& What To Do About It.
Iron deficiency is one of the classic "risks" that people assume vegans are vulnerable to. It's true – we are at risk. But hey, so is everyone. In fact, iron deficiency is the most frequent nutrient deficiency and the most common health problem in the world  – that's right, it's not just a vegan problem! I have seen frequent meat-eaters with debilitatingly low iron levels, and vegans who never have a problem – but mostly I see new or life-long vegans who are worried about their iron levels, are unsure if they're getting enough, or are taking unnecessary iron supplements.
Iron is a tricky mineral – it is dangerous in high amounts, but a deficiency can be debilitating. The lower iron levels become, the less iron your intestines absorb, and the harder it is to recover from the deficiency. Understanding the sneaky signs and symptoms of low iron can help you get a diagnosis and treatment before your levels drop too low.
Blood & Iron
Iron is an essential trace mineral that the body uses for growth, energy production, and immune health. One of its major roles is in the formation of healthy blood and carrying oxygen within red blood cells. It is essential for both the synthesis and function of haemoglobin, a protein that is like a long, wriggly ribbon bunched up inside red blood cells that carries oxygen from the lungs to cells all over the body. Attached to the haemoglobin “ribbon” are iron ions – they must be there for oxygen ions to attach to. Without these iron ions, haemoglobin just doesn't work .
Completely essential to life, right?
Iron Deficiency vs Anaemia
According to the Merck Manual:
"... anemia is a condition in which the number of red blood cells or the amount of hemoglobin is low.”
Because of its role in both the production of red blood cells and healthy haemoglobin, iron deficiency leads to anaemia – but is not anaemia in and of itself. Iron deficiency can present without anaemia, and anaemia can also present without an iron deficiency due to other causes (e.g. vitamin B12 deficiency, hereditary conditions, some types of cancers).
Causes of Vegan Iron Deficiency
Red blood cells contain a lot of the body's iron, so losing any blood can deplete iron levels quickly. We're talking bleeding disorders, frequent nose bleeds, heavy or irregularly frequent menstruation, surgery (including giving birth), or frequent blood donations. Blood loss can also be sneaky – some gastrointestinal disorders can cause bleeding in the intestines that is difficult to detect as the blood combines with the stool. Gut damage that leads to this kind of subtle blood loss and iron deficiency can also be caused by the use of some over-the-counter pain relievers such as aspirin and ibuprofen!
Given that iron is a trace mineral (i.e. there is very little of it found in our food), it can be challenging to reach the required amount through diet alone without making a serious effort – this goes for all types of diets, from those blood-mouth Paleos to the angelic raw vegans! The Australian recommended daily intake (RDI) of iron ranges from 6mg to 18mg per day, depending on gender and life stage. These requirements are even higher during times of growth such as pregnancy, breastfeeding, childhood, adolescence, and even body building or starting a new work-out routine.
Endurance activities like marathon running and long-distance swimming also eat up iron stores, and can also cause a premature break-down of haemoglobin in the blood. Sure, vegetarians and vegans need to keep an eye on their iron intake – the highest levels of dietary iron are found in meat and other animal products. But guess what? A 2016 prospective study found that vegans had higher intakes of iron than meat-eaters! 
Any disorders or diseases of the small intestine (e.g. coeliac disease) can stop the absorption of iron, leading to an iron insufficiency and eventually to a deficiency. But other issues with digestion can also affect iron levels – for example, stomach acid is required to free iron from protein-rich foods like tempeh during digesting. Without adequate digestive fluid, iron remains trapped in the food and excreted through the bowels. There are a number of reasons for low stomach acid – most commonly, it naturally decreases as we age!
NOTE: Conditions that cause bleeding in the gastrointestinal tract (peptic ulcers, colon polyps, or hernias) can go undetected until serious symptoms appear – tell your doctor if you experience any gastrointestinal symptoms alongside iron deficiency.
Additional Risks Factors for Iron Deficiency in Children:
Low birth weight or premature birth
Mother with low iron levels during pregnancy and/or breastfeeding
High intake of cow's milk before two years of age
Unbalanced diet (vegan or otherwise)
Additional Risk Factors for Iron Deficiency in Teenagers:
Extreme or sudden growth spurts
Onset of menstruation, often with heavy flow
Fad diets and restricted eating
Iron Deficiency Symptoms
Fatigue & Weakness
Fatigue is a common symptom of iron deficiency, with or without anaemia . Without enough iron, blood cells don't deliver enough oxygen to tissues throughout the body. Almost all cells in the body require oxygen to create energy. This is particularly true of the brain, which utilises over 25% of the body's total oxygen consumption – more than the skeletal muscles, skin, and liver!  When the brain is drained, symptoms of fatigue set in.
Fatigue can be hard to define and it usually has a gradual onset.
Here's what fatigue could look like:
Difficulty waking up, or hitting the snooze button a lot no matter how much sleep you had.
Tiredness after mild exertion like walking, showering, or carrying groceries.
Lethargy or a feeling that it is too much of an effort to do anything, including getting up off the couch. This is usually a physical feeling, not mental – but it could be both!
Feeling like it's too much effort to socialise or interact with others.
Weakness is different to fatigue but they tend to go together in iron deficient anaemia (but not always! Tricky!). Weakness has more to do with a lack of oxygen that is being delivered to the skeletal muscles. This results in a deficit of cellular energy, meaning that the muscles don't have enough “juice” to contract and relax properly.
Weakness could present as:
Finding it difficult to lift things that used to be easy to haul (e.g. bags of groceries, babies, pets...)
Feeling like you have pushed yourself to your physical limits even when you have been sedentary – e.g. feeling like you've gone for an extra-long hike when you've actually been on the couch all day.
Muscle soreness that isn't improved with stretching, baths or massage.
Poor grip strength. Opening jars is suddenly really difficult.
NOTE: Fatigue and weakness are very common symptoms for a huge variety of health conditions – particularly acute illnesses that may go away on their own – but tell your doctor or medical team if you experience weakness or fatigue for over 2 weeks – it could be due to an iron deficiency or anaemia.
NOTE 2: While weakness and fatigue are the most common symptoms of iron deficient anaemia, some people can have an iron deficiency without developing these symptoms at all! Don't wait around for the fatigue to kick in if you are experiencing any other symptoms.
Mood Swings, Depression & Anxiety
As if feeling weak and run down isn't bad enough – research has shown that low iron levels may contribute to mood swings and conditions like depression and anxiety. A 2018 study of 1,000 adults found there was a strong connection between iron levels and depression. Most people who had a history of depression also had history of low iron .
Iron is essential for the creation of the hormones and neurotransmitters (chemicals that work with the nervous system and brain), particularly the ones that influence mood, cognition, and mental well-being.
Studies have shown that low iron levels can seriously decrease the amount of adrenaline and noradrenaline found in the brain. Low amounts of these key hormones can cause feelings of apathy and a condition called “low arousal” – nothing can get you up and going! Low iron has also been shown to cause low levels of serotonin – this is the “happy” neurotransmitter, responsible for feelings of joy, motivation, and interest, as well as appetite, sleep, and libido. 
Looking at the physical structures of the nervous system, there is a protective lining around nerves called “myelin”. Guess what myelin needs for ongoing repair and function? Iron. Without healthy myelin, nerves can fire incorrectly and send mixed-up signals throughout the nervous system.
Children and teens are super susceptible to the mood and cognitive symptoms of an iron deficiency – their nervous systems and brain tissues are still growing, and that kind of growth demands very high levels of iron . Pregnancy is another time of high growth that requires high levels of iron. A retrospective study of 142 patients showed that women with an iron deficiency were 2.5 times more likely to develop depression during pregnancy than those who had healthy iron levels .
Other neurological symptoms caused by iron deficiency can include:
Finding it hard to stay focussed
Shortness of Breath
When there is an insufficient amount of iron to carry oxygen through the body, the lungs have to work overtime to load oxygen onto available haemoglobin. This can look like huffing and puffing just walking down the street, or feeling like you can't take a deep enough breath. Some people with iron deficiency experience chest pain instead of shortness of breath – be sure to tell your doctor if you're one of them.
Body Signs of Iron Deficiency
Swollen Tongue with red smooth texture. Having an iron deficiency can cause a condition called glossitis which makes your tongue look shiny, puffy and red. The surface of the tongue becomes smooth and shiny from a lack of oxygen delivered to the mouth tissues. The tongue may continue to swell and you may have difficulty talking, chewing or swallowing in later stages. There may be pain, and the taste buds on the tongue may disappear – don't worry, they will regrow once iron levels are restored to a healthy level! 
Pale Palms and Creases Pale skin is a classic sign of iron deficient anaemia, where there is an insufficient supply of red blood cells to flush the skin with a pink hue. The easiest way to see this is on the palms of the hands. If you're unsure what constitutes “pale”, check out the lines on the palms – because these crevices are thinner than the rest of the skin of the palm, they are more closer to the vascular system and more translucent. Normally, stretching the palm would cause these creases to appear pink or red. In iron deficiency anaemia, they'll remain the same pale shade as the palm or a very light pink. 
Pale Conjunctiva The conjunctiva is a clear, thin membrane that covers part of the front of the eye and the inside of the eyelids. It covers the highly vascular eye tissues that have a strong blood supply. To check for iron deficiency, look in the mirror, gently pull down your bottom eyelid and check out the colour of the conjunctiva lining the lid. Normally, the inside of the eyelid is distinctly flushed with a rich, red-ish pink colour that is different to the white-ish pink of the eyeball. In iron deficiency, it may present as a pale pink or even white colour. 
Hair Loss Hair follicles need cellular energy. When deprived of oxygen, a hair follicle will move into its “telogen phase” – this is where no new hair is being made, and the existing hair shaft is released from the follicle. The telogen phase is normally followed by an active period called the “anagen phase” – this is where new hair grows, as cells divide rapidly and create a new, thick hair shaft. Guess what cellular division and follicle activity requires? A lot of oxygen for cellular energy and iron as part of the building material for the hair shaft. Without enough iron, the hair simply falls out and doesn't grow back until iron stores are restored. While iron deficiency is typically only associated with unusual, patchy hair-loss, recent research suggests that low levels of iron may also speed up age-related pattern baldness .
The immune system requires iron for its development, function and maintenance. This key element is used in DNA replication, the growth and health of immune cells, and for many immune reactions. An iron deficiency impairs all levels of immunity – from the front-line defences of the mucus membranes in the sinuses, mouth, throat and digestive system, through to the white blood cells that attack pathogens throughout the body. Several studies have shown that the level of iron in the blood can influence the frequency of acute infections  .
However, not everyone with an iron deficiency will experience frequent infections – in fact, some people feel like their immune systems are stronger when their iron status is low. It's all about feeding the bad guys – some pathogens love iron and will steal it from the host in order to thrive. In some cases, an iron deficiency could actually protect against infections because there is just not enough iron for pathogens to survive on .
If you are sick and iron deficient, taking an iron supplement may actually feed these pathogenic microorganisms, making the infection even harder to shake . Seek medical advice before beginning iron supplementation during or after an infection!
NOTE: Some infections can even mask an iron deficiency in blood work. The inflammation from infections (especially infections that cause a fever) increases the number of iron transporters in the blood. This looks like there is more iron but really there are only more transporters. One study suggests waiting at least one month after a fever before relying on blood work to accurately assess your iron levels.  
Iron is required for ovarian health and sperm production. A landmark study in 2006 found that people with fertility issues who took iron supplements were 40% more likely to become pregnant than those who didn't . While the study has its flaws (e.g. it didn't account for other dietary factors, smoking, or alcohol use), it's decent evidence that iron is one essential component of conception.
Interestingly, the study found that consumption of non-heme iron (i.e. plant-based sources) was related to better fertility, while consumption of heme iron (i.e. animal sources) had no impact at all...
Iron Deficiency in Children & Teens
From childhood to early adulthood, key growth spurts and development milestones require a steady supply of iron. Unfortunately, children and teens are at high risk of iron deficiency due to picky or restricted eating habits. Iron is needed for cell division and many stages of growth in all types of body tissue. A deficiency of iron during development and growth can lead to a range of issues, from mild social difficulties through to severe cognitive dysfunctions .
Children and teenagers with low iron may show these additional signs of iron deficiency:
Growing slower than peers
Loss of appetite
Eating dirt or other non-food items
Poor co-ordination and motor skills
Poor attention span
Prolonged effects on behaviour and development milestones
Children with anaemia may be less active and more timid than their peers 
Correcting an Iron Deficiency The Right Way
Correcting the iron deficiency can go one of two ways – you can do it the easy & direct way, or the long drawn-out & kind of dangerous way.
Step 1: Iron Deficiency Diagnosis
To get on the easy path, first thing's first – get a proper diagnosis! An iron deficiency can be easily confirmed through a blood test. Haemoglobin level is a key indicator of iron status, and the normal ranges for adults is 12.0 – 17.5 g/dL (but pathology labs have different reference ranges, so check with your doctor).
Anything below a normal level may cause symptoms of anaemia – in fact, anything at the lower end of “normal” may cause symptoms in some people. Your doctor can also check the size, shape and concentration of red blood cells through the same blood test – this can give a clue about other nutrient deficiencies that often go hand-in-hand with low iron (e.g. vitamin B12).
Specialised iron studies check for ferritin (the protein that stores iron the body), transferrin (the transporter that moves iron around the body) and transferrin saturation (an indicator of how much iron is actually bound to transferrin). A nutritionist (hi!) can read these test results to identify why you have low iron, and exactly how to fix it.
If you are unable to get a blood test for any reason (e.g. cost, access to healthcare, phobia) then you may be able to guess if you have an iron deficiency with the following quiz:
Answer Yes or No to the following questions:
1. Do you feel tired or fatigued?
2. Do you feel weak?
3. Do your skin, nails or gums look pale of feel cold?
4. Do you get short of breath or breathe rapidly?
5. Do you get dizzy or lightheaded?
6. Is it difficult to concentrate?
7. Does your pulse race? 8
. Do you have heart palpitations (are you conscious of your heart beat often?)
9. Is your menstrual cycle irregular?
10. Do you have numbness or coldness in your hands and feet?
11. Do you have Restless Legs that keep you up at night?
12. Are you irritable and grumpy?
13. Do you feel sad or depressed?
14. Do you suffer from recurring infections or colds?
15. Is your haemoglobin levels less then 130 – 170 g/l for adult males and 120 – 150 g/l for adult females (you’ll get this in a blood test)
16.Have you ever been diagnosed with anaemia?
Add up all of your YES answers.
Answered YES to 0 – 4 questions: Chances are you don't have an iron issue.
Answered YES to 5 questions: You may have an underlying iron deficiency.
Answered YES to 6 or more: You likely have an underlying iron deficiency.
Answered YES to ALL: It is HIGHLY likely you have an underlying iron deficiency.
NOTE: There is still a big ol' chance that these signs and symptoms could be caused by other issues. Taking an iron supplement without first assessing your iron levels can be risky – iron accumulates in the body and can cause serious toxicity. Seriously – if you can get a blood test to confirm the deficiency, do it! Iron deficiency symptoms can also be symptoms of other nutrient insufficiencies or a serious unrecognised health problem.
tl;dr: Get a clear and trusted diagnosis before treating yourself. If you don't, you're taking the risky road.
Step 2: Correct the Underlying Issue
This may be the most important step. Iron deficiencies don't just develop out of nowhere. Most are related to the diet but often there is an undiagnosed medical condition causing blood loss or malabsorption. Eating buckets of spinach and throwing supplements down your gob won't solve the problem -- it's like filling a bucket with holes in it. Plug up the hole first!
Speak to your doctor, naturopath or nutritionist about possible causes of your iron deficiency. They can take an objective and informed view of your health history and suggest a course of treatment.
Granted, there are many risk factors that you may not be able to address. Genetics, life stage (e.g. pregnancy or adolescence), access to enough food, and medical conditions that cause excessive bleeding are often unchangeable risk factors -- but there's nothing you can't work around. Is "being vegan" an unchangable risk factor? If you ask me, it's not even a risk factor. You do NOT have to stop being a vegan to correct an iron deficiency. I have never seen a client who has truly needed to eat animal products to get adequate iron to correct a deficiency. Identify the real cause before reaching for the red meat.
Step 3: Get onto A Good Quality Iron Supplement ASAP
Don't mess around with an iron deficiency – get on top of it immediately. Don't take low quality supplements, and don't do it alone. Speak to a nutritionist or naturopath for personalised advice about which form of iron will work best for you, and who will monitor your progress.
Once you have a confirmed diagnosis of iron deficiency, its underlying cause and an all-clear from your medical team, you can begin taking iron supplements. They are available as tablets, capsules and powders and often contain vitamin C to improve their absorption. It is important to take your iron supplement daily, or as prescribed, to provide the body with a steady supply. Many people feel improvement in iron deficiency symptoms within 2 weeks of taking iron supplements – but it is important to continue taking the supplements for as long as your nutritionist or doctor has prescribed.
TIP: If you are prone to constipation, take an enteric coated iron supplement – other forms are notorious for slowing down the bowels! CAUTION Too much iron can lead to toxicity, diabetes, liver damage, hormone dysfunction and heart failure. Use only as directed.
Iron supplementation is usually a quick and effective way to treat an iron deficiency – but there is a catch. Iron is toxic in high doses and can cause serious damage when it accumulates in the body. Taking iron supplements unnecessarily, or for longer than needed, can lead to iron overload and increase the risk of developing diabetes, heart failure, arthritis, liver disease and hormone issues. Keep in mind that symptoms of an iron deficiency may actually be caused by a number of different conditions and speak to your health practitioner before taking iron supplements.
References  World Health Organization (2018) Vitamin and Mineral Information System – Database on Anaemia. http://www.who.int/vmnis/database/anaemia/en/
 Finch, C. A. (1957) The role of iron in hemoglobin synthesis. Conference on Hemoglobin. https://www.ncbi.nlm.nih.gov/books/NBK224286/
 Sobiecki, J., et al. (2016) High compliance with dietary recommendations in a cohort of meat eaters, fish eaters, vegetarians, and vegans: results from the European Prospective Investigation into Cancer and Nutrition–Oxford study. Nutr Res., 36:5, 464 – 477. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4844163/  Yokoi, K. & Konomi, A. (2017) Iron deficiency without anaemia is a potential cause of fatigue: meta-analyses of randomised controlled trials and cross-sectional studies. Br J Nutr., 117:10, 1422 – 1431. https://www.ncbi.nlm.nih.gov/pubmed/28625177
 Zhu, X., et al. (2012) Quantitative Imaging of Energy Expenditure in Human Brain. Neuroimage., 60:4, 2107 – 2117. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3325488/  Park, S. Y., et al. (2013) Iron Plays a Certain Role in Patterned Hair Loss. J Korean Med Sci., 28:6, 934 – 938. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3678013/
 Erriu, M., et al. (2016) Diagnosis of Lingual Atrophic Conditions: Associations with Local and Systemic Factors. A Descriptive Review. Open Dent J., 10, 619 – 635. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5123136/
 Kalantri, A., et al. (2010) Accuracy and Reliability of Pallor for Detecting Anaemia: A Hospital-Based Diagnostic Accuracy Study. PLoS ONE, 5:1, e8545. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2797134/
 Sheth, T. N., et al. (1997) The Relation of Conjunctival Pallor to the Presence of Anemia. J Gen Intern Med., 12:2, 102 – 106. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497067/
 Hidese, S., et al. (2018) Association between iron-deficiency anemia and depression: A web-based Japanese investigation. Psychiatry Clin Neurosci., 72:7, 513 – 521. https://www.ncbi.nlm.nih.gov/pubmed/29603506  Chen, M., et al. (2010) Association between psychiatric disorders and iron deficiency anemia among children and adolescents: a nationwide population-based study. BMC Psychiatry., 13, 161. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3680022/  Dama, M., et al. (2018) Iron Deficiency and Risk of Maternal Depression in Pregnancy: An Observational Study. J Obstet Gynaecol Can., 40:6, 698 – 703. https://www.ncbi.nlm.nih.gov/pubmed/29307706
 Golz, A., et al. (2001) The association between iron-deficiency anemia and recurrent acute otitis media. Am J Otolaryngol., 22:6, 391 – 394. https://www.ncbi.nlm.nih.gov/pubmed/11713723
 Johnson, E. E., et al. (2012) Iron metabolism and the innate immune response to infection. Microbes Infect., 14:3, 207 – 216. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3270215/
 Jonker, F. A. M., et al. (2017) Anaemia, iron deficiency and susceptibility to infection in children in sub‐Saharan Africa, guideline dilemmas. BJH., 177:6, 878 – 883. https://onlinelibrary.wiley.com/doi/full/10.1111/bjh.14593
 Pieracci, F. M. & Barie, P. S. (2005) Iron and the risk of infection. Surg Infect., 6:1, S41 – 46. https://www.ncbi.nlm.nih.gov/pubmed/19284357
 Eskeland, B., et al. (2009) Influence of mild infections on iron status parameters in women of reproductive age. Scandinavian Journal of Primary Health Care., 1502 – 7772. https://www.tandfonline.com/doi/pdf/10.1080/028134302317282752
 Suchdev, P. S., et al. (2017) Assessment of iron status in settings of inflammation: challenges and potential approaches. Am J Clin Nutr., 106:6, https://academic.oup.com/ajcn/article/106/suppl_6/1626S/4823192
 Jáuregui-Lobera, I. (2014) Iron deficiency and cognitive functions. Neuropsychiatr Dis Treat., 10, 2087 – 2095. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4235202/
 Chavarro, J. E., et al. (2006) Iron intake and risk of ovulatory infertility. Obstet Gynecol., 108:5, 1145 - 1152. https://www.ncbi.nlm.nih.gov/pubmed/17077236