Eating For Energy | Fatigue & exhaustion | Maternal health | Nutrition | Postnatal depletion

So, you’ve got low iron level? 5 important things you need to know about treating iron deficiency in motherhood

Nov 14, 2023 | 0 comments

Low iron levels are one of the most common things I see in the blood work of the mothers I work with, which is not surprising considering iron deficiency is the most common nutrient deficiency in women of reproductive age (World Health Organization, 2008).

While it’s crucial to identify and address iron deficiency, recognising low levels is only the first step of the journey. Unfortunately, many women discover they have low iron levels, receive a prescription for a subpar supplement, and are left to navigate the rest on their own. However, sometimes the path to resolving this issue is more intricate. It involves understanding the root cause, selecting the right form, dose, and timing for supplementation, and considering how to sustain adequate iron levels via the diet once supplementation is stopped.

In this article, I’ll be highlighting 5 things you need to understand to not only correct your iron levels but maintain optimal levels in the long term.

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Firstly, why is iron important?
#1: You need to understand why your iron levels are low
#2: Not all iron supplements are created equally
#3: Is it just low iron, or is it iron + something else?
#4: Realistic timeframes for correcting low levels
#5: Eating enough iron rich foods to maintain your levels
Your personalised iron-support plan

Firstly, why is iron important?

Before we dive deeper on the important things you need to know to correct your low iron levels, let’s take a quick look at why iron is important in this phase of life.

During the perinatal period, particularly during pregnancy, we have a greater need for iron to support the physiological processes of growing and birthing new life. In pregnancy, women need 27mg/d of iron, compared to 18mg/d while menstruating and 9mg/d while breastfeeding.

Iron is unique in that it is one of the very few nutrients that we need less of postpartum (if breastfeeding) than we do when pregnant. This accounts for lactational amenorrhea (the absence of the menstrual cycle due to breastfeeding) and the lack of blood loss each month.

These daily intake levels (RDIs) mentioned above can guide us about roughly how much iron each mother needs, but there are many factors unaccounted for in these general guidelines, including iron status before & during pregnancy, type of birth, postpartum haemorrhage, stage of postpartum healing, and any future plans for more children.

Some of the essential functions of iron in the perinatal period include:

Tissue healing after pregnancy & birth
Energy production
Mood regulation
Mental clarity
Supporting good quality sleep
Production of hormones (thyroid & oestrogen)
Immune function

Common signs & symptoms of deficiency include:

Fatigue
Weakness
Pale skin
Paleness of the gums, nail beds, palms, or conjunctiva
Shortness of breath, especially after exertion or exercise
Heart palpitations
Poor concentration
Low mood
Poor appetite
Cold sensitivity
Feeling easily overwhelmed
Restless legs at night
Brittle hair and nails
Hair loss (however, remember postpartum hair loss is a normal part of the hormonal recalibrations after pregnancy)

**#1: You need to understand why your iron levels are low**

Commonly, the approach to iron deficiency stops at supplementing without investigating the root cause of the deficiency. While inadequate intake from food is a frequent contributing factor, especially in the perinatal period where the demand for iron can be significantly increase (such as during the late stages of pregnancy, see more above), there are other potential culprits to consider.

In addition to low dietary intake, some of the other causes to consider and investigate properly are:

Postpartum haemorrhage
Heavy menstrual blood loss
Coeliac disease
Infections, in particular gastrointestinal infections like parasites
Ongoing inflammation (leading to iron deficiency of chronic disease)
Other blood loss, e.g. through the digestive tract in conditions like inflammatory bowel disease, ulcers, or polyps
Issues related to poor absorption, such as low stomach acid or insufficient digestive enzymes

Other nutrient deficiencies

Iron metabolism in the body is also dependent on other nutrients like copper and vitamin A, and a deficiency of either of these can impact how effective supplementation will be. Vitamin B12 and folate are also both needed for effective red blood cell formation (important for iron’s role in the molecule haemoglobin found within every red blood cell) and co-supplementation can improve iron status.

If the true underlying cause/s is not properly identified and addressed, supplementation may be ineffective at increasing levels, or if they do increase levels, then they may just drop again once supplementation is stopped. The goal is always to use iron supplements for the shortest time needed and no longer, so the true cause for low iron levels must be identified as soon as possible.

Related blog: Do you have postnatal depletion?

#2: Not all supplements are created equally

Iron supplements vary widely in their quality, dose, and form. Choosing the right supplement tailored to your needs is crucial.

Dose:

Contrary to common belief, more isn’t always better when it comes to iron dosage. Many widely recommended over-the-counter iron supplements are excessively high in dose, which can flood the digestive tract with iron and trigger the shutdown of absorption pathways (mediated by a protein called hepcidin). Doses under 40mg/d are more beneficial as they appear to avoid this blockage of absorption.

Form:

Research from recent years highlights that one of the most efficiently absorbed forms of iron is iron bisglycinate. This form is very well tolerated and avoids many of the common side effects associated with other forms found in supplements, such as constipation or nausea.

Timing & interfering factors:

The timing of when you take your iron supplement is also very important, as absorption is highest at certain times of the day and can be impacted by other interfering factors. The ideal timing for iron supplements is either first thing in the morning or last thing at night, taken on an empty stomach, and taken away from coffee, tea, large serves of dairy, and other supplements containing calcium, zinc, or magnesium. These things should be separated from iron supplements by ideally 2 hours. If iron on an empty stomach makes you feel nauseous, take it alongside a meal (bonus points if the meal is rich in iron!)

Frequency:

Finally, there is evidence that shows up that intermittent dosing, such as every second day or a few times a week, is just as effective, if not more so, than daily high doses. This is most likely due to the absorption mechanisms mediated by hepcidin (as mentioned above).

Related blog: The Ultimate Prenatal Vitamin Guide

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#3: Do you only have low iron? Or do you have low iron + something else?

While it’s great that iron levels are almost always screened for in women of reproductive age, it’s not unusual for low iron levels to coexist with other imbalances.

So before your fatigue or mood changes or any other symptoms you’re currently struggling with are blamed solely on low iron, a thorough assessment should be completed to screen for other common causes of fatigue and exhaustion, and other common imbalances seen in the perinatal period, such as low thyroid function, low vitamin B12 levels, blood sugar imbalances, or chronic stress.

#4: Realistic timeframes for correcting deficiency

Iron levels can be slow-moving and most women will need to supplement for several months before seeing a meaningful increase in iron levels (commonly measured via the ferritin marker, but a full iron studies panel, c-reactive protein, and full blood exam is the most comprehensive way to assess iron level).

If your prescription is well-matched to your starting iron levels and needs, and underlying imbalances have been screened for and are being addressed, then an increase of 10-20 mcg/L of your ferritin levels every 3 months is realistic. This can mean, depending on your current levels, that correcting iron deficiency can take upwards of 6 months.

Regular retesting, ideally every 3 months, is important to track whether the progress is sufficient. If your levels haven’t improved or are progressing slower than expected, it’s essential to reassess the prescription or explore other potential underlying causes hindering an increase.

Instead of taking a passive ‘wait-and-see’ approach, proactively retest regularly and be prepared to adjust your treatment strategy based on the results observed every 3 months.

#5: Are you eating enough iron-rich foods to maintain levels long term?

While low intake of iron from food and your diet is only one possible cause of iron deficiency (see #2 above for the others), it’s certainly the most common one I see in clinic. So, in these cases, while supplementation is useful for getting levels up more quickly than can be done from food alone, focusing on increasing intake of iron from food should also be a primary goal from the very beginning.

Prioritising iron rich foods can be a confusing topic these days, because the best sources of iron are animal foods like meat, fish, seafood, and organs. However, the general public health message is to reduce intake of animal foods due to their associated risk with conditions like cardiovascular disease and cancer. Many women hear this message and think they’re doing the right thing by avoiding animal foods, if not completely then as much as possible. But this only serves to increase the risk of iron deficiency, especially during high-need periods like pregnancy.

Plant foods do contain iron, but due to the significantly lower bioavailability of iron from plants (meaning lower absorption and utilisation) this can leave women short changed when it comes to the actual amount their bodies are receiving from the foods they are choosing.

The absorption rate can vary as much as 20% between animal sources and plant sources of iron (average is 25% and 5% respectively). It is well-recognised in nutrition science that when consuming iron from plants, an individual may need to consume up to 80% more iron than if they were obtaining it from highly-bioavailable animal source (NHMRC, 2005), and yet this is rarely mentioned in the public conversation about iron for women. Dietician Lily Nichols recently wrote an excellent article on this topic for those interested in a deeper dive on this.

In the perinatal period, women need to prioritise the most bioavailable sources with every main meal, especially if pregnant or menstruating, as needs are high in these times (27mg/d and 18mg/d respectively). This is significantly less than I see most women consuming, whether plant-based or not.

For vegetarian or vegan women, iron-rich plant foods become unequivocally important and should be the foundation of every meal. These foods include nuts and seeds like cashews, pumpkin seeds, and sesame seeds, cooked leafy greens, broccoli, cooked beans, and tofu. Absorption of plant iron can be increased by vitamin C, therefore pairing iron-rich plant foods with vitamin C-rich foods is recommended for vegans and vegetarians.

Your personalised iron-support plan

Correcting iron deficiency is not always as easy as simply taking a supplement and hoping for the best. As we’ve discussed, it’s important to understand the ‘why’ behind your low iron levels and then come at treatment from this angle, understanding that supplements are just one part of the equation.

If you would like support to formulate your own personalised iron support plan, I work with women across the perinatal period to correct iron deficiency and uncover and address other underlying causes for fatigue and exhaustion. You can see how I can support you here.

Do you have any other questions about your iron levels or iron deficiency? Leave them in the comments below and we can chat more.

Georgie xx

References:

NHMRC. (2005). Nutrient Reference Values for Australia and New Zealand. Australian Government Department of Health and Ageing.

World Health Organization. (2008). Worldwide prevalence of anaemia 1993-2005: WHO global database on anaemia. / Edited by Bruno de Benoist, Erin McLean, Ines Egli and Mary Cogswell. 40.