unhealthy

Anemia is a possible downside to lower iron absorption, but there are a few potential upsides: Low iron stores are associated with higher glucose tolerance and might help prevent diabetes ( 7). High iron stores have been linked to cancer. High iron stores have been linked to heart disease. Based on an early study, this was believed to be a strong link for a number of years. Now that more evidence has come in, the link appears to be only in cases of very high iron storage levels, such as ferritin levels of greater than 200 g/l (vegans' ferritin levels are rarely above 100 g/l). As of 2010, this theory has lost almost all ground, see: Wood RJ. The iron-heart disease connection: is it dead or just hiding? Ageing Res Rev. 2004 Jul;3 (3):355-67. (Link) Sun Q, Ma J, Rifai N, Franco OH, Rexrode KM, Hu FB. Excessive body iron stores are not associated with risk of coronary heart disease in women. J Nutr. 2008 Dec;138(12):2436-41. ( Link) Zegrean M. Association of body iron stores with development of cardiovascular disease in the adult population: a systematic review of the literature. Can J Cardiovasc Nurs. 2009;19(1):26-32. ( Link )

Hemochromatosis
Hemochromatosis is a disease of unhealthfully high iron absorption. Its most serious, homozygous form occurs in about 1 in 100 blacks and 1 in 200 nonblacks. Its less serious, heterozygous form occurs in 30% of blacks and 12% of nonblacks (4). Most affected people do not know they have the disease ( 4). People with hemochromatosis are at risk for cirrhosis (4), liver cancer (1), and other diseases. Alcoholic cirrhosis, other liver diseases, iron-loading abnormalities, and other rare diseases can also cause iron overload ( 1). Because of the possibility of hemochromatosis, men and postmenopausal women should not actively try to increase iron absorption unless they know they have low iron stores.

Celiac Disease
Celiac disease is the cause of some cases of unexplained iron deficiency anemia ( 10). Celiac disease is a condition in which gluten (from wheat, barley, and rye) cause an autoimmune reaction against the intestinal cells. Often, someone has severe diarrhea, vomiting, and other problems. But other times celiac disease goes unnoticed. It occurs in about 1 in 133 people in the U.S.A. (10).

Proton Pump Inhibitors

Proton Pump Inhibitors (PPIs) are widely prescribed to treat gastrointestinal diseases. Research has shown that they can cause iron deficiency anemia (16). If you take PPIs and find that you have anemia, talk to your doctor about a possible connection.

Recommendations
Table 2. Dietary Reference Intake (DRI) for Iron Age (years) DRI (mg) Veg DRI (mg) Upper limita (mg)

The new U.S. DRIs for iron distinguish between vegetarians and nonvegetarians (see Table 2). The DRI for vegetarians was determined by increasing the regular DRI by 1.8 times (5). This is controversial

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0 - 6 mos 7 - 12 mos 1-3 4-8 9 - 13 boys, 14-18 girls, 14-18 breastfeeding, 14-18 men 19+ women 19-50 breastfeeding, 19-50 women 50+ pregnancy
a

.27 11 7 10 8 11 15 10

.27 11 12.6 18 14.4 19.8 27 18

40 40 40 40 40 45 45 45

because the recommendations were not based on studies of vegetarians, but rather based on vegetarian diets designed to reduce iron absorption. Such a high DRI makes it almost impossible for premenopausal women to meet the DRI without supplements and many vegetarian dietitians do not think it is necessary for most vegetarians to get this much iron. Iron amounts listed on a nutrition label are based on 18 mg/day. For example, 25% of the Daily Value = .25 x 18 mg = 4.5 mg. You do not need to worry about iron if you are otherwise healthy and eat a varied vegetarian or vegan diet. If you are concerned about iron absorption you can take steps to increase it by removing coffee, tea, and calcium supplements from meals; adding vitamin C to meals; and increasing legume intake. If your concerns persist, you should have a doctor measure your iron status. If your iron stores are too low, your doctor might suggest eating meat or taking an iron supplement. If your doctor says you should eat meat, you might want to show him or her this article. Anemia in meat-eaters is normally treated with large doses of supplemental iron, not with eating more meat. Similarly, vegetarians with IDA do not need to start eating meat but can also be treated with supplemental iron. IDA is normally treated with 100 to 200 mg/day for 4 to 6 months. These large amounts can cause nausea, diarrhea, or constipation, and should only be taken under a doctor's care.

8 18 9

14.4 32.4 16.2

45 45 45

8 27

14.4 48.6

45 45

The Upper Limit for iron intake is set to prevent gastrointestinal distress rather than to prevent any possible chronic diseases from iron overload.1 Those who engage in regular, intense exercise may need an additional 30%.5

In some women, iron supplementation does not lead to an increase in iron stores. In one study of such women, adding L-lysine (1.5 - 2 g/day for 6 months) to iron supplementation did increase iron stores and decreased hair loss by one half. I have a vegetarian friend who eats spinach whenever she feels anemic and she says it fixes the problem. Although feeling anemic does not mean someone is anemic, perhaps she is onto something.

References
1. Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc. Washington, DC: National Academy Press, 2001. 2. Seshadri S, Shah A, Bhade S. Haematologic response of anaemic preschool children to ascorbic acid supplementation. Hum Nutr Appl Nutr. 1985 Apr;39(2):151-4. (Link ) 3. Groff J, Gropper S. Advanced Nutrition and Human Metabolism, 3rd ed. Wadsworth: 2000. 4. Mahan LK, Escott-Stump S. Krause's Food, Nutrition, & Diet Therapy, 10th ed. Philadelphia, PA: W.B. Saunders, Co., 2000. 5. Mangels R. "Update on the New DRI's" Vegetarian Nutrition Update Sum 2001;10(4):1-7. 6. Craig WJ. Iron status of vegetarians. Am J Clin Nutr. 1994 May;59(5 Suppl):1233S-1237S. 7. Hua NW, Stoohs RA, Facchini FS. Low iron status and enhanced insulin sensitivity in lacto-ovo vegetarians. Br J Nutr. 2001 Oct;86(4):515-9. 8. Position of the American Dietetic Association and Dietitians of Canada: Vegetarian Diets J Am Diet Assoc. 2003 Jun;103(6):748-65. 9. Quintaes KD, Farfan JA, Tomazini FM, Morgano MA, de Almeyda Hajisa NM, Neto JT. Mineral Migration and Influence of Meal Preparation in Iron Cookware on the Iron Nutritional Status of Vegetarian Students. Ecology of Food and Nutrition. 2007;46:125-141. 10. Niewinski MM. Advances in celiac disease and gluten-free diet. J Am Diet Assoc. 2008 Apr;108(4):661-72. 11. Waldmann A, Koschizke JW, Leitzmann C, Hahn A. Dietary iron intake and iron status of German female vegans: results of the German vegan study. Ann Nutr Metab. 2004;48(2):103-8. Epub 2004 Feb 25. 12. Sharma DC, Mathur R. Correction of anemia and iron deficiency in vegetarians by administration of ascorbic acid. Indian J Physiol Pharmacol. 1995 Oct;39(4):403-6. PMID: 8582755 . (Abstract only) 13. Siegenberg D, Baynes RD, Bothwell TH, Macfarlane BJ, Lamparelli RD, Car NG, MacPhail P, Schmidt U, Tal A, Mayet F. Ascorbic acid prevents the dose dependent inhibitory effects of polyphenols and phytates on nonheme-iron absorption. Am J Clin Nutr. 1991 Feb;53(2):537-41. PMID: 1989423.

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14. Hurrell RF, Reddy M, Cook JD. Inhibition of non-haem iron absorption in man by polyphenolic-containing beverages. Br J Nutr. 1999 Apr;81(4):289-95. PubMed PMID: 10999016. | link 15. Schlesier K, Khn B, Kiehntopf M, Winnefeld K, Roskos M, Bitsch R, Bhm V. Comparative evaluation of green and black tea consumption on the iron status of omnivorous and vegetarian people. Food Research International. 2012 May;46 (2):522-27. | link 16. Sarzynski E, Puttarajappa C, Xie Y, Grover M, Laird-Fick H. Association between proton pump inhibitor use and anemia: a retrospective cohort study. Dig Dis Sci. 2011 Aug;56(8):2349-53. (Abstract) | link

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