Posted on: April 8, 2016 at 12:00 pm
Last updated: September 22, 2017 at 12:20 pm

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Iron deficiency is one of the most common conditions I see in practice and also one of the most misdiagnosed. These patients are told their iron is fine by either their doctor or the receptionist but this is far from the truth.

Iron deficiency symptoms:



These symptoms can vary based on your iron levels. Some will just have one extreme version of a symptom and others will have a bunch of these symptoms.

  • Feeling tired all of the time
  • Feeling cold all of the time
  • Restless sleep
  • Weak nails
  • Pale nailbeds (refer to picture)
  • Restless leg syndrome
  • Muscles spasms
  • Shortness of breath when trying to exercise
  • Palpitations
  • Pale skin
  • Hair loss
  • Low blood pressure
  • Depression and post-partum depression
  • Chronic fatigue
  • Brain fog
  • Random sharp stabbing left-sided chest pain
  • Poor blood sugar control
  • Dark bags under eyes (pale skin reveals the dark veins in that area)

There’s much more juicy information below, please click on “Read More” if you’d like to learn more information about iron deficiency. I discuss why it’s so commonly undiagnosed, proper reference ranges, why certain iron supplements are terrible and others are amazing, causes of iron deficiency, why you feel cold when you have low iron and who should get their iron tested.

Why do I have low iron symptoms but my doctor says I’m fine?

I can tell within seconds of seeing these patients that they have low iron but they’ve been told that they are fine. There are a couple of different reasons for this. We use ferritin to test your iron and it measures iron storage. They used to test free iron but it was influenced by what you ate in the past 24 hours so it wasn’t accurate.

The reference range for ferritin for most labs is terrible! Most labs will give a range from around 11-291ug/L, which is way too broad. To most docs, if your ferritin is a 12 you’re “fine” but if it’s a 10 you need to be on an iron supplement. This is ridiculous! By the time you get anywhere near 11 you have been severely deficient in iron for over 4 months!

In my experience most iron deficiency symptoms don’t go away until you’re around 80ug/L. This is widely variable depending on each individual though. The reference range mentioned above has to cover 95% of the population so we have to look at it functionally.

If your hair is falling out, your cold and tired all of the time there’s a good chance your iron is low. We’re all different, I’ve had some patients who were losing hair and their ferritin was around 50ug/L. Once I got their ferritin up to 80-100ug/L the hair loss went away. On the other hand, I’ve had patients who had a ferritin of 40ug/L and had no symptoms at all.

We all have different requirements and metabolisms. Another reason why iron deficiency goes undiagnosed is because it’s not tested. Quite a few doctors think if your hemoglobin is at a healthy level your ferritin is as well. This isn’t always true.

Proper ferritin reference ranges

Ferritin (ug/L)
Iron deficiency
Depleted iron stores
Reduced iron stores
Adequate iron stores

CBC (complete blood count) and iron levels

The Complete Blood Count (CBC) is a great indicator which is ignored as well. Your hemoglobin is a protein that carries oxygen from your lungs to your tissues. If the reference range is 120-160 and yours is at 122 there’s a good chance that you’re anemic.
My patients’ doctors always say, “I’m not concerned if the CBC is only off by a little bit” but they should be. If the patient has signs of anemia and their CBC isn’t up to par, we need to normalize it to get rid of those symptoms. The CBC can tell you about the oxygenation of the tissues (hemoglobin), how many cells versus fluid (hematocrit), how big the cells are (MCV), distribution of red blood cells (RDW) and if your white blood cells or immune cells are increased or decreased.
White blood cells are usually decreased in people with anemia. Sometimes you can tell iron is low just by looking at the CBC. If MCV or MCH are low and RDW is high it’s a good indicator of iron deficiency. CBC is ran almost every time a patient gets blood work done. I usually just test ferritin to confirm. Sometimes an iron panel is necessary to do as well which I’ll discuss another time.
Briefly, ferritin can be elevated due to inflammation, so there are people who have an elevated ferritin but still have an iron deficiency. An iron panel will give you more information on this and inflammatory markers such as hs-CRP and ESR can be tested as well.  

Why low iron causes you to feel cold

Iron is a heat conductor. If you have hardly any of it in your system you’ll feel cold. Patients with Hemochromatosis (too much iron) are usually very warm since they have so much iron flowing through them. Iron deficiency usually comes with low blood pressure as well since the blood is thinner and with low blood pressure comes coldness as well. If you’re not pushing blood to your extremities well because of low blood pressure you’re going to have cold hands and feet. 

Conditions which have similar symptoms to iron deficiency

Feeling cold, tired and weak can also be a result of hypothyroidism, Hashimoto’s thyroiditis, chronic fatigue syndrome and low blood pressure. Brain fog can be a result of any of these conditions as well as candidiasis and a plethora of other conditions.

It’s also common to have a combination of these conditions. I have quite a few patients with low iron, low blood pressure and hypothyroidism. You have to think if hypothyroidism slows your digestion down, you won’t secrete proper stomach acid so you won’t be able to extract iron from your food, which will lead to low iron and low blood pressure.

Causes of iron deficiency

  • Inadequate iron intake: If you’re not consuming iron you won’t be able to use it or store it.
  • Vegetarian or vegan diet: You absorb approximately 2-18% of iron from plant sources, but 50-80% from animal sources as long as your digestion is up to par.
  • Wheat consumption: I’ve had numerous patients whose ferritin wouldn’t budge until I took them off of wheat. Most likely because wheat was causing inflammation of the intestines so they weren’t absorbing anything.
  • Dairy consumption: Same deal as wheat. I’ve had quite a few patients whose ferritin would not increase until I got them to stop consuming all dairy.
  • Food sensitivitiesIf your abdomen is bloated you’re not going to be absorbing nutrients optimally
  • Diarrhea: If food is taking the fast lane through you, you won’t have time to absorb its goods.
  • Excess intake of black coffee or black tea: The tannins in black coffee or tea are used to turn cowhides into leather. If we are constantly exposed to them we’ll decrease absorption of all nutrients. In Hemochromatosis (iron overload), patients are instructed to consume black drinks liberally to prevent absorption of iron.
  • Donating blood: You’ll drop about 20-40 units of ferritin each time you donate blood. Just because your hemoglobin is fine doesn’t mean your ferritin is. Get your ferritin checked before you donate blood.
  • Heavy periods: If you’re bleeding out more iron than you’re consuming you’re going to get low iron stores.
  • Celiac disease: All nutrients are deficient in this condition
  • Acid blocker medications: Proton pump inhibitors like Nexium, Prevacid and Pantaloc are designed to prevent stomach acid secretion. We need stomach acid in order to break down food to absorb its nutrients. Long-term use of these medications will cause an iron deficiency, along with basically other nutrient deficiency.This is the most common reason why men usually have an iron deficiency.
  • Stress: If you’re in fight or flight mode, blood is shunted from your intestines to your muscles. As a result of this, your body will be prepared to run away from things rather than break down food and absorb nutrients from it.
  • Excess caffeine: Same reason as stress. Caffeine is basically synthetic stress so it has the same effect. The caffeine and tannins in coffee are a bad combo for causing an iron deficiency.
  • Low stomach acid (hypochlorhydria): if you can’t break foods down properly you won’t be able to get iron from it. This can be due to a high carbohydrate diet, zinc deficiency, stress, acid blockers, anxiety, eating on the go, and several other reasons.
  • Colon cancer Sometimes the first sign of colon cancer is an iron deficiency anemia.

Proper iron supplementation

Most people avoid iron supplements because they make them constipated or cause abdominal pain. This is because most iron supplements that are prescribed are in a terrible form. They use ferrous gluconate or ferrous fumarate which are not absorbed very well and they are harsh on our digestive system.
The best form of iron to use is iron bisglycinate. It’s a lot easier on the intestines and absorbs a lot better. I’ve had patients come in who were on ferrous gluconate or fumarate for 3+ years and their ferritin didn’t budge, but after being on iron bisglycinate for 3 months their ferritin increased by over 40 units!
Iron should also be taken with vitamin C to increase absorption. Iron should not be taken with calcium, magnesium, copper, zinc, fiber, eggs, chamomile tea, peppermint tea, or milk thistle, since they all prevent absorption of iron. If you’re unsure about taking proper iron supplements or need help interpreting your blood work contact your local licensed Naturopathic Doctor.

Not testing ferritin can be irresponsible

It boggles my mind that ferritin is not a required test during and after pregnancy. Having adequate iron stores is important for the baby’s health, increasing survival rate if hemorrhaging occurs, preventing post-partum depression and so Mom isn’t extremely tired while trying to take care of her active baby.
I’ve had so many patients tell me they never imagined that they could actually have energy throughout the day because they’ve lived with it for so long. Ferritin should be tested in anyone who has any of the symptoms I mentioned at the beginning of this article, pregnant women, post-partum women, vegetarians and vegans especially, but I would recommend everyone get their ferritin tested at least once to see where it’s at.

Thanks for reading! Please share this with any of your friends who have been diagnosed with an iron deficiency or who have the symptoms I mentioned. No one has to, or should live with this condition. Also if you learned from this and would like an update every time I post new stuff please sign up for my email list here. Also, check out my article on IBS if you have digestive issues that could be contributing towards iron deficiency.


Dr Justin Gallant ND

Dr. Justin Gallant
Naturopathic Doctor
Contributor to The Hearty Soul.

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