Fatigue in IBD - why iron deficiency is an important consideration
What is iron and why is it important?
Iron is a mineral that has many very important roles in our bodies. It is an essential component of haemoglobin (in red blood cells which transports oxygen around our bodies), important for energy, fat and blood sugar regulation, and immunity, to mention just a few.
Low iron or iron deficiency anaemia can lead to feelings of tiredness, fatigue, weakness, dizziness, tingling legs and pale skin.
We get iron from the food we eat – there are two different types of iron in foods – haem iron and non-haem iron. Haem iron comes from animal sources like meat, poultry, fish and eggs. Non-haem iron comes from plant sources like green leafy vegetables, lentils, nuts, seeds and dried fruit. Haem iron is more easily absorbed by our bodies - about 25% is absorbed from a meat containing meal on average, but this can increase to 40% during iron deficiency and decrease to about 10% when iron levels are higher. The amount of non-haem iron absorbed from a meal can depend on different factors including iron levels in the individual person and other nutrients in the meal that may aid (vitamin C) or inhibit (tannins and phytates) absorption, but it is less well absorbed at around 5-15%.
Prevalence of Iron deficiency in IBD
Statistics show that iron deficiency can be seen in up to 70% of people with IBD and iron deficiency anaemia in about one third of patients with IBD. Iron deficiency the decrease of the total content of iron in the body, and iron deficiency anaemia is when low iron levels reduce blood cell production.
Iron deficiency in people with IBD happens for a number of reasons including decreased iron intake from food, difficulty absorbing iron in the duodenum and upper jejunum (more common in Crohn’s Disease affecting these areas), and bleeding from inflammation of the lining of the intestine - very common in Ulcerative Colitis.
How to rectify?
There are two ways to help rectify iron deficiency – orally and intravenously.
Orally, supplements are made up of iron salts (iron sulfate, fumarate, and gluconate). These are often given in higher doses but our duodenum (part of our small intestine where iron is absorbed) can only absorb a maximum of 10-20mg of iron per day. This can mean that a most of the supplemented iron is not absorbed and can have an impact on our digestive tract further down causing symptoms like cramps, nausea, and diarrhoea.
Studies have shown that taking iron orally can reduce Lactobacillus and Bifidobacterium bacteria, two groups of important bacteria for our digestive health, and increase abundance of Enterobacteriaceae, a family of bacteria that may be pro-inflammatory and have been found in greater amounts in people with IBD. This can lead to gut dysbiosis, increase inflammation and diarrhoea and has the potential, in some people, to increase flare risk.
It has been suggested that high doses of oral iron should be avoided in IBD because of this and anyone with IBD should be careful when taking multivitamin supplements with high doses of iron. To try and avoid issues, iron can be taken on alternate days in low single doses to help increase absorption but reduce side effects.
New oral iron medication called Feraccru, which is iron maltol, is now available on the NHS for treatment of iron deficiency anaemia in patients with IBD. This form of oral iron seems to be better tolerated with fewer side effects and, in comparison trials with intravenous iron it has been shown to have similar effects at increasing iron levels.
What can you do?
Get tested – iron deficiency screening is usually routine with people with IBD, however, if you think you may be deficient and have not been tested for a while, ask your GP. European Crohn’s and Colitis Organization (ECCO) guidelines suggest that patients who have been treated for iron-deficiency anaemia be monitored every 3 months for the first year, and every 6–12 months for the recurrence of anaemia. Testing for iron levels is a simple blood test.
Treatment – if you have iron deficiency or iron deficiency anaemia you will usually need treatment with either oral or intravenous iron. If taking oral iron supplements ask you doctor about Feraccru (Iron Maltol) instead of the normal iron salts supplements (iron sulfate, fumarate, and gluconate).
Be careful with supplements – as iron supplements may increase inflammation be careful of taking iron supplements if you don’t need them. Speak with your doctor or nutrition professional before taking any supplements. Most multivitamins contain iron so opting for one without iron can be helpful too and taking iron separately, if need or suggested by your healthcare professional.
Eat iron containing foods daily – we can all support our levels of iron by consuming foods that contain iron daily (see above). When we are eating non haem iron sources, we should try to include some foods containing vitamin C with the meal too, to help our body absorb the iron more effectively.
I have written a free e-book to help you find a way forward for your everyday life with Inflammatory Bowel Disease. Whether you are right at the beginning of your journey with IBD or have been living with your condition for years and feel like you have tried almost everything, there are things you can do everyday, beyond the medication you are taking, to help you take back control.
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We are all wonderfully unique and what works for one person may not work for another so please seek help and advice before changing your diet to work out the right way forward for you.