Which form of iron is best absorbed?

15 Apr.,2024

 

Iron is an important mineral that helps maintain healthy blood. A lack of iron is called iron-deficiency anemia, which affects about 4-5 million Americans yearly. [1] It is the most common nutritional deficiency worldwide, causing extreme fatigue and lightheadedness. It affects all ages, with children, women who are pregnant or menstruating, and people receiving kidney dialysis among those at highest risk for this condition.

Iron is a major component of hemoglobin, a type of protein in red blood cells that carries oxygen from your lungs to all parts of the body. Without enough iron, there aren’t enough red blood cells to transport oxygen, which leads to fatigue. Iron is also part of myoglobin, a protein that carries and stores oxygen specifically in muscle tissues. Iron is important for healthy brain development and growth in children, and for the normal production and function of various cells and hormones.

Iron from food comes in two forms: heme and non-heme. Heme is found only in animal flesh like meat, poultry, and seafood. Non-heme iron is found in plant foods like whole grains, nuts, seeds, legumes, and leafy greens. Non-heme iron is also found in animal flesh (as animals consume plant foods with non-heme iron) and fortified foods.

Iron is stored in the body as ferritin (in the liver, spleen, muscle tissue, and bone marrow) and is delivered throughout the body by transferrin (a protein in blood that binds to iron). A doctor may sometimes check blood levels of these two components if anemia is suspected.

Recommended Amounts

RDA:  The Recommended Dietary Allowance (RDA) for adults 19-50 years is 8 mg daily for men, 18 mg for women, 27 mg for pregnancy, and 9 mg for lactation. [2] The higher amounts in women and pregnancy are due to blood loss through menstruation and because of the rapid growth of the fetus requiring extra blood circulation during pregnancy. Adolescents 14-18 years actively growing also need higher iron: 11 mg for boys, 15 mg for girls, 27 mg for pregnancy, and 10 mg for lactation. The RDA for women 51+ years drops to 8 mg with the assumption that cessation of menstruation has occurred with menopause. It may be noted that menopause occurs later for some women, so they should continue to follow the RDA for younger women until menopause is confirmed.

UL:  The Tolerable Upper Intake Level is the maximum daily intake unlikely to cause harmful effects on health. The UL for iron is 45 mg daily for all males and females ages 14+ years.  For younger ages, the UL is 40 mg.

Food Sources

Meats, poultry, and seafood are richest in heme iron. Fortified grains, nuts, seeds, legumes, and vegetables contain non-heme iron. In the U.S. many breads, cereals, and infant formulas are fortified with iron.

Heme iron is better absorbed by the body than non-heme iron. Certain factors can improve or inhibit the absorption of non-heme iron. Vitamin C and heme iron taken at the same meal can improve the absorption of non-heme iron. Bran fiber, large amounts of calcium particularly from supplements, and plant substances like phytates and tannins can inhibit the absorption of non-heme iron. [3]

Sources of heme iron:

  • Oysters, clams, mussels
  • Beef or chicken liver
  • Organ meats
  • Canned sardines
  • Beef
  • Poultry
  • Canned light tuna

Sources of non-heme iron: 

  • Fortified breakfast cereals
  • Beans
  • Dark chocolate (at least 45%)
  • Lentils
  • Spinach
  • Potato with skin
  • Nuts, seeds
  • Enriched rice or bread

What about iron supplements?

Confusion with iron supplements

Iron is available in supplement form. Some cereals and multivitamin/mineral supplements are fortified with 100% of the RDA for women for iron (18 mg). Over-the-counter high-dosage iron supplements prescribed for those with iron-deficiency anemia or who are at high risk for it may contain 65 mg or more. Commonly reported side effects of using high-dosage iron supplements include constipation and nausea.

There are several types of iron available as over-the-counter supplements, e.g., ferrous sulfate, ferrous fumarate, ferrous gluconate. Confusion is also caused by two number amounts listed on the label, a higher number and a lower number. What is the difference among supplement forms and which number should you refer to for the right amount to take?

Elemental versus chemical form of iron. If two iron amounts are listed on the label, the larger number is the chemical compound form because iron is bound to salts (e.g., ferrous sulfate), whereas the smaller number refers only to the amount of iron in the compound, also called the elemental iron. Elemental iron is the more important number because this is the amount available for the body to absorb. However, a physician may not specify in a prescription if the iron amount is the chemical form or the elemental iron. For example, a ferrous sulfate iron supplement may list a total of 325 mg of ferrous sulfate on the front of the label but 65 mg of elemental iron in smaller print on the back. If a physician prescribed 65 mg of iron, would you take five pills to equal 325 mg, or just one pill, assuming the prescription referred to elemental iron?

Different types. All types of supplemental iron help to increase red blood cell production but vary in cost and amounts of elemental iron. Ferrous gluconate is usually sold in liquid form and some clinical studies have shown that it is better absorbed than ferrous sulfate tablets. However, ferrous gluconate contains less elemental iron than ferrous sulfate, so a greater dosage may be needed to correct a deficiency. It is also more expensive than ferrous sulfate. Newer slow-release forms of iron have been introduced, which may help reduce gastrointestinal side effects, but they are more expensive and usually contain less iron.

Any confusion with iron supplement types and amounts can be resolved by asking your doctor to specify both the elemental amount and the chemical compound amount. You can also ask a store pharmacist for assistance in interpreting a doctor’s prescription or to recommend an appropriate amount if you do not have a prescription.

Signs of Deficiency and Toxicity

Deficiency

An iron deficiency is seen most commonly in children, women who are menstruating or pregnant, and those eating a diet lacking in iron.

Iron deficiency occurs in stages. [4] The mild form begins with a decrease in stored iron, usually either from a low-iron diet or from excessive bleeding. If this does not resolve, the next stage is a greater depletion of iron stores and a drop in red blood cells. Eventually this leads to iron-deficiency anemia (IDA) where iron stores are used up and there is significant loss of total red blood cells. Typically, a doctor screens for anemia by first checking a complete blood count (including hemoglobin, hematocrit, and other factors that measure red blood cell volume and size). If this is below normal, ferritin and transferrin levels may be measured to determine if the type of anemia is IDA (there are other forms of anemia not caused specifically by an iron deficiency). All of these measures would decrease with IDA.

Signs of IDA:

  • Fatigue, weakness
  • Lightheadedness
  • Confusion, loss of concentration
  • Sensitivity to cold
  • Shortness of breath
  • Rapid heartbeat
  • Pale skin
  • Hair loss, brittle nails
  • Pica: cravings for dirt, clay, ice, or other non-food items

IDA is usually corrected with oral iron supplements of up to 150-200 mg of elemental iron daily. Those at high risk of IDA may be prescribed 60-100 mg daily. Blood levels should be rechecked periodically, and supplements discontinued or taken at a lower dosage if levels return to normal, as long-term high dosages can lead to constipation or other digestive upset.

Groups at risk for IDA:

  • Pregnant women—during pregnancy a woman produces much greater amounts of red blood cells for the fetus, increasing the need for additional dietary or supplemental iron. IDA during pregnancy can lead to premature birth or low birth weight so iron is routinely included in prenatal vitamins. The Centers for Disease Control and Prevention recommend that all pregnant women begin taking 30 mg daily of supplemental iron. [3]
  • Menstruating women—women who experience heavy bleeding during menstruation (lasting longer than 7 days or soaking through tampons or pads once every hour) can develop IDA.
  • Children—infants and children have high iron needs due to their rapid growth.
  • Elderly—older ages are associated with a higher risk of poor nutrition and chronic inflammatory diseases that can lead to anemia. [1]
  • Vegetarians—those who eat a diet without heme iron from meats, fish, and poultry may develop IDA if they do not include adequate non-heme iron foods in the diet. Because non-heme iron is not well-absorbed, either greater quantities of these foods my be required or careful attention is needed in how they are eaten to improve absorption (consuming with vitamin C-rich foods while avoiding eating with calcium-rich foods, calcium supplements, or tea).
  • Endurance athletes—running can cause trace amounts of gastrointestinal bleeding and a condition called “foot-strike” hemolysis that breaks down red blood cells at a faster rate. Female endurance athletes who are also menstruating are at greatest risk for IDA. [4]
  • People with chronic kidney failure on dialysis—the kidneys make a hormone called erythropoietin (EPO) that signals the body to make red blood cells. Kidney failure reduces the production of EPO and therefore blood cells. In addition, there is some blood loss during hemodialysis.
What is anemia of chronic disease?

Anemia of chronic disease (AOCD) occurs not from a low iron intake but with conditions that cause inflammation in the body, such as infections, cancer, kidney disease, inflammatory bowel disease, heart failure, lupus, and rheumatoid arthritis. The body may actually contain normal amounts of iron, but levels in the blood are very low. Inflammation changes the body’s immune function, preventing the body from being able to use available stored iron to make red blood cells and also causing blood cells to die out more quickly.

Treatment for AOCD focuses on treating the inflammatory condition. Increasing iron in the diet typically does not help. If the inflammation or condition improves, the anemia will usually decrease as well. In rare severe cases, a blood transfusion can be given to quickly boost the amount of hemoglobin in the blood.

Toxicity

Toxicity is rare because the body regulates iron absorption and will absorb less if iron stores are adequate. [2] Excessive iron occurs most often from taking high-dosage supplements when not needed or from having a genetic condition that stores too much iron.

Common signs:

  • Constipation
  • Upset stomach
  • Nausea, vomiting
  • Abdominal pain

Some people have a hereditary condition called hemochromatosis that causes an excessive buildup of iron in the body. Treatments are given periodically to remove blood or excess iron in the blood. People with hemochromatosis are educated to follow a low-iron diet and to avoid iron and vitamin C supplements. If left untreated, iron can build up in certain organs so that there is a higher risk of developing conditions like liver cirrhosis, liver cancer, or heart disease. 

Did You Know?

It is possible to obtain enough iron in a vegetarian/vegan diet with careful planning. Try this easy dish that can boost iron levels by combining foods rich in non-heme iron and vitamin C:

  • In a large bowl, combine cooked beans or lentils with diced fresh tomatoes, raw baby spinach, pumpkin seeds or cashews, and raisins or dried chopped apricots. Drizzle with a simple lemon vinaigrette made from 2 tablespoons lemon juice, ½ teaspoon Dijon mustard, 3 tablespoons olive oil, and 1 teaspoon of honey (optional). Stir ingredients well and allow to sit for at least 15 minutes to incorporate the flavors.

Related

Vitamins and Minerals

Last reviewed March 2023

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What is ferrous sulfate?

Ferrous sulfate is a type of iron supplement. You normally get all the iron you need from the foods you eat. Your healthcare provider may recommend ferrous sulfate if you don’t get enough iron in your diet. Iron supplements can be especially beneficial for women or people assigned female at birth.

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What is iron?

Iron is one of the minerals your body needs to function properly. Your body needs iron to produce hemoglobin and myoglobin. Hemoglobin is a protein in your red blood cells. Hemoglobin helps your blood carry oxygen from your lungs to all your body‘s tissues and organs. Myoglobin is a protein in your muscles and helps supply oxygen to the cells in your muscles.

If you don’t have enough iron, your body can’t make these proteins, and you may develop iron-deficiency anemia. Iron-deficiency anemia is the most common type of anemia. Anemia is a blood disorder in which your body doesn’t have enough red blood cells

What is iron-deficiency anemia?

Iron-deficiency anemia can occur if you don’t have enough iron in your body. The condition develops when you lack the iron that your red blood cells need. Factors that can lower your body's supply of iron include:

Blood loss

You lose iron when you lose blood. You can lose blood in many ways:

Issues with absorbing iron

Some health conditions and medications can decrease your body’s ability to absorb iron. These may include:

  • Rare genetic disorders that block your intestines from absorbing iron.
  • Endurance sports that cause athletes to lose iron through their gastrointestinal tracts.
  • Certain digestive conditions such as ulcerative colitis and Crohn’s disease.
  • Intestine and stomach surgeries, including weight loss surgery.
  • Conditions that can destroy too many red blood cells (certain infections, autoimmune diseases and inherited blood cell disorders).

Iron-deficiency anemia can also happen if your diet doesn't have enough iron in it or if you have an increase in your body's need for iron (for instance, during pregnancy).

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What are the symptoms of iron-deficiency anemia?

You may not have any symptoms if you have a mild case of iron-deficiency anemia. Symptoms of more severe cases of the condition may include:

  • Feeling tired (fatigue).
  • Pale skin.
  • Difficulty breathing.
  • Chest pain.
  • Fast heartbeat.
  • Dizziness.
  • Headache.
  • Feeling cold (including the sensation that your hands or feet are colder than usual).
  • Infections (caused by problems with your immune system).
  • Craving for nonfood items such as ice or dirt.
  • Restless legs in which you have a strong urge to move your legs.

Who is most likely to develop iron-deficiency anemia?

Anyone can develop iron-deficiency anemia, although the following groups have a higher risk:

  • Menstruating and pregnant people.
  • Frequent blood donors.
  • People who have kidney failure (especially if they are on dialysis), because they have trouble making red blood cells.
  • Premature babies or infants with low birth weights.
  • People with certain cancers or heart failure.

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How is anemia diagnosed?

Your healthcare provider may order a blood test to check your complete blood count. The blood test will measure your hemoglobin and how many red cells are in your body. If these levels are low, your provider can make a diagnosis of anemia.

How is anemia treated?

Depending on the cause of iron-deficiency anemia, your treatment will vary. Your healthcare provider may recommend eating foods that are high in iron. They may also suggest an oral (taken by mouth) iron supplement such as ferrous sulfate. If you can’t take an oral supplement, you may need to get iron through a vein (intravenously).

What foods are high in iron?

You can find iron naturally in many foods. Many food products have also been fortified with iron. Iron-rich foods include:

  • Lean meat and poultry.
  • Seafood such as salmon.
  • White beans, kidney beans, lentils and peas.
  • Nuts and dried fruits.
  • Green leafy vegetables such as spinach.
  • Fortified bread and breakfast cereals.

Your body can absorb iron from plant foods better when you eat it with meat, poultry, seafood and foods that are high in vitamin C. Foods that contain a lot of vitamin C include fruits and vegetables such as oranges, strawberries, tomatoes and broccoli.

What is oral iron supplementation?

In addition to eating foods that are rich in iron, you may have to take an oral iron supplement. The benefit of an oral iron supplement is it treats your symptoms by increasing the levels of iron and hemoglobin in your body.

The iron in your body is called "elemental iron." Oral iron supplements contain different amounts of elemental iron. When you choose a supplement, be sure to check the label to see how much elemental iron it contains. A greater amount of elemental iron means your body will absorb more iron.

What are the different types of ferrous sulfate?

There are many different types of oral iron supplements. Ferrous sulfate comes in tablet or liquid form:

  • Tablets: The most common tablet size is ferrous sulfate 325 milligrams (mg). Tablets come in standard or delayed (extended) release formats.
  • Liquid: You can also take ferrous sulfate as a liquid iron supplement. The liquid comes as an elixir or as drops.

How should I take iron supplements?

If your healthcare provider has recommended an iron supplement, use it only as directed. You should take the supplement on an empty stomach. Take your medication at least one hour before or two hours after you eat a meal.

If you’re using a tablet form, swallow the tablet whole. Don’t try to crush, chew or break it. If you’re using a liquid form, measure the medicine carefully. Use a dosing syringe, not a kitchen spoon. You may not get an accurate dose of the medication.

Your healthcare provider may recommend a special diet while you’re taking ferrous sulfate. Follow their instructions precisely. Store the supplement at room temperature, and keep it out of reach of children.

Other instructions to keep in mind:

  • Although the supplement works best on an empty stomach, you may want to take it with food so it doesn’t upset your stomach.
  • You shouldn't take iron supplements with milk, caffeine, antacids or calcium supplements.
  • Try to take your iron supplement with vitamin C (for example, a glass of orange juice) to increase absorption.

What are the side effects of ferrous sulfate?

Iron supplements can cause is constipation, so drink plenty of water. You may need to take a stool softener along with the supplement. Iron supplements can cause several other side effects. These may include:

  • Heartburn.
  • Loss of appetite.
  • Stomach cramps.
  • Nausea.
  • Diarrhea.
  • Dark poop (stool).

The side effects of ferrous sulfate supplements are usually temporary. They should go away as your body gets used to the medication.

What are the best iron supplements?

Your healthcare provider will help you decide what the best iron supplement is best for you. They’ll also tell you how much iron you need to take every day. The best way to take the iron supplement is through two or more doses each day. This way your body absorbs the greatest amount of iron. However, you should take extended-release iron products once a day.

When will I start to feel better?

It may take one to four weeks (after you start your iron supplement) before you start to feel better. Continue to watch your symptoms and take note of side effects. If you have any questions or concerns, talk to your healthcare provider.

How long will I have to take an oral iron supplement?

Your healthcare provider will let you know how long you have to take an iron supplement. After your hemoglobin and iron levels are back to normal, you may need to continue the iron supplement for another six months. You may have intermittent blood tests to measure your iron level.

A note from Cleveland Clinic

Ferrous sulfate is a type of iron supplement that can help you prevent or treat iron-deficiency anemia. Check with your healthcare provider before you start on any supplements. If your provider recommended you start on ferrous sulfate, make sure to follow their guidance closely. Ferrous sulfate has many benefits but it can also cause side effects. Only take an iron supplement for as long as your provider instructed. Taking more iron than your body needs can cause serious health issues.

Which form of iron is best absorbed?

Iron Supplements for Anemia (Ferrous Sulfate): Types, Benefits & Side Effects