Friday, March 20, 2009

Iron

We need iron. Without enough iron, we'll get sick. But too much iron can kill us.

As with so many things relating to our health, it's a balancing act.

Most people who eat meat get sufficient iron. Some foods these days are also supplemented with iron.
The chocolate syrup Bosco was designed to get children to consume more iron. Cooking in iron pots, especially cooking acid foods, adds iron to our diet. Multivitamins designed for younger people contain iron (especially those for pregnant women, as the fetus consumes a lot of iron).

Hence nonpregnant Western people who aren't vegetarians usually get enough iron from their diet. People in Third World countries who don't get much meat, however, are often iron deficient.

Heme iron, or the iron that is in hemoglobin, the oxygen-carrying molecule in red blood cells, is absorbed even more efficiently than the nonheme iron that you get when you eat vegetables or take an iron-containing multivitamin pill. So eating meat, especially red meat and liver, should ensure that you get enough iron.

Vitamin C will increase the absorption of iron, and large amounts of calcium or whole grains will decrease it.

Those of us over 60 probably remember all those ads for "tired blood" in the 1950s and 1960s that implied that older people were tired because they didn't have enough iron and needed to supplement with Geritol.

So should we all try to get as much iron as possible?

Nope.

There is some evidence that high iron levels contribute to heart disease, and most "senior vitamins," designed for people who are at an age at which heart disease is more likely, don't have any added iron. Some people think that losing blood every month helps to protect younger women from heart disease. This protection is lost after menopause.

Iron levels have other interesting effects on our health.

Like us, most bacteria require iron in order to grow. Our bodies are smart, and they apparently know this. So when we get an infection, our bodies start reducing the iron in our blood, especially when we have a fever.

The bacteria, in turn, try to develop ways to snatch the iron away from the proteins that carry it around and store it in our cells. Hence taking iron supplements when you have an infection is probably not a great idea.

So why am I babbling on about iron? Because there are two different iron-level conditions that are relevant to diabetes. The first is hemochromatosis, a genetic disease found most commonly among people with Celtic ancestry.

Hemochromatosis makes you absorb too much iron, and the high iron levels attack many organs in the body, including the beta cells. So people with the hemochromatosis gene are at very high risk of getting diabetes.
Some people absorb enough iron that their skin turns slightly brown, and if they develop diabetes, it's sometimes called bronze diabetes because of the bronzed color of the skin.

The other condition is the exact opposite, a form of anemia, or too little hemoglobin in your blood. It occurs when you don't absorb enough iron or when you lose iron because you've lost a lot of blood. Without iron, you can't make hemoglobin, and without hemoglobin, you can't make enough red blood cells.

This condition is called, not surprisingly, iron-deficiency anemia.

A test for both these conditions is the ferritin test. Ferritin is the protein that the body uses to store iron, and it's a good indicator of overall iron levels in the body. Low ferritin could mean iron-deficiency anemia. High ferritin could mean hemochromatosis.

There's another wrinkle to the iron story and diabetes. Iron-deficiency anemia can make your hemoglobin A1c test higher than it should be on the basis of your daily blood glucose measurements. A recent study showed that increases in A1c levels often found in late pregnancy are in fact caused by iron-deficiency anemia rather than by increases in blood glucose levels.

Conversely, if you find you have iron-deficiency anemia and you treat it with iron supplements, your A1c will go down.

The reason that iron-deficiency anemia makes the A1c decrease is not clear. It may be related to the red blood cell lifespan. Some people think it's related to oxidative stress.

And although iron-deficiency anemia makes the A1c go up, hemolytic anemias make the A1c go down. Hemolytic anemia is any kind of anemia that destroys the red blood cells, as this reduces the lifespan of the cells and hence results in abnormally low A1cs.

The interpretation of the A1c test assumes the red blood cells live an average of 120 days. In fact, the actual lifetime of red blood cells even in healthy people can vary
from person to person, which may be one reason some people seem to get A1c results that are either higher or lower than what they expect on the basis of their home blood glucose readings.

So many things can affect our health, and so many things can affect the lab tests we use to monitor our health.

I think the important thing is to remember that no lab test is 100% accurate for all patients under all conditions. If you get an abnormal lab test, don't panic. Sometimes it helps to have the test repeated, just in case it was lab error. Other times it's simply a suggestion that something might be wrong. Then you can work on what you think might have caused the positive lab test and see if that fixes the problem.

If you have reasons to think you might have hemochromatosis (Celtic or Scandinavian ancestry; relatives with hemochromatosis), it would be a good idea to get a test for ferritin. If you have reasons to think you might be anemic (fatigue, pale skin, rapid heartbeat, especially if you're vegetarian), it wouldn't hurt to ask your doctor for the same test.

If you don't have either and your A1c continues to differ from what you think it should be, you might just be someone whose red blood cells live longer or for a shorter time than average.

33 comments:

  1. I am a runner and didnt realise that my iron would be depleted through exercise and this led to me believe i had plateaued in terms of my fitness, where in reality, little did i know that iron deficiency was the real cause! I am on iron supplements and my levels have come back up but now I have the added side effect of constipation, so i’ve adjusted my doses (as recommended by my nutritionist) and hopefully this will help to correct this - very worrying though for a while of feeling constantly tired and 'drained.

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  2. Hi Gretchen
    I read your post with interest. What I am curious to know is which readings should you trust?

    I have been treated for low ferritin with iron supplements. I have seen my HbA1c decrease during this time to 6.1%, however my home glucose monitor often shows higher readings than I would expect compared to my low HbA1c.

    Is the new 'iron treated' HbA1c an accurate portrayal of my blood glucose or are the home tests a better indicator. It is very confusing.

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  3. Lucy, you are correct. It is very confusing. Some home tests are accurate and some are not. It depends on the meter and on the technique of the tester. Take a fingerstick the next time you have a lab test and see how your meter compares.

    Also, you can go high after meals and if you come down quickly, that won't have much affect on A1c.

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  4. I mean, of course, it won't have much effect.

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  5. Hi,

    I am really interested as a T2 in iron levels. My haemoglobin level is 14.8 (sorry I don't know how to convert). Is this too high, it's supposed to be within the normal range but with diabetes there always seems to be a lot of conflict. I have read that the only way to reduce your iron levels is to give blood, are there any other ways? I am post menopausal so I know that this makes a diffierence now.
    I appreciate any replies thanks

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  6. Anonymous, I'm afraid I don't feel comfortable giving advice about what iron levels are best. If your levels are in the normal range, do you have any reason to think they're too high for you?

    I don't know any way to reduce levels other than avoiding red meat, not cooking in iron pots, and giving blood. But you don't want to reduce your iron levels too much. We do need some iron or we'll be anemic.

    Note that when you give levels of something, you need to include units or the numbers are meaningless.

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  7. I understand that elevated ferritin can lead to type2 diabetes and I was wondering if 219.5 ug/L is considered too high.

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  8. Anonymous, I don't have the normal range for ferritin in my head. What does your lab result give for the normal range? Do you think you have hemochromatosis? Does your doctor? This is not something we should try to self-diagnose.

    If your lab report doesn't give a normal range, call the lab and ask. If that doesn't work, do an Internet search on "ferritin normal range."

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  9. I'm taking a medical education test; can you answer this question/: Hgb A1C is an unreliable indicator of glycemic Hx in pts with which one of these conditions: Hemochromatosis, hemophilia, hereditary spherocytosis, heroin addiction or HIV.

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  10. I can, but if it's a test I don't think I should.

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  11. Gretchen,
    I caught on to this thread while doing research on my problems with fatigue and brain fog which has worsened over the past two years. I suggested Hemochoratosis to him and he said it couldn't be, but offered no other explanation.
    The normal range for ferritin from what I have seen varies from place to place and lab to lab. It can be as low as 30 to 125 or as high as 50 to 500. My local lab pegs the high at 400. It shows more needs to be done with research out there. I am not a nut but when you look at all the symptoms of high iron, it could be a great deal of symptoms could be being treated and the real cause is hidden in plain sight.

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  12. Anonymous, Have you had your own iron levels tested?

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  13. Hi Gretchen,
    Will Serum Ferritin fluctuate according to your menstual cycle? I had a test done in January and my level was 7, which my Dr said was way below average. So I've been taking supplements (Hema-Plex) and now, in April, my level is 34, which is in the average range. I looked though and realized that in January, I had taken the test about 1 day after my period ended and this new one was taken about 10 days before my period should start.

    Thank you!

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  14. anonymous, This is not something I've studied, but here are a few links:

    http://www.ncbi.nlm.nih.gov/pubmed/4951508

    http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2867%2990911-7/abstract#

    http://books.google.com/books?id=b0iiYNob_WwC&pg=PA261&lpg=PA261&dq=serum+iron+menstrual+cycle&source=bl&ots=wj09xsaaEH&sig=D435MkAMNCxXcJGyjuNJ2Vni7CY&hl=en&ei=0qegTdTAK8X20gHRg6SaDQ&sa=X&oi=book_result&ct=result&resnum=6&ved=0CDgQ6AEwBTgK#v=onepage&q=serum%20iron%20menstrual%20cycle&f=false

    You can find more by googling the appropriate terms, like "serum iron menstrual cycle."

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  15. I have been having fluctuating Hemoglobin levels on and off for some years now. I have had numerous tests done even gone to a hematologist and the doctors keep telling me I am fine. Within the last 3 years I have started to get really tired and occasional pain only on the left side of my body, could this be related to a hemoglobin absorption or functionality problem ?

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  16. Jennifer, I'm sorry about your problem; it can be so frustrating when you're told you're fine but you're not. However, I'm not a doctor, and even an MD can't diagnose people online.

    Your problems might be unrelated to hemoglobin, and the best option would be to be persistent in seeing a physician about the pain and fatigue.

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  17. Hi Gretchen,
    I have recently had my Haemoglobin tested it is low 9.9; my BP is normal; but my sugar is close to high 47. My Height is 5."8 and weight 88kg. Have been to the GP, advised to loose weight and increase HB level. Please guide

    Thanks & Regards,
    CT

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    1. CT, Thanks for writing. I'm not a physician and I can't prescribe. Even a physican can't give medical advice online like this. Did your doctor tell you how to increase your hemoglobin?

      I don't understand your sugar levels as you didn't give units. 47 mmol/L would be incredibly high (846 mg/dL), and I'd think the doctor would do more than telling you to lose weight. Didn't he prescribe medication?

      Have you modified your diet?

      Unless your GP provided more help than what you state, I'd try to find a different GP.

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  18. I am so happy to read this. I was diagnosed with iron-deficiency anemia (I'm also a marathon runner - had no idea that could be the reason why!) by my doctor and she also told me I had elevated A1C test so I was pre-diabetic. How interesting that the iron issue could possibly cause that. I'm going to bring that up to her and see what she says.

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  19. My wife was diagnosed with hemochromatosis yet her recent bloods revealed very low iron and she was put on a course of iron tablets. Have you come across this before?

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    1. Michael, That does sound odd to me. Is it possible she was given a drug to reduce iron levels and they gave too much? Or did she donate blood to reduce iron and that reduced it too much? Or does she also have another condition that would reduce iron levels?

      What was her doctor's explanation?

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    2. Well she didn't speak to the doctor. Her receptionist phoned with the results of the test. She indicated that the .doctor thought it was 'strange but had no explanation. She doesn't receive treatment for hemochromatosis as she is still menstruating and that keeps her in check. She suffers from a lot of non specific ailments like swollen knees which is very pain full and she can find it hard to stand from seated, can get very lethargic' numerous lypoma, for a time she was menstruating three times a month, now hardly ever.

      I'm not sure if its relivent but she suffers from angsiaty and depression.

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    3. Michael, Is it possible for your wife to see another doctor? One who would take all this seriously and see if something could be done about the anxiety and depression? No doctor can diagnose via the Internet (and I'm not an MD), so it's important you get her to see someone else, if that's possible.

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  20. GRETCHEN, BEEN READING ALL OF THE ABOVE WITH INTEREST. MY WIFE OF 76, ACTIVE WITH NO APPARENT KNOWN HEALTH ISSUES HISTORICALLY GIVES BLOOD WHEN THE RED COMES TO TOWN. SHE HAS GIVEN BLOOD ONCE THIS YEAR BUT WAS REJECTED TWICE FOR LOW IRON. SHE IS SCHEDULED FOR A COLINOSCOPY (sp) NEXT WEEK. SHE IS ACTIVE ALL THE TIME YOU WOULD THINK THAT SHE IS PREPARING FOR A MERRITHON.. NO BLOOD FOUND IN STOOLS OR OTHER BLOOD LOSS KNOWN ISSUES. I'M NOT TOO SAVEY OF THE MEDICAL TERMS,HOWEVER HER MOTHER WAS DIABETIC. SHE IS ON IRON SUPPLEMENTS, DOESN'T EAT MUCH MEAT, WE ARE A CHICKEN, FISH AND PORK FAMILY EXCEPT I CHEAT WITH A STEAK WHEN SHES OUT WITH FRIENDS. OH, SHE DOES HAVE ACID REFLUX AND IS TAKING MEDS FOR THAT AND STAYS AWAY FROM TOMATOES AND OTHER ACID FOODS. WHAT TESTS DO YOU RECOMMEND.

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    1. Ralph, If your wife has low iron and is taking iron supplements, I assume that means her doctor is testing her for iron levels.

      If you're concerned about diabetes, ask your doctor for a hemoglobin A1c test, or get a meter and test her after meals. You can also buy home A1c testing kits, A1c Now.

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  21. Would iron result be accurate the day after a marathon? I had lab work completed the day after my marathon( less than 24 hrs after) and my iron showed normal. After about 7 months,I went to the doctor for constant fatigue and they did not recheck my iron because it was normal they day after my marathon. As an active runner being this tired I know is not normal for me, even with more miles than I am doing now. Therefore any information you could give me would be great. Thank you.

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  22. I had my iron tested the day after my marathon per my doctor’s instructions, with her being aware I had just completed a marathon, and my iron came back normal. However after several months and a decrease training, I continue to be extremely and abnormal tired. I recently went to the doctor for my fatigue and they did not check my iron, B-12, or thyroid again as they said they all were normal seven months ago. Would iron results be accurate if they were completed less than 24 hours after a marathon and should a ask that my labs be redone?

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    1. Kweese, I'm afraid the relation between iron and strenuous exercise is something I don't know a lot about.

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  23. What a fascinating article! Thank you for this.

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  24. Hi Gretchen. I really appreciate you taking the time to share your expertise. I saw your response above about hemochromatosis and low iron. Fwiw, I suspect I have hemochromatosis. I'm a carrier and in 2012 my levels were iron 186, binding 416, Sat 50%, and then it was tested again and slightly lower.. 156, 364, 42%. I just tested last week (as I'm not menstruating anymore.. very little over last 5 years, but I do donate blood twice a year) and was very surprised to see anemia... 40/324/10%. I'm going to retest now my mild cold is gone. I have hashimotos and I wonder if the attacks are messing with my iron via some underlying function not working properly.

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  25. Can you get tested for hemochromatosis?

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  26. For a few years now my iron levels have fluctuated significantly just 6 months ago I was told that my iron levels were 3x more than what they should be. Another blood test was taken about 3 months ago and it was found that my iron levels were too low that it was crucial that I increase my daily iron intake ASAP, I have recently gone vegan and at first I felt absolutely energetic so much more than I have ever felt before, but just today I found red spots under my chin and have fond that I have a purpuras inflammation which is common in anemic's. I have absolutely no idea what to do, doctors cannot figure what it is I have though they do know not anything genetic as I have had blood tests specifically to prove that. Would you have any clue what it is I may have Gretchen?
    - Anonymous 17yr old

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    1. Anonymous, I'm not a doctor and can't give medical advice. But if you went vegan before the low-iron results, you might not be getting enough iron, depending on how you're interpreting the vegan diet.

      Some people take diets to extremes. If it were me, I'd try eating red meat again and remeasuring. Just keep in touch with your doctor, who seems to be paying attention to this.

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