Plant-based diets, low iron & what to do about it!
In 1709, a French physician and philosopher named Julien Offray de La Mettrie uttered the poetic (but somewhat misguided) phrase
The human body is a machine that winds up its own springs: it is a living image of the perpetual motion.
I suspect old mate Julien has never had low iron.
When you have low iron you feel nothing like an efficient machine, perpetually powered by self-winding springs. You feel more like a rust-bucket, gears grinding to a halt, brakes screeching, tyres slowly deflating.
If he doesn’t know what that feels like, our French amigo is rather lucky. Iron deficiency is really common, and unfortunately in many cases it can go undiagnosed and untreated for long stretches of time.
I think there are a few reasons for this. Firstly, you can have quite low iron levels without feeling absolutely exhausted. You might get sick slightly more often than before, you might feel a little less driven, a little less motivated, but it’s more of a general murky lethargy, rather than some acute whallop over the head that sends you to bed for days on end. It’s not until your levels get really low that you start thinking surely something has to be up.
Secondly, we live in a culture that often praises exhaustion and overwork, as though they are signs of virtue. In the face of others’ stupefying overachievement, many of us are left wondering WHY we’re not going at 100 miles an hour too. Personally, when I’m tired I have a terrible habit of just feeling guilty about ‘under-functioning’. Instead of simply listening to my body and allowing myself to rest, I try to push through at half-pace, while still feeling guilty and lazy anyway. If you’re at all like me, you might be misdiagnosing yourself with a case of laziness, when really there is an underlying physiological cause that ought to be addressed.
Iron is an essential mineral. We need it in order to make Hemoglobin, a protein that enables red blood cells to carry oxygen throughout the body. So, when your iron levels are low, it is harder get enough oxygen to the tissue and muscle cells that need it. All of our cells require oxygen (and glucose) to be able to generate energy, so: low iron = impaired hemoglobin production = reduced oxygen transport = low energy.
An important thing to note is that low energy isn’t the only symptom of low iron. If less oxygen is reaching your cells, your body can be affected in numerous ways. It may help to familiarise yourself with the other symptoms of low iron, so you know what to look out for.
Symptoms of iron deficiency
My own experience of that murky, low-iron-induced lethargy took the form of: progressively finding more and more excuses not to exercise; sleeping for 8 or 9 hours but still waking up tired; the occasional head-spin and stars-in-the-eyes sensation when I stood up too fast; a sporadically fluttering heartbeat (disconcerting!); progressively darker and bigger under-eye circles and a general lacklustre, unmotivated sense of fatigue and weakness. I have also recently found myself CRAVING burgers and steaks, which is very unusual for me (I asked the doctor about this and she confirmed that sudden meat cravings can also indicate low iron!). Other symptoms of iron deficiency can include:
Unusually white inner-eyelids (these are usually pink or red in people with normal iron levels)
Shortness of breath
Cold hands and feet
Getting sick more often than usual
Inflamed or sore tongue
Restless legs (a strong desire to move or twitch your legs, which is often worse at night)
Other unusual cravings (for things like ice, chalk or dirt!)
Fortunately for me I didn’t get sick noticeably more often or have an inflamed or sore tongue, restless legs or a craving to eat ice, chalk or dirt. However, pretty much all the other symptoms ring true (I’ve always been pale though so who knows if that’s low iron or just my Nanna’s Irish genes coming through).
So, what leads someone to become iron deficient? There are a few factors that put some people more at risk of developing an iron deficiency. These are:
Once again, my sisters, it seems we’ve got the short end of the stick! Women are much more likely than men to be iron deficient, for three main reasons: 1. monthly blood loss, 2. the physical demands of pregnancy, and 3. the physical demands of breastfeeding. All three of these bodily processes require heaps of iron, so if we’re not consuming enough we’re likely to develop an iron deficiency. Dang!
Chronic blood loss.
It’s not just blood loss through periods that can cause low iron. If you’re susceptible to frequent nosebleeds (although I’d imagine they have to be pretty damn frequent), if you regularly donate blood, or if you have another medical condition that is causing blood loss, you may find your iron levels dropping too.
Children and adolescents require extra iron to fuel their growing bodies. Interestingly, you may also need to increase your iron intake if you’re trying to grow yourself one of those widely-revered Kardashian-esque behinds (or, in other words, if you’re trying to put on muscle mass). Doing regular and intense exercise or doing a lot of weights prompts the body to ramp up its red blood cell production, and increased iron intake is required to support this.
It’s a simple enough equation. To have enough iron in your body you need to be consuming enough iron in the first place. Dietary iron comes in two kinds: heme iron and non-heme iron. Heme iron is the iron that comes from animal products, especially lean red meat and seafood (particularly clams, mussels, oysters and caviar). Non-heme iron is the kind found in plants. Unfortunately, our bodies are generally better at absorbing heme iron than non-heme iron, which is a P.I.T.A for vegetarians and vegans. The good news is that you can increase your absorption of iron (both heme and non-heme) by eating them alongside foods rich in vitamin C (like tomatoes, oranges and lemons). Plenty of people are able to maintain vegan and vegetarian diets, and as long as they make a concerted effort to eat plenty of pulses, legumes and other iron-rich foods, they do ok. For some of us, however, it’s a bit of an uphill battle, for the following reason:
Some of us are just crappy iron absorbers. Pretty sure that’s me. I eat healthily most of the time. I try to get my fill of chickpeas, tofu, lentils and other iron-rich foods. But without supplements to help boost my levels I’ve found that they continue to drop over time.
So, how much iron is enough?
If you’ve previously had your iron tested you might be familiar with the kinds of values that come back from an iron test. Usually when you take a blood test to assess your iron levels, what’s really being measured is the amount of Ferritin in your blood. Ferritin is the main protein in charge of storing iron, so if you have high levels of Ferritin, it suggests that you’ve got a lot of iron in your blood. If your Ferritin levels are low, it suggests you may be iron deficient. Ferritin levels usually range from 12 to 300 nanograms per millilitre of blood.
My blood test
When I got tested, my Ferritin level was 27. I’ve had a ferritin level of 20 before, and I have a hunch it was even lower at one point (around the time I lost interest in bothering to make my bed and when just holding up clothes on coat changers exhausted my arms!). My doctor gave me this rule of thumb for interpreting your Ferritin level results:
If your Ferritin is below 50 it is considered low and supplements, a change of diet or an iron infusion may be recommended
If your Ferritin is between 50 and 100 and you feel tired, your tiredness is likely due to an iron deficiency, and supplements, a change of diet or an iron infusion may be recommended
If your Ferritin is above 100 it is considered normal, and you may be feeling tired for other reasons.
The most important thing to remember is that before you try to adjust your diet, start supplements or ask for an iron infusion, the sensible course of action is to determine exactly what your Ferritin levels are. You do not want to start taking over the counter iron supplements on the off-chance that you might have an iron deficiency because too much iron is damaging to the liver and can harm other organs.
So you have low iron, what next?
Ok, so you did the right thing and got your Ferritin levels tested and they came back in the low range. Now you’ve got a few options.
Firstly, you could try to adjust your diet. As I’ve mentioned, the foods we eat contain two types of iron: Heme and Non-heme. Good sources of Heme iron include lean red meat, liver, egg yolks, shellfish and molluscs. Good sources of Non-heme iron include lentils and other pulses, oats, green & leafy vegetables, beans, brown rice, dried fruits (especially apricots) and nuts.
The annoying thing for people who would like to follow vegetarian or vegan diets is that our bodies are just generally better at absorbing Heme iron (the kind found in animal products). Basically, it is easier for our bodies to access the iron stored in animal meat because of the way the iron is bound to the other molecules in the meat. We can still extract and absorb non-heme iron from plant products, but we need to eat a lot more of them to get the same amount of iron into our bloodstreams. For a more in-depth explanation about iron regulation and transport in the body, check out this article.
If you’re a good iron-absorber (unlike me) it is possible to get enough dietary iron from an entirely plant-based diet. You just gotta bulk up on the beans! However, if you’re not great at absorbing non-heme iron, you might need to boost up your levels. You can do this via iron supplements, or you can opt for an iron infusion.
I’ve only tried taking one iron supplement so far - a liquid-based supplement called Spatone. Many pill-based iron supplements are known for their less-than-desirable effects on your digestive system (read: constipation). Keen to avoid anything like that, I opted for Spatone, as it is known to have a milder effect on digestion. And it’s not bad. It boosted my iron up from 20 to 50 in a few months last year, but it’s not the cheapest thing in the world (about $1 per sachet, and I was taking 2 a day) and you have to take it every day for a few weeks before you start noticing an effect. Nevertheless, I think I’m going to go back to using Spatone more consistently, because it’s still cheaper than a daily takeaway coffee and gives a much bigger energy boost in the long run.
This time when I found out my iron was low again I’d had enough. I had already started including clams and other molluscs into my diet in an attempt to get some Heme iron, and for a while I thought it was working, but… no luck. I was sick of feeling tired and run down and, to be honest, I wanted a quick fix. I was also just curious about the whole thing. I have no idea what it feels like to have normal levels of iron, and I thought that an infusion would give me a really clear and rapid comparison that I could hold onto. I wanted way to know ‘this is what good feels like’ so that I could tell if my levels dipped below ‘good’ again in the future.
Iron infusions take 1-2 hours (usually closer to 1 hour) and involve intravenous delivery of iron (mixed with a saline solution) directly into your vein. You CAN also get an iron injection, where the iron is injected directly into your muscle (usually on your buttocks). These take next to not time, but are known to be much more painful and can leave a rust-coloured stain that takes UP TO TEN YEARS to fade. No thanks, I’d rather 2 hours of sitting around and no decade-long stain!
Before your infusion your doctor will write you a script for the iron that will be injected into your veins. Mine was called Ferinject. It was a 10ml vial, containing 500mg of iron. My doctor prescribed two vials (1000mg of iron), but when I came in on the day he decided I only needed one. You take your prescription and pick the iron up from the pharmacy, then bring it to the clinic where you’ll have the infusion. It gets mixed with ~250ml of saline solution. Combined, the iron and saline look like a big murky brown bag of mud. Mmmm iron-mud, dripped directly into your veins, delicious.
The actual procedure was easy and fine. The doctor inserted a cannula into my vein in my left arm, which barely hurt at all, then he injected a bit of saline solution through the cannula into my vein (they do this to make 100% sure that the cannula is going directly into the vein, as opposed to into the tissues surrounding the vein). I thought it might be uncomfortable having the saline solution shot through my vein, but all I felt was a gentle cold sensation creeping up my arm. Then the nurse attached a tube to the cannula, which the bag of iron-water dripped through.
Side note - interesting fact! Did you see that episode of House MD or whatever it was where someone got an air bubble injected into their vein and then immediately died? TOTAL BOLLOCKS. I was sitting looking at my iron-water dripping into my vein and noticed a bubble in the tube and obviously immediately thought if it reached my vein I’d immediately die. Turns out you’d have to inject something like 50ml of air into your vein for there to be any problem, little bubbles are fine. So if you see a little bubble in your IV drip tube don’t stress!
It takes about 30 minutes for the iron-water to go into your veins through the IV. Then, when that’s done, the nurse swaps in a new 250ml drip-bag (I don’t know what it’s actually called so I’m calling it a drip-bag). This time the bag just contains saline solution. They feed that into your veins for another 30 minutes. This is done to ensure that there’s no iron left floating around in the vein at the injection-site, which might leak out and stain the surrounding skin that rust-colour (works like a charm, my skin stayed all nice and normal coloured). The nurse monitors you the entire time to make sure you aren’t having an allergic reaction to the iron. Allergic reactions are very rare, but if your face starts to feel itchy, your tongue starts to swell or you start to have difficulty breathing the nurse is on hand to take care of you. All up, everything should take about an hour, then you’re all done.
After the infusion.
I felt totally fine after the infusion. My arm was a little sore where the cannula had been put in, but otherwise I felt totally normal, and was able to leave the doctors’ clinic right away.
In the days following the infusion some people can have some side-effects. Generally these are mild and resolve themselves in a few days. I had a very mild headache the day after my infusion and I felt a bit wiped out. Apparently you can get flu-like symptoms two days after the infusion (things like muscle aches, severe headaches, fever and fatigue)… in my case two days after the infusion would be tomorrow, so cross your fingers for me! Reactions like that are really rare though - only about 1 in 4000 people experience them - so the odds are in my favour!
6 weeks after your iron infusion you should make an appointment to get your iron levels tested to confirm that the infusion did its job, and that your levels are now back to normal. My doctor told me he expects my iron levels to shoot up in the next few weeks, from 27 to 220! I don’t think my iron has been that high in at least a decade, so I’m pretty excited about it! The other good news is that once your levels are bumped up, even if you struggle to get enough iron to keep them there, your body will still lose its iron stores very slowly. My doctor told me that if I continue to lose iron at the same rate that I was before the infusion, my levels should only drop about 30-50 units per year. This gives me at least two good years before my levels get under 100! Huzzah!
If you think you might have an iron deficiency I hope you found this information useful. It’s a real pain but the good news is it’s so common and really easy to treat. And stay tuned, because I’m going to keep an eye on my energy levels (and the rings under my eyes) over the next few weeks, and I’ll add a few little diary entries (replete with unflattering photos) to this as I go, to show how long it took me to start feeling better and looking less like a haggard ghost!