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Eat enough iron but still deficient?

"I eat red meat every day and I'm still iron deficient!"

They're words I commonly hear in clinic.

How can it be the case that you're eating well over the recommended daily intake for iron but your levels still aren't improving -- and in some cases may actually be dropping?

The answer, like most things health related, lies in the digestive tract.

Your body has a pretty hard job on its hand to regulate your iron levels. That's because, unlike other minerals, the body has no controlled and regulated excretion pathway for iron. Of course, if you menstruate you lose some iron there in an uncontrolled manner, and we lose some through other methods such as perspiration. But for the most part, once iron is in your system, it is simply recycled and redistributed according to your body's needs.

To complicate matters further, iron is a friend but also a foe. We need iron but too much of it can reek havoc so your body tightly controls how much it lets in.

This is where your gut comes in.

Any iron you consume orally (whether that be from food or supplements) gets absorbed through the small intestine.

Before it can be absorbed though, it has to first be cleaved apart from the food proteins it was attached to. This predominantly happens in the stomach and this process is reliant on you having adequate stomach acid, which many of us don't.

If you have consumed plant based (non-heme) iron, another step has to occur to change the form of the iron to the form that your small intestine can absorb.

Once the iron enters your small intestine, it needs to cross through the lining of the intestine to get into your bloodstream. For this process to happen effectively, you need to have a healthy intestinal environment. If the lining of your small intestine has been damaged through something like coeliac disease, excess alcohol, certain medications or small intestinal bacterial overgrowth, your ability to absorb iron is greatly reduced.

The final step to getting your iron out of your small intestine and into your blood stream is controlled by something called hepcidin. Hepcidin's job is to make sure too much iron doesn't get in, so it blocks absorption from your digestive tract. Your liver sends out hepcidin when it detects too much iron is present (e.g. you have just taken a couple of iron supplements or had an infusion), and it also sends it out if you are inflamed.

We often think of inflammation with regards to infected wounds but a much more common form is chronic low grade inflammation, which can be caused by a number of factors. Whenever there is inflammation present, which can be in your digestive tract, your body will reduce the amount of iron it lets in, via producing more hepcidin. In simple terms, this is because your body thinks the inflammation must be from a parasite or pathogenic bacteria. These pathogens feed on iron and use it to replicate, so in order to protect you from this, your body blocks iron from being absorbed. It also does other cool things like hide away iron that's already in your body, but that's a story for another day.

So now we have three possible scenarios that will reduce the amount of iron you absorb, regardless of how much you eat: 1) low stomach acid; 2) a suboptimal small intestinal environment; and 3) inflammation.

Every week I see people in my clinic with one or more of these factors (and there are other factors too!) that are impacting their ability to absorb iron.

The good news is that once we know what is causing your iron absorption to be blocked, we can get to work fixing it.

Book a consult today and let's get your iron deficiency sorted.

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