Question

In spite of eating a whole food plant-based diet and getting plenty of dietary iron, my wife has gotten consistently deficient lab results. She is not exactly excited about the idea of talking to her healthcare provider, who will most likely blame it on her vegan diet, but she would like to resolve this issue. Any thoughts would be appreciated.

Jason

Answer

When it comes to iron, there is a lot to say for this topic to be correctly understood and effectively addressed, which I will present below. Why certain people are deficient in iron, regardless of what diet they eat, and how to remedy the situation are much more complex than most people and medical professionals alike realize.

Who is at highest risk of iron deficiency?

1. Women - The highest risk group for iron deficiency are women, regardless of their dietary choices, during their reproductive years. This is because they lose blood through menstruation each month and through any potential pregnancies. About two-thirds or nearly 70 percent of the body’s iron is found in red blood cells in the blood in the form of hemoglobin. Thus, heavy, prolonged, or regular blood loss can deplete iron levels in the body, and women with heavy periods are most at risk of iron deficiency and anemia. (Men, on the other hand, are most at risk of iron overload.) If a woman is also dealing with any of the subsequently listed factors, the risk of iron deficiency increases that much more.

2. Malnourished Individuals - Another group that is at risk of iron deficiency includes any child or adult who is malnourished, meaning that they are not receiving enough calories and balanced nutrients.

3. Individuals who do High-Intensity or Endurance Exercise - Those who partake in excessive exercise, but specifically long-distance joggers and marathon runners, are at risk of iron deficiency. Suggested reasons for this occurrence include the destruction of blood cells when the feet hit the hard ground frequently and for long periods, loss of blood through the kidneys and urine, iron lost in the sweat, intestinal bleeding, reduced absorption of iron from the gut and decreased production of blood cells in the bone marrow.

4. Individuals with Inflammatory Digestive Disease - A third group that is at risk of iron deficiency includes anyone who suffers from conditions that create inflammation of the intestines, such as Irritable Bowel Syndrome (IBS), Crohn’s disease, or Ulcerative Colitis. These conditions interfere with the normal functioning of the intestines and prevent proper nutrient absorption that can lead to iron deficiency.

5. Individuals with Bacterial Infections - In addition to decreased absorption due to chronic inflammatory processes, the presence of bacterial infection in the body can also reduce iron absorption, especially ones like H. Pylori. The body does this to deprive bacteria of iron, which is one of the core micronutrients required for bacteria to proliferate and cause disease.

6. Individuals who Consume Alcohol - Alcohol interferes with the nutrition process by affecting digestion, storage, utilization, and excretion of nutrients. Individuals who drink regularly or heavily usually do not get proper nutrition to begin with, and the nutrients they do get are not assimilated well. Alcohol consumption can cause deficiencies in vitamin A, C, D, E, K, and B vitamins, as well as some minerals. Iron deficiency, for example, can result due to gastrointestinal bleeding or not getting having enough vitamin C and B vitamins to absorb and use iron adequately. Although this will apply most to heavy or regular drinkers, even small amounts can create stress and imbalance in the bodies of sensitive individuals. Similar concerns apply to users of recreational drugs.

Are plant-based eaters at a higher risk of iron deficiency?

There are commonly held beliefs in our meat-centric society that anyone who does not consume meat is at a higher risk of iron deficiency or that their diet is to blame for their iron deficiency. These faulty beliefs are applied to vegans, vegetarians, and other plant-based eaters, and are spread by medical professionals just as much as they are by the public. So I fully understand when a plant-based eater is hesitant to visit their healthcare provider and be treated unjustly. The belief is based on the fact that meat contains heme iron, which is more readily absorbed by the body than non-heme iron, which is found in plant foods. However, quality research does not find this to be a hindrance, and it does not necessarily apply to everyone. On the contrary, ample research has demonstrated that it is better to avoid heme iron, as it creates increased health risks.

All the main health advisory bodies – ADA, BMA, WHO, PCRM – agree that iron deficiency anemia is no more common in vegetarians than it is amongst meat-eaters.

Viva! Health Research Team - Iron Deficiency Anemia

The team at Dr. Greger’s NutritionFacts.org who sift through thousands of medical studies each year state that “Women who eat plant-based diets don’t appear to have higher iron deficiency anemia rates than women eating a lot of meat.”

It is commonly thought that those who eat plant-based diets may be more prone to iron deficiency, but it turns out that they’re no more likely to suffer from iron deficiency anemia than anybody else.

Michael Greger, MD, FACLM - Plant versus Animal Iron

This finding is also echoed in a report in The American Journal of Clinical Nutrition by Winston J Craig, who is a professor of nutrition and director of the dietetics internship program at Andrews University in Michigan.

Vegans generally have an adequate iron intake and do not experience anemia more frequently than others.

Winston J Craig, PhD. - Health Effects of Vegan Diets

There may be a slight risk of iron deficiency in the beginning when an individual, like a woman or child, switches from a diet that included meat to one that is solely based on plants, as the body has to readjust its iron-absorbing mechanism. However, within a few months, there should be no higher risk of iron deficiency, assuming an appropriate plant-based diet is being consumed. By its very nature, a nutrient-dense diet that health-conscious plant-based eaters consume has more iron and most nutrients, than an average diet that includes animal products. A 2003 UK study even tested this with regular vegans and vegetarians, ones who were not necessarily following optimal whole food, plant-based guidelines. So while more care should be applied at the start of going plant-based, with time, the health benefits of non-heme iron are better. They don’t include the health risks of heme iron, which include iron overload and higher rates of oxidation and inflammation in the body.

With the above in mind, I want to emphasize that all vegan, vegetarian, and plant-based diets are not equal and can vary widely in terms of their nutritive and health value. The quality of these diets depends entirely on the food choices the person eating any of them is making. There are many people in these categories that are not health-conscious and eat nutrient-deficient plant-based diets that are made up of refined foods, ultra-processed foods, and junk foods. Some individuals also do not eat enough food for their needs, and as mentioned earlier in this section, anyone who is malnourished is at a higher risk of nutrient deficiencies. Therefore, we have to be cautious about how we group people because blanket statements and narrow perceptions can lead to a lot of misinformation.

It is also valuable to point out that people often tend to pay much more attention to their diet, nutrient numbers, and getting routine blood work after they go plant-based than at any previous time in their life. This can easily lead people to wrongly associate nutrient deficiencies with their new plant-based diet when the deficiencies could have been there all along and are part of a bigger problem. Women who are prone to an iron deficiency on diets that include meat can be equally likely to experience a deficiency when plant-based, and it would be incorrect to blame the plant-based diet for the deficiency. Interestingly, some women in this scenario get better iron levels after going plant-based due to improved absorption of iron with high amounts of vitamin C that are often present in healthy plant-based diets.

Ultimately, the worst thing that one can do in times of iron deficiency on a plant-based diet is to revert to eating meat out of fear, thinking that it will provide healthy iron levels. This is one of the most outdated and faulty beliefs that unfortunately continues to permeate through our society thanks to heavy marketing of meat as an iron source, even though it does not provide a good or sustainable solution. There is no need to expose oneself to all of the health risks associated with meat when there are many safe and effective ways to address iron deficiency on a plant-based diet in other ways.

Is there a true deficiency?

Next, it is vital to find out if there is an actual deficiency that requires any correction. The “right” amount of iron, like other nutrients, does not adhere to any one-size-fits-all guidelines. Norms vary between people based on their age, sex, health, and lifestyle factors. Also, clinical numbers that indicate what is normal and what is deficient are not set globally, but by each country or region of the world, are not even consistent between all labs, and do get modified from time to time. It is valuable to keep all this in mind because if a person is classified as being iron-deficient, it does not mean that they are for their needs; likewise, if they are told their numbers are normal, it does not mean that they are sufficient for their needs. Some people, specifically those who are of a smaller build, can have naturally low iron levels that would be flagged as problematic by lab results, when in fact, they are perfectly normal for that person. So while clinical numbers are good to pay attention to, they should not be taken as the only indicator of a problem or lack thereof.

The most important indicator to pay attention to is how the person is feeling. Are there negative health symptoms? Are there specific iron-deficiency symptoms such as unusual or regular fatigue and lack of energy, heart palpitations, shortness of breath, a pale complexion, hair loss, brittle nails, or low immunity? If so, then a blood test can provide further insight into the potential problem. However, if a person is feeling fine and they go to have routine blood work done, and it comes back as showing an iron deficiency, this does not automatically mean that there is such a problem. The medical field is full of false positives and false negatives, so alternate measures should always be taken to assess any health concern or condition in the best manner. This is especially important when it comes to iron, as supplementing with iron without just cause can cause more harm than good. The risks of iron supplements include oxidative stress, and any resulting iron overload is associated with increased the risk of heart disease, cancer, diabetes, arthritis, and liver problems.

How to treat iron deficiency?

If the health symptoms and blood results indicate that there is an iron deficiency, the next step is to assess how serious it is. If the iron levels are just slightly lower and overall the person feels okay, meaning that there may be mild but not severe iron-deficiency symptoms, then the best solution in such a case is to address the mild deficiency through the diet. I will explain more about this in the next section. If the iron is found to be very low, and severe health symptoms are present, or the person is a woman who is pregnant, then iron supplementation will usually be required in addition to dietary modifications. The exact iron dose, frequency, and duration of use should be determined by a healthcare provider to meet the person’s health needs best.

If iron supplements are required, then one round of supplements for three months is typical, which allows the body to build up its iron levels and stores. Iron supplements should not be depended upon for regular or prolonged use, as this interferes with the body’s own ability to regulate its iron needs properly and can lead to the health problems mentioned above. Keep in mind too that iron takes about three months to build up in the body, so instant results should not be expected.

Note that iron supplements come in many forms, including tablets, capsules, liquids, and powders. Iron supplements can also contain various chemical types of iron, with the most common being ferrous gluconate, ferrous sulfate, and ferrous fumarate. To increase the bioavailability and absorption of the iron and to decrease any negative digestive (gastrointestinal) side effects of iron supplements, chelated forms of the mineral, like ferrous bisglycinate are most recommended. Also, the most natural option should be chosen for optimal health purposes, meaning one without additives like chemical fillers, colors, and flavors, or any animal by-products.

In addition to diet, homeopathy can also be used to treat iron deficiency and anemia. It provides several remedy options to treat iron deficiency and anemia in a safe and side-effect-free way. The homeopathic remedies strengthen the vital force in the body, optimize the health of the blood, and can enhance how the body absorbs and uses iron.

Dietary iron solutions for plant-based diets

Eat the right foods daily. A healthy plant-based diet should consist of fresh fruits, non-starchy and starchy vegetables, legumes, and whole, unprocessed grains, along with some nuts or seeds, mushrooms, and spices. Aside from mushrooms, all of these foods should be eaten daily in sufficient amounts for your age, body size, health, and lifestyle needs. This is a diet that will provide the best protection against nutrient deficiencies and chronic diseases.

Focus on iron-rich foods. For those who need to pay more attention to their iron sources, an effort should be made to have higher amounts of leafy greens and green vegetables, especially spinach, and legumes, including beans, lentils, tempeh, and tofu. In practical terms, a generous portion of greens should be eaten with at least two of our main meals daily. Leafy greens are easily consumed as part of delicious green smoothies or whole meal salads. Green vegetables can also be added to salads or consumed as part of easy STAR meals. As for legumes, at least 1 cup of legumes should be consumed daily. Cooked beans are essential additions to whole meal salads, and they can also be eaten as part of soups, chilis, burritos, bean patties, and hummus or similar legume dips and spreads. A perfect combo in this regard can be made of green vegetables dipped in hummus. Do keep in mind that other whole plant foods from the fruit, vegetable, grain, nut, and seed categories also contain varying amounts of iron, which will positively contribute to the overall total of iron consumed daily.

Focus on cooked, blended, and dried foods. Since a person can eat more cooked foods than raw foods in any given sitting, this is another way to increase the amount of iron in the diet. Imagine what 2 cups of raw spinach looks like after it has been cooked or blended in a smoothie; its volume becomes significantly reduced. So you can eat two or three times as much if you cook it or blend it. The same goes for other dark leafy greens, vegetables like eggplant, and mushrooms. When it comes to fruits, dried fruits will provide more iron than fresh raw fruits. Dried unsulfured apricots and dates are also useful dietary additions to boost iron sources. Try to avoid cooking fruits, which are not high sources of iron, and will lose more than they gain if they are cooked. In general, apply gentle cooking methods, meaning use the lowest heat, least water, and cook for the shortest amount needed, any fresh foods that you prepare to avoid losing other nutrients, especially vitamin C.

Soak dry legumes, grains, nuts, and seeds. Soaking is a beneficial practice that not only increases the health and nutrition benefits of the particular food, but it also decreases digestive inhibitors, like phytate, that can interfere with the absorption of minerals, like iron. For more information on this topic, please refer to my help articles on soaking beans and grains and soaking nuts and seeds. On this note, if a person consumes any bread, then choose sprouted whole grain bread, which will provide more iron and not have the problems associated with refined and non-sprouted grain products.

Add in molasses. Another plant-based ingredient that can provide a lot of iron easily is unrefined organic molasses. They can be consumed in a variety of ways, such as added to smoothies, oatmeal or similar breakfast grain bowls, or drizzled on top of plant-based ice cream or some fruit.

Consider fortified foods. Above and beyond whole plant foods, if dietary iron is still a concern, especially for women who are iron deficient, then some lightly processed iron-fortified plant foods may be a good option instead of turning to supplements.

Eat iron with vitamin C. The final dietary tip is to pair iron-rich foods with vitamin C-rich foods because iron requires vitamin C for best absorption. This is easily done as part of a whole food plant-based diet, given that there is some vitamin C in all fruits and vegetables. For example, green smoothies include both leafy greens and fruits, which makes for a perfect combination. Do not limit yourself to oranges only either, as strawberries, blueberries, grapes, papayas, pineapples, apples, and other fruits are all excellent sources of it too. When eating whole meal salads, make a creamy vegan sauce, which depends on lemons or limes or squeeze them directly into your salad.

Be cautious with tea and coffee use. - Beverages with caffeine should be minimized or avoided, as caffeine can interfere with the absorption of certain nutrients, such as iron.

Avoid dairy. - Although dairy will not be a concern for vegan plant-based eaters, it will for vegetarians who consume dairy. Research has found that calcium may interfere with iron absorption, and dairy, not just due to its calcium composition, has also been associated with inhibiting iron absorption. This is only one of many problems related to dairy.

How to know if you are getting enough iron?

From a holistic perspective, there is no need to count nutrients in specific foods, as this is both an unnatural way to eat and not guaranteed to provide us with what we need or expect. For example, how foods are grown, such as the quality of the soil, will cause the same food item to be higher or lower in a certain nutrient than its cited reference number. Reference numbers vary by sources that test the food items. And even if the specific food provided the expected nutrient amount, it is not guaranteed that your body will get this depending on your state of health and your body’s ability to effectively extract and absorb the particular nutrient. This is why the most effective way to eat is to focus on eating enough food for your needs from the right foods daily, as outlined in the section above. However, when one is concerned about getting enough of a certain nutrient, it is a good idea to be aware of some general reference points, as follows:

  • In the US and Canada, the recommended dietary allowance (RDA) for iron is 8 mg/day for adult men and postmenopausal women, and 18 mg/day for pre-menopausal women. Vegetarians and vegans are advised to get up to 1.8 times more iron to account for the lower absorbability of non-heme iron.

  • In the UK, the reference nutrient intake (RNI) for iron is 8.7 mg/day for adult men and postmenopausal women, and 14.8 mg/day for premenopausal women. Source: NHS.uk

  • Cooked leafy greens provide, on average, 1mg (kale) to 6mg (spinach) of iron per cup (250ml / 8 oz).

  • Cooked vegetables provide, on average, 1mg (broccoli) to 2mg (potato / sweet potato) of iron per cup (250 ml / 8oz).

  • Cooked legumes (beans and lentils) provide, on average, 2.5mg (peas) to 7mg (lentils) of iron per cup (250ml / 8oz).

  • Cooked grains provide, on average, 1mg (brown rice) to 6mg (sorghum) of iron per cup (250ml / 8oz).

  • Cooked mushrooms provide, on average, 0.3mg (white button) to 0.7mg (Portobello) of iron per cup (250ml / 8oz).

  • Raw nuts provide, on average, 1mg (almonds) to 4mg (cashews) of iron per 1/4 cup (60ml / 2oz).

  • Raw seeds provide, on average, 0.6mg (sunflower) to 6mg (hemp seeds) of iron per 1/4 cup (60ml / 2 oz).

  • Raw fruits provide, on average, 0.4mg (blueberries) to 0.9mg (blackberries) of iron per cup (250ml / 8 oz).

Take into consideration the mind-body connection

From a holistic perspective, every disease or set of symptoms has a mind-body connection, where different mental states can positively or negatively affect biological functioning. While this concept is increasingly understood and embraced today, it is often missed when it comes to nutrient deficiencies. However, everything in our body and the balance it tries to maintain is influenced by our thoughts and emotions. To understand the mind-body connection of a nutrient deficiency, it is most helpful to understand the symptoms that it creates in a person.

“The brain and peripheral nervous system, the endocrine and immune systems, and indeed, all the organs of our body and all the emotional responses we have, share a common chemical language and are constantly communicating with one another.”

Dr. James Gordon, Founder of the Center for Mind-Body Medicine

In addition to the optimal health and nutrition of human beings, this is a field of study that I have been dedicated to for many years now and have seen a distinct trend in the mental and emotional patterns of women who are iron deficient. There is a reason why women specifically are at a higher risk of iron deficiency, and it goes beyond the biological functions of menstruation that we talked about above. This requires an in-depth explanation that is beyond the scope of this article. To provide a summary, we must take into account two differentiating attributes between men and women. The first is how women approach and process specific life experiences, which results in greater use of life energy and emotional investment. The second is how feminine energy has been treated over the ages and widely is to this day, resulting in female oppression, suppression, and repression, in our patriarchal society. These two factors are common to all women and can help us understand why both women who consume meat and women who consume plant-based diets can have iron issues equally. It is overly simplistic and faulty of our society to assign an iron problem or higher risk to the vegan population due to the heme versus non-heme iron found in animals versus plants. If it was just that, most of the world’s women who eat meat wouldn’t have the iron problems they do.

Universally, iron is a symbol of strength, and biochemically it is responsible for energy management and vital processes related to the heart and lungs. As I have seen, time and time again, women of particular constitutions who are prone to feeling weak internally or lacking strength, have low iron or the most iron problems when they are most energetically depleted on a mental and emotional level. This can stem from and include being undermined, undervalued, or taken for granted in their personal or professional life; being overburdened by life’s chores, such as household management and mothering; being emotionally-depleted after stressful life events; being over-nurturing, and being overrun by self-doubt and worry. If we look on the flip side with men being at risk of iron overload, this is connected to too much strength where it gets expressed as forceful, dismissive, domineering, intimidating, and aggressive energy.

Essentially, the more depleted a woman is in her vital life energy - chi, the more at risk she appears to be for iron deficiency. This will most commonly occur after a period of extreme or unexpected stress, which overwhelms the woman’s coping ability, or after years of being worn down, or due to having low self-worth. For young women, these problems begin in their teenage years as they attempt to understand their role and worth in environments that may be non-conducive to their mental and emotional wellbeing. Adult women, especially today, juggle too many roles that split them in too many directions and deplete their mental and emotional coping abilities. These include the duties that come with being a daughter, a mother, a wife, a home caretaker, a friend, and whatever roles their job or career demand. Our bodies will always try to support us and adapt to any challenges that come their way but only up to a point. Anytime stressors overwhelm the body’s ability to maintain balance and heal itself is when symptoms and disease set in.

The more we can examine our health holistically and tackle things at the root level, the more we understand about the cause and effect of any given experience. We are also able to break cyclical patterns in our lives that never seem to get fully resolved. This is why it is valuable for women who are prone to or suffer from iron deficiency or anemia to reflect on and consider how they perceive themselves and their life and handle their stress. The first step is always awareness, and then one can make effective changes that will benefit all areas of their health and wellbeing.

Concluding advice

For the best course of treatment or prevention, all of the factors that I outlined above should be examined in one’s life to assess what are the most likely causes and solutions. While the simplest solution is to consume more iron, proper iron assimilation depends on many factors, and if there is a problem with the body not being able to absorb it or use it effectively, then it requires a much more extensive approach than just getting more iron.

Further Reading & Resources

  1. Iron Deficiency Anemia – Causes, Diets, & Treatments from NutritionStudies.org

  2. Iron Deficiency Anemia Nutrition Guide from Physicians Committee of Responsible Medicine

  3. Anemia from Blood Loss from Dr. McDougall’s Health & Medical Center

  4. Iron Deficiency Anemia from Viva Health

  5. For a personalized health assessment, connect with a plant-based practitioner at PlantBasedDoctors.org