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There are a lot of potential reasons one might feel tired all the time. Sometimes it is simply a sleep issue, either not enough sleep or poor quality sleep. But if you feel your sleep is adequate and you still feel frequently tired, it might be time to look for a medical cause.
When people come in with fatigue, I always test their iron or check their recent blood work if it's been done. Low iron seems to be the most common cause of fatigue for my patients. Testing iron requires a blood test. A CBC and a Ferritin reading are what I typically run to look for iron deficiency. Both these tests are relatively cheap. A CBC is useful for assessing other forms of anemia as well.
Ferritin values are sometimes high in people with chronic disease even when iron stores are low. Sometimes we run additional tests to keep track of iron in those with chronic disease or inflammatory conditions.
While low iron is a frequent cause of fatigue, there are a number of other conditions in which fatigue is a symptom. Sometimes it makes sense to look for a thyroid disorder, autoimmune condition, digestive issue, mental health condition or even a heart pathology. The list of potential causes is large.
Which testing we select (I say 'we' because you are absolutely part of this decision making process) is based on symptoms, previous diagnosis, life circumstances etc. We don't want to waste money on useless tests but we should test enough to rule out anything big.
More often then not though, my fatigue patients test positive for iron deficiency anemia.
Why Do People Become Low in Iron?
There are 3 groups of causes for iron deficiency.
1. Inadequate Iron Intake:
This happens when your diet lacks sufficient iron-rich foods. Iron is found in both animal and plant sources. Animal sources are a bit more absorbable but it is usually pretty easy to get sufficient iron in the diet from plant sources with proper education.
Iron requirements are estimates and they need to be adjusted for age and life stage. The following table is similar to the one from Health Link BC and contains the amount of iron an individual should aim for each day. People who menstruate have higher iron needs than people who don't.
Age (years) | Male | Female |
1 to 3 | 7 mg | 7 mg |
4 to 8 | 10 mg | 10 mg |
9 to 13 | 8 mg | 8 mg before menstruation starts, 11 mg after menstruation starts. |
14 to 18 | 11 mg | 15 mg |
19 to 49 (or until menopause) | 8 mg | 18 mg |
After menopause (Around 50) | 8 mg | 8 mg |
Pregnancy | N/A | 27 mg |
Breastfeeding under 19 | N/A | 10 mg |
Breastfeeding 19 and over | N/A | 9 mg |
If you suspect your intake is low, you can track your intake by recording the foods you eat for a week to get an idea how much iron you consume. I like MyFitnessPal for this as it lets your log recipes fairly easily. If you find you are not hitting the above targets, there is a downloadable list of iron containing foods below that you can try to consume more often.
2. Increased Iron Loss:
Blood loss leads to iron loss because iron is stored in red blood cells. The most common cause of blood loss is menstruation which is why it is more difficult to maintain iron stores in that phase of life. Other common causes of increased blood loss include gastrointestinal bleeding from ulcers, hemorrhoids, or cancer. Endometriosis and heavy menses, kidney and bladder conditions can lead to blood loss. Chronic blood loss depletes the body's iron stores faster than they can be replenished. Of course, an episode of acute blood loss from surgery, child birth or an injury can lead to iron deficiency, though those situations are usually quite obvious.
To treat blood loss due to bleeding, you have to treat the cause of the bleeding and likely supplement iron. Severe bleeds may require more advanced care like an iron or blood transfusion (preferably in the ER).
3. Anemia of Chronic Disease:
Iron deficiency in the context of chronic disease, often referred to as Anemia of Chronic Disease (ACD) or Anemia of Inflammation, occurs when chronic illnesses interfere with the body’s ability to use iron effectively. Unlike simple iron deficiency anemia, where there is a lack of iron available, ACD involves sufficient iron stores in the body, but the iron is not used properly to make hemoglobin. Chronic kidney disease, inflammatory autoimmune conditions, cancer and chronic infections can all lead to this type of anemia.
Supplementation may be used as part of the treatment protocol for ACD when safe to do so but typically the chronic or inflammatory disease needs to be addressed.
How To Reverse a Simple Iron Deficiency
Anemias that are caused by lack of iron intake can usually be solved by increasing iron consumption. This strategy alone may not work so well for anemia of chronic disease and anemia due to excessive blood loss so it is often worth ruling those potential problems out. These two categories of conditions require additional treatment beyond increasing iron consumption.
Iron Replacement by Diet
Consuming more iron rich foods should be a part of all iron deficiency treatment plans. If you are able to consume more iron in your diet than you lose, your iron levels should stabolize in most cases. While supplementation is often easier than changing the diet, it is best to learn to consume enough iron by diet so iron supplements can be eventually stopped.
In the iron content chart linked above, you may notice the foods are arranged in order of most to least so you can focus on including the foods at the top of the list for the greatest effect. Pay special attention to the serving size as it is not consistent. I included plant and meat sources so you can see how they compare. While animal sources may be a bit more absorbable, many plant foods have a fair amount of iron. I see anemia fairly evenly among people who consume meat and people who do not. Consuming iron rich foods with vitamin C rich foods might help iron absorption a little.
Tracking iron intake each day can help people meet the daily goal in the above chart. You can add up iron sources on paper or use one of the many diet tracking programs. It takes a consistent effort to improve iron stores with diet alone but it is often achievable with some relatively easy dietary shifts.
Iron Replacement by Supplementation
Often I recommend iron supplements for my iron deficient patients to improve their iron levels quicker. I will not be including dose or specifics in this section because that advice is unique to each patient and iron supplementation really should be monitored, especially at higher doses. There are also some cancer risk implications surrounding some specific iron supplements. Be sure to talk to a health professional so you are fully informed.
Often patients need to supplement for a few months before their levels improve, they notice more energy and they feel better overall. Some people react poorly to high dose supplements. Like most natural health products, side effects and interactions are possible. Constipation is a common side effect and iron can bind to calcium and some drugs making them ineffective. If high dose supplements cause a problem, levels still improve dosing every second day or with lower doses. It may take a bit longer to recover iron levels on lower dosed supplements.
Regardless of the strategy, iron levels should be rechecked in 3 months to ensure they are improving.
Can I Get Too Much Iron?
Oh absolutely. Iron is one of the most overdosed natural health products. Iron poisoning, also known as iron overdose or iron toxicity, occurs when a person ingests too much iron, leading to toxic effects in the body. This condition is particularly dangerous because iron is highly reactive and can cause significant damage to organs and tissues when present in excessive amounts. The liver is particularly affected and the overdose can be deceptively fatal with patients appearing to recover before their condition gets worse.
Iron poisoning is very, unlikely if supplements are taken at their proper doses. It is important to keep these supplements out of the reach of young children, especially if they taste good.
Some people have a genetic predisposition towards having too much iron, called hemochromatosis. People with this condition do better using diet to reverse an occasional deficiency, though deficiency is uncommon in this condition (but still possible). People with hemochromatosis may require occasional trips to the blood bank to remove their excess iron.
I hope this is a helpful summary. If you have any general questions you would like me to add to this post, you are welcome to submit a question on the contact page. If you suspect you are iron deficient and would like to book an appointment to investigate, click on the blue Book Now button at the top of the page to see available appointment times.
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