SUBCLINICAL IRON DEFICIENCY Part 4

SUBCLINICAL IRON DEFICIENCY
Part 4

“Testing and Treating”
By G. Douglas Andersen, DC, DACBSP, CCN

When a patient's hemoglobin (Hb) and hematocrit (Hct) are not out-of-range, it is sometimes difficult for them to convince a gatekeeper that they need additional test’s to rule out an iron problem. When I suspect an iron deficiency in this type of patient, I'll recommend an iron trial. The test is positive if supplemental iron makes the patient feel better. Please note: I do not recommend iron just because a patient is tired. They must have other signs and symptoms (See Andersen, GD. Subclinical Iron Deficiency Part 3 Dynamic Chiropractic) and they must have a supportive history including regular iron losses with inadequate iron replacement. Because too much iron can act as a pro-oxidant, I do not have patients take iron for more than 7 days if they do not feel a big difference. Usually, a subtle change is noticed on the third day. By the 4th and 5th days, the change becomes noticeable. When a patient with normal Hb & Hct informs their gatekeeper how much better they feel after a few days of iron, additional tests for iron are almost always approved. When that happens, I tell the patient that even though 1 week of iron made them feel better, it is not nearly enough to alter tests that measure iron reserves.

There is no single test (other than a positive iron trial) that provides gold-standard accuracy for iron deficiency prior to the development of anemia. And since each test measures a different aspect of iron, conflicting results are not uncommon. Table 1 includes the most common tests to evaluate iron levels. Ordering a combination of tests, such as serum iron, ferritin and transferrin will reduce the chances of a misleading result. These are the three I recommend in those cases where a patient has insurance that allows the DC to order directly and avoid an iron trial. Then, depending on the extent of the deficiency, I will recommend a follow up test in 8-12 weeks. In those cases where the second test shows that the problem has been solved, I have males stop taking iron and females take it 5 days a month beginning on the first day of their period.

Table 1
Lab tests for Iron Evaluation

Substance Comments

Hemoglobin Often within normal ranges until anemia develops

Hematocrit Dehydration & high altitude can cause false normal by
raising test scores

Serum iron Used alone, it isn't an accurate marker because of
diurnal variations.

Serum Ferritin             The most accurate single test for low iron.
                                    Injury, infection and immune problems that promote
                                    inflammation can cause a false normal by
                                    elevating ferritin. Alcohol can also increase.

TIBC                            Total Iron Binding Capacity. The amount of iron
                                     that can be bound to serum protein. Positive
                                     when high. Oral contraceptives may elevate
                                     and cause a false positive.

Transferrin                   Concentration is proportional to the amount of
                                     iron bound to serum protein, therefore it is
                                     another way of expressing TIBC & is high when
                                     iron is low

% Transferrin               Serum iron divided by TIBC x 100 = percent
saturation                     of transferrin saturation. Like hemoglobin,
                                     this test may not be low until iron deficiency is
                                     significant.

*NOTE: Specific numbers were not included because normal ranges vary between labs.

Once you start looking for iron problems, you will discover 3 categories of patients who, with questioning, have diagnosed deficiencies they have not acted on.

1. Patients with low hemoglobin and/or hematocrit on a recent CBC.
2. Patients who were told that they have anemia but never acted on it.
3. Patients who tried iron and quit because of constipation, nausea or GI upset.

For patients who fall into the first or second groups, my first question is "Do you have iron at home?" If they do, I instruct them to take it, preferably in divided doses away from food, with some vitamin C ( either supplement or with orange juice). Compared to the RDA's, (see table 2) the amount of iron that's recommended to correct a deficiency or a full blown anemia (30 - 150 mg/d elemental) seems high. This is because iron is generally not well absorbed (although there is a wide variance between individuals.) Iron uptake also parallels iron reserves. As the deficiency declines, so does the absorption percentage.

Table 2
Iron – Recommended Dietary Allowances in Milligrams:
Ages Mg/day

7 – 12 months 11
1 – 3 years 7
4 – 8 10
9 – 13 8
14 – 18 11m, 15w
19 – 50 8m, 18w
51 + 8

Pregnancy - 27mg
Lactation under age 19,10mg. Over 19, 9mg
ods.od.hih.gov/factsheets/iron
There are many types of iron supplements available over-the-counter. The amount of elemental (actual) iron in them varies. So does the labeling. Some products list both total and elemental amounts. Others, such as most bis-glycinate (aka glycinate) will only list elemental levels. For example, a 300 mg iron pill from ferrous gluconate provides a true iron dose of 36 mg. See table 3.

Table 3
Common Iron Supplements
Type                                            % Elemental Iron
Ferrous sulfate                                        20%
Ferrous gluconate                                   12%
Ferrous fumarate                                     33%
Bis-glycinate chelate                               27%
Ferric ammonium citrate                       16.5%

Dosing

The dosing guidelines for iron also vary. Treatment for a deficiency can range from 30 to over 150 mg a day of elemental iron. In general, I begin with 50 to 120 mg a day in divided doses, taken away from food. Iron, unlike most minerals, is absorbed best on an empty stomach. I do not recommend more than 60 mg at one time. I will start with 1 in the morning and 1 before bed. If taking iron away from food causes nausea or an upset stomach, I have the patient take it with food. Vitamin C helps the body utilize iron, which is why it's advised to take some with iron. This may be a supplement or a glass of orange juice. A mega dose isn't required. 50 - 100 mg of vitamin C is all that's needed. Some iron products, contain vitamin C, which makes things easier for both provider and patient.
For those patients who have had, or do have side effects such as constipation or stomach problems (even when taken food) I recommend iron glycinate, technically known as bis-glycinate. This form normally comes in elemental doses in the 28-30 mg range. It causes dramatically fewer side effects than other forms.
Iron is tricky enough that this could easily be a 6-8 part series. If you have any questions, feel free to contact me.

1. Killip, S., Bennett, JM., Chambers, MD. Iron Deficiency Anemia. Am Fam Phys 2007. 75(5) 671-8.
2. Center for Disease Control and Prevention. Recommendations to prevent and control iron deficiency in the United States. MMWR 1998;47(No. RR-3).
3. Centers for Disease Control and Prevention. Iron deficiency—United States, 1999–2000. MMWR. 2002;51:897–9.

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