When Megan Ryan first noticed fatigue in herself, she assumed it was something normal.
After all, she was a single mother of a three-year-old child and she worked.
Almost every day, when she picked up her son from kindergarten, she would fall asleep with him during his afternoon nap.
She didn't think much about it.
"I just thought, 'Oh, that's what motherhood is like,'" says Ryan, who lives in upstate New York, USA.
At a routine health check-up in June 2023, the doctor asked her if she was feeling exhausted.
Blood test results showed that Ryan had iron deficiency anemia.
When she looks back on it today, it's clear to her that there were other signs.
Despite exercising regularly, Ryan suddenly began to feel out of breath on routine walks in nature.
She had only been iron deficient once before - during pregnancy.
Her midwife suspected anemia when Ryan mentioned to her that the only thing she craved during pregnancy was ice.
This is a classic sign of that desire, which, in turn, symptom of iron deficiency.
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Iron deficiency is the most common a lack of a micronutrient which affects every third person today.
It is especially prevalent among children, as well as women of reproductive age, including pregnant women.
This condition can cause a wide range of consequences.
When a pregnant woman does not have adequate iron stores, for example, it can affect the development of fetal brain, and it is bigger and risk of low birth weight for the baby, premature birth, miscarriage during pregnancy and stillbirth.
In babies and children, insufficient iron can affect long-term development, and studies show that children are prone to expressing behavioral problems, are less happy and satisfied, and tend to be more socially inhibited.
This can also affect a child's motor skills and cognitive abilities even years after the deficiency is corrected.
In adults, iron deficiency is one of the world's leading causes of disability.
In rare cases, can also endanger life.
A widespread problem
"It's a big global problem," says Michael Zimmerman, professor of human nutrition at the University of Oxford in the UK.
"It's common, goes away very quickly, and is associated with a variety of disabilities," says this longtime researcher into micronutrient deficiencies.
Most scientists agree that iron deficiency is common condition.
But there are a whole series of unclear questions.
How exactly is iron deficiency defined or how likely is it, in the absence of other symptoms, to increase the risk of poor health outcomes?
When should someone or should they not use iron supplements?
What is not disputed is that some groups are more susceptible to iron deficiency than others.
In women, for example, iron deficiency anemia (when the body does not have enough iron to make the necessary number of red blood cells) is the leading cause of disability worldwide.
A study of American blood donors showed that iron levels were low in 12 percent of women, but in less than three percent of men, reflecting the consequences of regular blood loss during menstruation.
Then there is the impact of pregnancy, which redirects nutrients to the fetus, meaning that women are particularly at risk.
Another study showed that 46 percent of British women had anemia at some point during pregnancy, although not all cases resulted from iron deficiency.
Endurance sports, vegetarianism or veganism and frequent blood donation may pose an increased risk for both women and men.
People with certain medical conditions are more prone to low iron levels.
Kidney disease and celiac disease can reduce iron absorption.
Critical period
Children who do not have enough iron are the most at risk because this mineral is very important for their development.
"What is the fastest growth period in your entire lifespan? Early childhood," says Mark Corkins, chairman of the Nutrition Committee at the American Academy of Pediatrics (AAP).
"You triple your weight before you're a year old and double your height," he explains.
As our bodies grow, they need more blood, and red blood cells are based partly on iron.
Without that essential iron, says Corkins, you risk not being able to produce enough red blood cells to carry oxygen to growing tissues, including the brain.
Iron deficiency is especially common in children in low-income countries.
"In the studies I did in Africa, 70 percent of babies between six and 12 months old", has obvious iron deficiency anemia," says Zimmerman.
Even in wealthier countries, which have better diets and are more likely to fortify certain food products with iron, this deficiency still persists.
About four percent of children in the US, for example, has iron deficiency anemia, and some 15 percent struggle with iron deficiency.
Iron deficiency and anemia as a result
Anemia occurs when someone doesn't produce enough normal red blood cells or hemoglobin, the substance that carries oxygen through your bloodstream.
This could be due to various factors, but about half of all cases of anemia are due to iron deficiency.
Adults with iron deficiency anemia may experience weakness, extreme fatigue, or shortness of breath. among other symptoms.
Symptoms in babies and young children are similar, although they may also have problems sleeping – especially frequent night awakenings, restlessness during sleep, and difficulty falling asleep.
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Just because someone has an iron deficiency does not necessarily mean that they will also get anemia.
"Iron deficiency can be considered a precursor to anemia," says Sant-Rijn Pasricha, a clinical hematologist.
The severity of the deficiency plays a key role, explains Pasricha, who is also the director of the School of Population and Public Health in Melbourne, specializing in iron deficiency and related conditions.
When someone runs out of iron, their body starts making red blood cells differently, he says.
They become smaller and, eventually, the amount of oxygen-carrying hemoglobin in the bloodstream falls below healthy levels.
"That's when anemia caused by iron deficiency sets in," adds Pasriča.
The diagnosis of iron deficiency and anemia is mainly made through blood tests.
Usually through one that looks at levels of ferritin, a protein that helps store iron, or hemoglobin.
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Subject of discussion
Some specialists question whether iron deficiency is always a cause for concern, especially if it occurs in the absence of any physical symptoms and if the patient does not have anemia.
Pasriča is a co-author of a review aimed at better informing World Health Organization guidelines on iron supplementation in women.
In that research, he discovered something interesting.
Although women in clinical trials who were iron deficient and complained of fatigue found that their fatigue improved when they took iron supplements, the intervention did not change energy levels in women who were iron deficient but did not complain of fatigue.
"This tells us that (at least in adults), if you are clinically unwell due to iron deficiency, you need to get treatment and that will improve how you feel," Pasricha says.
"But it also indicates that if you feel perfectly well and someone discovers you have iron deficiency, treatment is not going to make you feel any different."
Iron deficiency in the absence of anemia has been studied less than anemia caused by its deficiency.
But there are some general conclusions we can draw, the researchers say.
"The consensus is that iron deficiency anemia is certainly worse, but iron deficiency is also associated with some kind of damage," Zimmerman says.
According to some studies, the consequences of anemia caused by iron deficiency, especially in children, can be long-term.
"It's not just poor health outcomes, but you're not maximizing your own development," says Korkins.
One review showed "consistent connection" between children with iron deficiency anemia and poorer cognitive performance compared to the control group.
However, researchers point out that the problem may not be iron deficiency anemia.
These could be general effects of anemia, which reduces energy levels.
The scientists also point out that in their review it is difficult to rule out the influence of socio-economic factors on children's behavior and cognition.
This complexity is at the core of all nutritional research: is the problem the absence of the nutrient itself, or is the deficiency a sign that something else is going on?
To further complicate matters, the criteria for defining iron deficiency in children is still a subject of great debate, Zimmerman says.
Children grow very quickly, he adds, and iron deficiency usually quickly leads to anemia, which means it is not easy to detect and study children with iron deficiency who are not anemic.
To supplement or not
It is often advised that children be supplemented with iron at any sign of deficiency or as a precaution.
The American Academy of Pediatrics recommends that exclusively breastfed babies start receiving iron drops. from the fourth month.
Because breast milk It has low levels of iron, while formula milk is usually fortified with it.
But some researchers question this approach.
Pasriča participated in the largest study to date that studied the impact of supplementation on child development.
The study, conducted on 3.300 eight-month-old babies in Bangladesh, randomly assigned children to receive either breast milk or formula for three months. daily iron supplementation or placebo.
He and his colleagues measured the children's neural development before and after supplementation.
"We found no evidence of functional benefit," he says, although they didn't see any harm either.
"Hemoglobin and iron status improved in children who received iron, but we didn't see that it affected their development," says Pasricha.
"Why - that's the question he really had trouble with," he adds.
Other research has yielded similar results.
In one study, even after infants with iron deficiency anemia were given supplementation to correct it, they continued to show an increase in restless sleep patterns compared to their peers, sometimes even years later.
A possible reason could be that even a short period of iron deficiency can lead to long-term damage.
One study showed that children with iron deficiency at birth had less activation in brain areas associated with cognitive control between eight and 11 months, even if their iron levels were corrected.
But another possibility, says Pasrica, is that low iron levels are not what causes poor development, but rather that they are an indicator of something else, such as a lack of other nutrients in the patient's diet.
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There could also be downsides to supplementing children who don't actually have a deficiency.
Some studies have shown that infants and children with adequate iron levels, who received supplementation, a lot of gojile i grew in height with control groups.
Randomized controlled trials have shown that babies who were randomly assigned to high-iron formula performed worse on cognitive tests such as visual memory, reading comprehension, and math, and 10 and with 16 years, compared to those with formulas with less iron.
Exactly how much iron supplementation would avoid these effects remains unclear, the researchers say, because other factors could be involved.
Some experts have criticized U.S. guidelines for supplementing all breastfed infants.
Supplements can also have other side effects.
Zimmerman, for example, studies how supplementation can affects the microbiome in humans.
Bacteria thrive on iron, he says.
The very small amount of iron in breast milk is bound to protective substances such as lactoferrin.
It helps keep iron away from potential pathogens in the intestines, which is a special protection for babies with immature immune systems.
Giving a six-month-old baby a micronutrient powder with iron, which many scientists recommend, could end up negatively, says Zimmerman.
"These powders have a lot of iron in them, which can lead to very rapid changes in the microbiome," he says.
Babies can't absorb all that iron, which ultimately affects the microbiome in their gut.
They are potentially shifting towards a balance that favors "the pathogens that we are most concerned about in babies," he says.
These include Escherichia coli, which grows exceptionally in the presence of iron.
Many clinicians and researchers, however, agree that when someone has iron deficiency or anemia caused by its deficiency along with accompanying symptoms, supplementation can be one of the fastest ways to help them.
One review of iron deficiency in endurance athletes showed that supplementation not only improved ferritin and hemoglobin, but also aerobic capacity.
Whether to take supplements or give them to a child is something people should decide with the help of a doctor, experts say.
A balanced diet
In an ideal world, babies would get enough iron through a balanced diet containing iron-rich foods, and no deficiency would occur at all, but that is not always possible.
Ingredients such as liver or red meat, legumes, including beans, edamame, and chickpeas, as well as nuts and dried fruits are considered good sources of iron.
American Academy of Pediatrics recommends that infants six to 12 months of age get 11 milligrams of iron per day.
For children, they suggest seven milligrams, and for those aged four to eight, 10 milligrams.
Part of the reason for the higher recommendation for younger babies is their accelerated development, experts say.
But it is also assumed that the first solid foods for newborns will be foods such as cereals with a high dose of iron, as well as fruits and vegetables.
These are non-heme sources of iron, which the body absorbs less readily than animal sources, such as meat, fish, and eggs.
"Diet is the best approach. Your body usually absorbs it better and uses it better," says Corkins.
"If someone is severely anemic and you're trying to heal them faster, you have to supplement."
And as for Ryan, she managed to correct her own iron deficiency both times it happened: during pregnancy with supplements and in 2023 with an iron infusion, which she received in her own hospital, every two weeks for five months.
"It wasn't a quick recovery," she says.
Over time, however, she noticed her fatigue disappearing.
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