Three stages of iron deficiency
Deficiency does not develop abruptly, but sequentially, and understanding this sequence explains why the same person receives opposite answers from different doctors. The body spends iron in a strict order: first, the reserve in the depot is used up, then the work of enzymes and tissues begins to suffer, and only at the very end does hemoglobin decrease. A year or more often passes between the first and third stages.
- Предлатентный дефицит: запасы в депо снижаются, ферритин падает, гемоглобин и самочувствие ещё в норме.
- Латентный, или скрытый, дефицит: железа не хватает тканям и ферментам. Появляются выпадение волос, ломкость ногтей, слабость, зябкость, одышка при нагрузке. Гемоглобин при этом остаётся в пределах нормы.
- Собственно анемия: гемоглобина не хватает, эритроциты становятся мелкими и бледными, все симптомы усиливаются.
Recovery works in reverse order and requires patience. First, hemoglobin rises with the drugs - this happens within a few weeks, and the person becomes noticeably better. And it is at this moment that most people stop treatment, considering the task completed. But by this time the depot is still empty, and stocks take much longer to fill than the analysis normalizes. An incomplete course is the second most common reason for the return of anemia after unresolved blood loss.
Symptoms Rarely Attributed to Iron
Everyone knows pallor, weakness and dizziness. But iron is part of many enzymes, not just hemoglobin, so the pattern of deficiency can be completely unexpected and over the years can be explained by anything - stress, weather, age.
- Hair loss all over the head, brittle and peeling nails
- Sticking in the corners of the mouth, dry and cracked lips, burning and flattened tongue
- Perversion of taste and smell: urge to eat ice, chalk, raw dough, earth, like the smell of gasoline, paint, acetone
- Restless legs syndrome - discomfort in the legs in the evening and the need to move the legs
- Shortness of breath and palpitations during normal activity, tinnitus, spots before the eyes
- Chilliness, cold hands and feet even when warm
- Decreased concentration, feeling of brain fog, irritability, poor exercise tolerance
- In children and adolescents – decline in academic performance, lethargy, stunted growth
- Frequent colds and long recovery after them: iron is also needed for normal immune function
A separate feature of this state is gradualism. The body manages to adapt to the slow decrease in hemoglobin, and the person stops noticing that he is getting more tired, can handle stairs less well, and wakes up exhausted. Therefore, people usually go to the doctor not with a complaint of anemia, but with hair loss, brittle nails, or with a desire to figure out why they “don’t have the strength,” and the reason is found along the way. In adolescents, the picture is further masked by rapid growth and workload at school, in pregnant women - by the pregnancy itself, in the elderly - by age and concomitant diseases.
Where does the deficit come from?
The reason always comes down to one of three options: more iron is lost than it is supplied; the need for it has grown; or it has ceased to be absorbed. Finding a specific mechanism is fundamentally important, because a course of drugs without eliminating the cause gives only a temporary result - anemia returns a few months after discontinuation.
- Heavy and prolonged menstruation is the most common cause in women
- Pregnancy and breastfeeding: the need for iron increases sharply
- Adolescence: rapid growth plus the onset of menstruation in girls
- Hidden blood loss in the gastrointestinal tract: erosions, ulcers, polyps, hemorrhoids, tumors
- Helicobacter pylori infection and atrophic gastritis - interfere with iron absorption
- Celiac disease and other diseases of the small intestine
- Stomach and intestinal surgeries, including bariatric interventions
- Strict vegetarianism and veganism without monitoring indicators
- Regular blood donation without replenishment
- Intense training, especially long-distance running
- Long-term use of drugs that reduce stomach acidity: without acid, iron from food is less absorbed
- Chronic kidney disease and chronic inflammatory diseases - here iron is not so much lost as blocked in the depot
- Multiple pregnancies and short birth intervals
- Diet with a predominance of tea, pastries and dairy products with a small amount of meat
It is also worth remembering the rule that doctors consider mandatory: in men of any age and in women after menopause, iron deficiency anemia is a reason to look for the source of blood loss in the digestive tract, even if there are no complaints about the stomach at all. In this group, it is often the first and only sign of a polyp or intestinal tumor.
What tests are really needed?
The minimum kit for assessing iron metabolism is much shorter than it seems, but a general blood test alone is not enough. It is also important how the tests are done: ferritin is not taken while taking medications has already been started and in the first weeks after an acute infection, otherwise the result will be overestimated and uninformative.
- Общий анализ крови с эритроцитарными индексами: гемоглобин, эритроциты, средний объём эритроцита (MCV) и среднее содержание в нём гемоглобина. При дефиците железа клетки мелкие и бледные.
- Ферритин — главный показатель запасов железа, его смотрят в первую очередь.
- Насыщение трансферрина железом и общая железосвязывающая способность сыворотки — уточняют картину.
- С-реактивный белок: ферритин повышается при любом воспалении, и на его фоне нормальная цифра способна скрыть реальный дефицит.
- Витамин B12 и фолиевая кислота — дефициты часто сочетаются и меняют картину крови.
- Поиск причины: анализ кала на скрытую кровь, гастроскопия и колоноскопия по показаниям, осмотр гинеколога, оценка функции щитовидной железы.
A separate situation is small red blood cells with normal or high ferritin. This is a reason to think not about iron deficiency, but about a hereditary feature of the structure of hemoglobin: thalassemia occurs quite often in the region, is lifelong and cannot be treated with iron supplements. Moreover, prescribing iron in such a situation is useless and unsafe if taken for a long time, so a ferritin test is also important as a way to avoid starting unnecessary treatment.
Pomegranates, buckwheat and hematogen: analysis of the myth
The advice “eat pomegranates and buckwheat will raise your hemoglobin” is passed down from generation to generation and remains the most common cause of lost months. The problem is two things at once: the amount of iron in the product and the form in which it is there.
- There is very little iron in pomegranate - fractions of a milligram per 100 grams, and even less in juice
- Buckwheat contains more iron, but it is non-heme plant iron: only a few percent is absorbed, and the phytates contained in the cereal interfere with this
- Heme iron from meat, liver and offal is absorbed many times better, but it also cannot meet the daily requirement for anemia: medicinal quantities simply do not fit on a plate
- Apples, beets, red wine, decoctions and pharmaceutical hematogen belong to the same category - this is a product, not a medicine
- Tea, coffee, dairy products and calcium supplements taken with food further reduce iron absorption
The correct conclusion is not that nutrition does not matter, but that it works for prevention and retention of results. Already formed deficiency is covered with drugs, and the diet helps not to return to the same state later.
How to take iron supplements so they work
A significant part of unsuccessful treatment is explained not by a “bad drug” or individual immunity, but by the way in which it was taken. Iron is sensitive to other foods and medications, and a few simple rules change the result more than choosing a specific remedy.
- Принимать натощак или хотя бы за 30–60 минут до еды: вместе с пищей всасывание заметно падает.
- Запивать водой или кислым соком — витамин C улучшает усвоение.
- Не совмещать с чаем, кофе, молоком, кальцием, антацидами и средствами, снижающими кислотность желудка: между ними и железом нужен интервал в несколько часов.
- Разводить по времени с некоторыми антибиотиками и препаратами для щитовидной железы.
- Настроиться на длительный курс: гемоглобин обычно поднимается за 4–8 недель, но приём продолжают ещё несколько месяцев, чтобы наполнить депо. Контроль ведут по ферритину, а не по самочувствию.
- Схему подбирает врач: в ряде случаев железо, принятое через день, усваивается лучше ежедневного — так работает регуляция всасывания в кишечнике.
Separately, it is worth mentioning the effectiveness criteria. 2-4 weeks after starting treatment, the doctor usually prescribes a control test: hemoglobin should increase noticeably. If this does not happen, the matter is not that you need to “drink longer,” but one of three reasons: the drug is not taken correctly, the iron is not absorbed, or ongoing blood loss persists. Each of them is solved in its own way, and in such a situation they return to searching for the cause, and do not just change the packaging.