iron reportI N T R O D U C I N G

D O C T O R D A W N ’ S

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CONTENTS 2

INTRODUCTION 3

1. GENERAL AWARENESS 4 Fig 1.1 Signs of low iron Fig 1.2 Daily iron requirements

2. WOMEN’S HEALTH 6 Fig 2.1 Pregnancy and anaemia Fig 2.2 People likely to have low iron

3. FITNESS 8 Fig 3.1 Iron loss during exercise

4. HAEMOCHROMATOSIS 9

5. IRON SUPPLEMENTATION 10

CONCLUSION 11

BIBLIOGRAPHY 11

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S U M M A R Y

Iron is an essential mineral that many of us don’t get enough of. Iron deficiency anaemia is caused by a lack of iron and is the most common vitamin and mineral deficiency in the UK. Iron plays an important role in the metabolism of energy, so it can reduce tiredness and fatigue. It is important for cognitive function, immune function and the production of red blood cells and haemoglobin.

Many of us don’t get enough iron in our diet and an inadequate intake can lead to a lack of energy, pale skin or even hair loss. There is no substitute for a healthy well-balanced diet, but if you struggle to get enough iron in your diet you may choose to supplement.

The main problem with traditional iron supplements is the side effects that they can cause. Some products avoid causing side effects by reducing the dose of iron, but this makes them less effective. If you’re looking for an iron supplement, look for one that is well absorbed and kind on your system.

I N T R O D U C T I O N

Dr. Dawn Harper is a NHS GP in Gloucestershire. She has worked as a media doctor for over ten years and is best known as of the of presenters on Channel 4’s hit series Embarrassing Bodies. Dr Dawn has put together ‘the iron report’ in association with Active Iron.

In this report, Dr Dawn draws on her own experience as a GP as well as the results of new research commissioned by Active Iron.

This research was conducted online in the UK by Opinions Market Research, with 1,018 people between Friday 10th – Monday 13th of August 2018. Quotas were set on gender, age and region to be representative of the UK population.

This report will outline general awareness on iron, the role of iron in women’s health, fitness, haemochromatosis and iron supplementation.

1 . G E N E R A L A W A R E N E S S

Iron deficiency anaemia is caused by a lack of iron and is the most common vitamin and mineral deficiency in the UK. According to the World Health Organization (WHO), iron deficiency is the top nutritional disorder in the world.1

Potentially millions suffer the effects of iron deficiency but the symptoms, such as fatigue, pale skin, and a racing heart, are often mistaken for everyday issues. Many of us don’t get enough iron in our diet and an inadequate intake can lead to a lack of energy, brittle spoon-shaped nails or even hair loss. The normal range for iron in the blood is anything from 10ng/mL to 300ng/mL, but for example, for anyone with thinning hair you could aim for a level of at least 70 ng/mL, according to Dr Dawn.

Iron is an essential mineral that is stored in the body as ferritin. Ferritin attaches to a protein called transferrin to be carried around the body. Iron can be released from ferritin when the body needs it.

Along with transporting O2 around the body, iron produces the chemicals that transmit signals between brain cells and helps protect your nerve fibres.

Other functions include producing energy from food, helping you to maintain a healthy immune system and encouraging normal growth in young children.2

Many people are not aware of the amount of iron they need. Daily iron requirements vary depending on age and gender.

Males aged 18-plus and women over 50 need 8.7mg daily. However, it’s recommended that women who are having monthly periods have 14.8mg.

Those at particular risk of low iron include pregnant women, people with digestive disorders, those who exercise a lot and vegetarians and vegans who don’t follow a balanced diet.

1 McLean, E., Cogswell, M., Egli, I., Wojdyla, D. and de Benoist, B. (2008). Worldwide prevalence of anaemia, WHO Vitamin and Mineral Nutrition Information System, 1993–2005. Public Health Nutrition, 12(04), p.444.2 Inmo.ie. (2018). Nutritional needs of pre-school children. [online] Available at: https://www.inmo.ie/Article/PrintArticle/1637 [Accessed 23 Oct. 2018].

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Women with problem periods are likely to have a higher iron requirement than others, according to Dr Dawn.Only a fraction of ingested iron is absorbed by the body. The amount may range from only 5% to 35% according to a journal in the National Center for Biotechnology Information.3 The amount of iron absorbed can depend on the circumstances and the type of iron.

Iron is found in a variety of foods, including pumpkin seeds, red meat, leafy greens, dried fruit, liver and legumes, but it’s important that you are absorbing it properly.

There are two types of iron found in food, non-heme and heme. Heme iron is absorbed by the body easier than non-heme iron. Heme iron is found in animal sources which includes beef, lamb, fish, pork and chicken. Non-heme iron is found in plant sources which includes spinach, pumpkin seeds and chickpeas. Red meats that are high in haemoglobin are known to be excellent nutrient sources of heme iron. They provide Fe+2 directly which can be transported across the intestinal absorptive cells and then exported to the bloodstream through the Fe+2 transporter ferroportin.

The flow of Fe+2 is sped up by several other mechanisms until it is picked up by transferrin, which delivers it into tissues. This process can be carried out up to 10 times daily to deliver the iron that the body needs.4 The total iron content of transferrin corresponds to less than 0.1% of body iron. A different process is thought to exist for the absorption of plant ferritins which are mostly present in legumes. However, most ferritin appears to be degraded during digestion.5

So although a vegetarian diet is often high in iron rich foods, these plant-based sources of iron are poorly absorbed in the diet. Other potential absorption obstacles include phytates in whole-grains and legumes, milk, or tannins in tea and coffee. High levels of Vitamin C can aid its absorption.

3 Nazanin Abbaspour, R. (2018). Review on iron and its importance for human health. [online] PubMed Central (PMC). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3999603/ [Accessed 11 Oct. 2018]. 4 Nazanin Abbaspour, R. (2018). Review on iron and its importance for human health. [online] PubMed Central (PMC). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3999603/ [Accessed 11 Oct. 2018]. 5 Zielińska-Dawidziak, M. (2015). Plant Ferritin—A Source of Iron to Prevent Its Deficiency. Nutrients, 7(2), pp.1184-1201.

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2 . W O M E N ’ S H E A LT H

Recent research conducted in the UK shows that most people are unsure of the recommended daily iron intake for women.

Almost half of the population (47%) stated they didn’t know the recommended daily intake for women aged 19-50. 20% think it is the same as for men of the same age, 20% think twice as much for men the same age, and 12% think half as much for men the same age. This indicates mixed messages and a lack of awareness around recommended iron intake for women.

Women need more iron than men due to blood loss from monthly periods, and iron requirements can be further increased during pregnancy. Blood volume increases by 30% to 50% during pregnancy in order to allow for blood flow for both mum and baby. That means a significant increase in iron requirements particularly in the second and third trimesters.

The World Health Organisation recommends 30mg of daily iron during pregnancy, especially the second and third trimesters. Anaemia in pregnancy is considered a global health problem. Almost 50% of pregnant women are affected by anaemia. Iron deficiency is the most common cause of anaemia in pregnancy according to the clinical data in the American Society of Hematology.6

The World Health Organization (WHO) defines anaemia of pregnancy as haemoglobin <11 g/dL, or hematocrit <33%, at any time during the pregnancy.

6 Achebe, M. and Gafter-Gvili, A. (2018). How I treat anemia in pregnancy: iron, cobalamin, and folate. [online] bloodjournal.org. Available at: http://www.bloodjournal.org/content/129/8/940 [Accessed 16 Oct. 2018]. 7 Hematology.org. (2018). Anemia and Pregnancy. [online] Available at: http://www.hematology.org/Patients/Anemia/Pregnancy.aspx [Accessed 16 Oct. 2018].

According to the American Society of Hematology, many women lack the enough iron needed for the second and third trimesters of pregnancy.7 They also state that mild anaemia is normal during pregnancy due to the increase in blood volume.

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Severe anaemia during pregnancy can put your baby at risk of developing anaemia later in infancy.8 There is also a greater risk of having a pre-term delivery or low-birth-weight baby.

Oral iron is the frontline therapy for iron-deficiency anaemia according to the American Society of Hematology.9 However, they state that up to 70% of patients experience significant gastrointestinal side effects (nausea, constipation, diarrhoea, indigestion, and metallic taste) that prevent adherence to treatment. Constipation caused by decreased bowel motility caused by elevated progesterone and the enlarging uterus pressing on the rectum in pregnancy is made worse by oral iron.

Don’t shy away from exercise during pregnancy, studies have shown women that exercise regularly during pregnancy tend to have easier labours – but remember the combination of pregnancy and exercise will increase your iron requirements.

Women are most at risk of low iron levels due to the loss of blood during their monthly period, as well as pregnancy.

8 Koura, G., Ouedraogo, S., Le Port, A., Watier, L., Cottrell, G., Guerra, J., Choudat, I., Rachas, A., Bouscaillou, J., Massougbodji, A. and Garcia, A. (2011). Anaemia during pregnancy: impact on birth outcome and infant haemoglobin level during the first 18 months of life. Tropical Medicine & International Health. 9 Achebe, M. and Gafter-Gvili, A. (2018). How I treat anemia in pregnancy: iron, cobalamin, and folate. [online] bloodjournal.org. Available at: http://www.bloodjournal.org/content/129/8/940 [Accessed 16 Oct. 2018].

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3 . F I T N E S S

Studies have shown that women with low iron levels find exercising more difficult than those with adequate levels. Increased difficulty in sustaining exercise and adapting to training are just two of the challenges women with low iron levels face.

In anaemic individuals, iron deficiency often not only decreases athletic performance but also impairs immune function and leads to other physiologic dysfunction. A Cornell University study found that iron-deficient women can improve their exercise endurance by taking iron supplements.

Jere Haas, Professor of Maternal and Child Nutrition and Director of the Division of Nutritional Sciences at Cornell University in New York, spoke to Medscape about the study. “Millions of women are working harder than they need in order to exercise or physically work, and they can’t reap the benefits of endurance training as easily. As a result, exercise is more difficult so these women are more apt to lose their motivation to exercise,” he said.

Professor Haas had completed a previous study in 1998 that found iron-depletion in non-anaemic women results in lower capacity for physical work and impaired exercise performance.

His new study shows that iron deficiency impairs the ability to increase aerobic endurance after a period of exercise training.

“In other words, we now know that iron-deficient women don’t benefit from training as much as women with higher iron status because of impaired metabolic responses to exercise, but that iron supplementation can compensate,” he said.

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Furthermore, not only do women with low iron levels find exercise more difficult, but iron deficiency can also be caused by intensive exercise. In a case study published by The British Journal of General Practice, three young female adults developed iron deficiency anaemia (IDA) induced by intensive physical training.

The study describes intensive physical training as the “forgotten cause” of anaemia. While iron deficiency is common in athletes involved in endurance sports, female marathon runners are among the worst hit – the prevalence is as high as 28%.

Several mechanisms are thought to cause iron loss during exercise. The case study concluded that exercise-induced anaemia must be considered in young female adults with unexplained IDA.

4 . H A E M O C H R O M AT O S I S

Too much iron is toxic, causing abdominal cramps, constipation or diarrhoea and bloody diarrhoea in children so it’s important to keep supplements well out of reach of small children. There’s also a condition called haemochromatosis where iron is absorbed more readily leading to deposits in the pancreas, liver and heart – causing diabetes, cirrhosis and heart failure. People with haemochromatosis should not take iron supplements.

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5 . I R O N S U P P L E M E N TAT I O N

Ferrous iron (Fe+2), is quickly oxidized to the insoluble ferric (Fe+3) form at the human body’s pH. When Fe+3 enters the first section of the small intestine, gastric acid lowers the pH allowing the transport of Fe+2 across the intestinal absorptive cells. This lowering of the pH by gastric acid which allows the transport of Fe+2 is called ferric reductases. This process “enhances the solubility and uptake of ferric iron”, according to the Review on iron and its importance for human health. However, if gastric acid production is impaired then iron absorption will be reduced substantially.

The main problem with traditional iron supplements is the side-effects that they can cause. Oral iron supplements have long been associated with negative gastro-intestinal side-effects such as diarrhoea, constipation, and cramping. Iron food fortification and oral iron supplements are limited by either poor absorption or poor tolerability. Very frequently, both occur together. Gut inflammation can even contribute to a reduction in iron absorption as illustrated by a recent study.10

The study, which used women in their controlled trials, compares iron absorption from oral iron supplements given on consecutive versus alternate days and given as single morning doses versus twice-daily split dosing. The women who were enrolled in the trials all had low iron levels. The trial was conducted for 14 days for the consecutive-day group and 28 days for the alternate-day group. The authors of the study found that providing iron supplements daily as divided doses increases serum hepcidin and reduces iron absorption. In other words, the iron supplements caused gut inflammation which in turn reduced the amount of iron being absorbed in the body.

Aside from the discomfort associated with gut inflammation, lower absorption rates mean individuals may not be getting all the iron that they need. Some products reduce the dose in order to reduce side-effects, but that makes them less effective.

Food supplements are not a substitute for a varied diet and a healthy lifestyle. Also, you should not exceed the recommended daily supplement dose of iron without consulting your doctor or pharmacist.

10 Stoffel NU, e. (2018). Iron absorption from oral iron supplements given on consecutive versus alternate days and as single morning doses versus twice-daily split dosing i... - PubMed - NCBI. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29032957 [Accessed 8 Jan. 2018].

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C O N C L U S I O N

If you’re feeling rundown and exhausted, you may think it’s just down to a busy lifestyle but the real reason could be a shortage of iron. Iron deficiency anaemia is the most common vitamin and mineral deficiency in the UK. Although research has found that at least four million Britons may be affected by a lack of iron, many of us don’t know how much iron we need or how to get it. If you’re struggling to get enough iron talk to your GP or pharmacist about iron supplementation. Choose one that is well absorbed and kind on your system.

B I B L I O G R A P H Y

Achebe, M. and Gafter-Gvili, A. (2018). How I treat anemia in pregnancy: iron, cobalamin, and folate. [online] bloodjournal.org. Available at: http://www.bloodjournal.org/content/129/8/940 [Accessed 16 Oct. 2018].

Hematology.org. (2018). Anemia and Pregnancy. [online] Available at: http://www.hematology.org/Patients/Anemia/Pregnancy.aspx [Accessed 16 Oct. 2018].

Koura, G., Ouedraogo, S., Le Port, A., Watier, L., Cottrell, G., Guerra, J., Choudat, I., Rachas, A., Bouscaillou, J., Massougbod-ji, A. and Garcia, A. (2011). Anaemia during pregnancy: impact on birth outcome and infant haemoglobin level during the first 18 months of life. Tropical Medicine & International Health.

McLean, E., Cogswell, M., Egli, I., Wojdyla, D. and de Benoist, B. (2008). Worldwide prevalence of anaemia, WHO Vitamin and Mineral Nutrition Information System, 1993–2005. Public Health Nutrition, 12(04), p.444.

Nazanin Abbaspour, R. (2018). Review on iron and its importance for human health. [online] PubMed Central (PMC). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3999603/ [Accessed 11 Oct. 2018].

Stoffel NU, e. (2018). Iron absorption from oral iron supplements given on consecutive versus alternate days and as single morning doses versus twice-daily split dosing i... - PubMed - NCBI. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29032957 [Accessed 8 Jan. 2018].

Zielińska-Dawidziak, M. (2015). Plant Ferritin—A Source of Iron to Prevent Its Deficiency. Nutrients, 7(2), pp.1184-1201.

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