Latest / Wellness by Designs - Practitioner Podcast / Beyond the blood test: what your iron results aren't telling you with Laura Taylor

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Beyond the blood test: what your iron results aren't telling you with Laura Taylor · Wellness by Designs - Practitioner Podcast

• 0:11
  SPEAKER_01: This is Wellness by Designs.
• 0:13
  SPEAKER_01: I'm your host, Andrew Whitfield Cook.
• 0:15
  SPEAKER_01: And joining us today is Laura Taylor, a naturopath who specialises in gut health and iron deficiency.
• 0:22
  SPEAKER_01: And iron deficiency is indeed what we're going to be discussing today.
• 0:26
  SPEAKER_01: Welcome to Wellness by Designs, Laura.
• 0:28
  SPEAKER_01: How are you?
• 0:28
  SPEAKER_00: I'm really well.
• 0:29
  SPEAKER_00: Thanks for having me, Andrew.
• 0:31
  SPEAKER_01: Oh, this is such a needed topic.
• 0:33
  SPEAKER_01: And please forgive my ignorance in this because I know that I'm going to be learning a heck of a lot myself.
• 0:41
  SPEAKER_01: Okay, so if we dive in.
• 0:46
  SPEAKER_01: You've explored the research on how, let's say, inflammation um affects iron absorption and mobilization importantly.
• 0:56
  SPEAKER_01: So can you explain how cytokines and and how inflammation interacts with iron as a mineral and nutrient and to influence the process?
• 1:08
  SPEAKER_00: Yeah, so it's quite a complicated process.
• 1:12
  SPEAKER_00: And to understand this, we really need to look first at how iron is absorbed.
• 1:16
  SPEAKER_00: So the small intestine, of course, is where our iron goes from our intestines into our body.
• 1:22
  SPEAKER_00: And in order for it to get out of the small intestine and into circulation, it has to go through the interacites that line the cell, taking us back to nutritional biochemistry from uni.
• 1:32
  SPEAKER_00: And that's essentially the portal that the iron needs to pass through.
• 1:35
  SPEAKER_00: And I guess the simplified version of what happens there is that the iron arrives in the small intestine, it enters that interacite through DMT1, so that's that divalent metal transporter.
• 1:46
  SPEAKER_00: And then once it's in the interacite, the next thing it needs to do is get out the other side into circulation.
• 1:52
  SPEAKER_00: To do that, it's got to go through, like I call it the ferroportin door, but it's it's it's just called ferroportin.
• 1:57
  SPEAKER_00: Um and when there's inflammation present, and this doesn't need to be significant, you know, acute inflammation, it can be subclinical just chronic rumbling inflammation.
• 2:08
  SPEAKER_00: We have elevated levels of inflammatory cytokines, um, and you know, our CRP can be elevated and all these other markers that are showing us there's inflammation in the body, and these essentially stimulate the liver to produce hepsidin.
• 2:22
  SPEAKER_00: And what hepsidin does is it acts like the gatekeeper.
• 2:25
  SPEAKER_00: So it's sent to the small intestine and it basically degrades that ferroportan door.
• 2:30
  SPEAKER_00: So now the iron that's waiting in the interacite, ready to be let into circulation, has nowhere to go because its door has disappeared.
• 2:38
  SPEAKER_00: Then this problem is compounded because enterocytes, as we know, only live for about 72 hours.
• 2:43
  SPEAKER_00: And so that enterocyte then dies, gets sloughed off the wall of the small intestine, and you know, we shed into the lumen and we excrete it through the bowel with the iron inside of it.
• 2:52
  SPEAKER_00: So, and this isn't the only place that hepsidin does this.
• 2:55
  SPEAKER_00: It does it um on uh ferroportin non-macrophages as well.
• 3:00
  SPEAKER_00: But you know, when we're talking about trying to build up our iron levels through supplements or our diet, we're really talking about what's happening um in the small intestine, and this is where we really see the impact that inflammation can have.
• 3:12
  SPEAKER_00: So, you know, even if you're eating plenty of iron or you're taking iron supplements, your absorption and your mobilization are gonna dramatically be dropped because the iron essentially gets trapped.
• 3:22
  SPEAKER_01: Right.
• 3:23
  SPEAKER_01: Okay, so we're gonna, this is gonna be a bigger one than Ben Herb.
• 3:28
  SPEAKER_01: Differentiating between true iron deficiency and inflammation mediated supposed iron deficiency.
• 3:36
  SPEAKER_00: Yes, yeah, it gets blurry.
• 3:39
  SPEAKER_00: So um there are so there's two types of iron deficiency.
• 3:45
  SPEAKER_00: So true iron deficiency being you don't have enough iron stores left, um, and functional iron deficiency, which is mainly caused by inflammation, where you might have enough iron left in the body, but it's not being mobilized or you can't access it because of that inflammation.
• 4:00
  SPEAKER_00: So in true iron deficiency, the body's iron stores are generally low, our ferritin is low, our transferrin will be high because it goes up when the liver is signaling that it's trying to go out and find more iron.
• 4:13
  SPEAKER_00: Um, transferrin saturation is usually low when our CRP will be normal.
• 4:16
  SPEAKER_00: So that's typically what you would see on a blood test.
• 4:19
  SPEAKER_00: Um, whereas in functional iron deficiency, um, the iron is present, but as I said, it's trapped.
• 4:25
  SPEAKER_00: And so we might see a normal ferritin or a high ferritin.
• 4:29
  SPEAKER_00: Um, but what we'll see is the transferrin being lower because the body um has enough iron, so it just can't, it just can't access it.
• 4:38
  SPEAKER_00: Um, it can get a little bit confusing though, because these two types of iron deficiency can overlap.
• 4:43
  SPEAKER_00: And I see this a lot in clinic.
• 4:45
  SPEAKER_00: So somebody might have started off with you know true iron deficiency and their ferritin might be somewhere, I don't know, let's say it's really low, six or seven, and then they've become inflamed.
• 4:54
  SPEAKER_00: And so that inflammation is now pushing up their ferritin level because as we know, when someone's inflamed, their iron gets sequestered into ferritin.
• 5:02
  SPEAKER_00: And so now their ferritin might be sitting at 31, 32, and so technically they're not deficient, but they feel like they are because it's not a true reading.
• 5:12
  SPEAKER_01: Okay, what about other markers though?
• 5:15
  SPEAKER_01: Like ferritin, you know, if we're talking about um uh saturation, if we're talking about the other markers, take us through what happens then.
• 5:25
  SPEAKER_00: Yeah, so in uh if there's in inflamm if there's inflammation that's affecting the iron um transportation, then as I said, we'll still see the transferrin sitting lower if that person has enough iron stores because the liver knows there's iron around.
• 5:39
  SPEAKER_00: It isn't going out saying we need to get more iron from the small intestine, let's go out and send more transferrin to get it.
• 5:45
  SPEAKER_00: But what happens is the the saturation level will be lower because saturation being how much iron is on each of those transferrin molecules.
• 5:52
  SPEAKER_00: And that's because the body is trying to protect you from what it perceives to be uh like a bacterial infection.
• 6:00
  SPEAKER_00: And so it knows that pathogenic types of bacteria use iron to replicate.
• 6:04
  SPEAKER_00: And so the liver, in all of its infinite wisdom, thinks, well, we must have an infection if there's inflammation.
• 6:09
  SPEAKER_00: And so instead of allowing that iron to be saturating the transferrin and moving around the body where it needs to go, it all gets taken out of circulation.
• 6:18
  SPEAKER_00: So you'll see this reduction in transferrin saturation, and you'll see an elevation in those acute markers like CRP, ESR, and potentially some of the more subclinical markers as well.
• 6:29
  SPEAKER_00: You know, if you're looking at your uh neutrophil lymphocyte ratio and albumin to globulin as well.
• 6:34
  SPEAKER_01: So, in effect, we're causing a supplement or medication-driven um hemochromatosis.
• 6:44
  SPEAKER_01: It's just not hereditary.
• 6:47
  SPEAKER_00: Yeah, essentially, and that can happen.
• 6:48
  SPEAKER_00: And I have seen people's ferritin levels jump up into the hundreds as a result of this.
• 6:53
  SPEAKER_00: Um, I think because the population that I'm mainly working with tend to also have true iron deficiency.
• 6:59
  SPEAKER_00: I don't often see it go that high.
• 7:00
  SPEAKER_00: It usually kind of brings it back into somewhat of a normal range.
• 7:04
  SPEAKER_00: But it can trip clinicians up because um we can sometimes think, oh, we really need to push ferritin higher and higher, which we'll get into a bit later on.
• 7:13
  SPEAKER_00: But if you know, if we see a ferritin of say 70 and think, oh wow, that's really good, we don't need to worry about anything there and we don't look any further, we might actually be missing this inflammatory picture.
• 7:24
  SPEAKER_01: Yeah.
• 7:25
  SPEAKER_01: So let's go into this ferritin story because you know, like I've even seen women having, you know, two, three, four infusions, and their iron is still low, quote unquote.
• 7:38
  SPEAKER_01: Yeah.
• 7:38
  SPEAKER_01: And so it's like even the even the GP's scrabbling for answers there.
• 7:43
  SPEAKER_01: So tell us what's going on.
• 7:44
  SPEAKER_01: Yeah.
• 7:45
  SPEAKER_00: Yeah.
• 7:45
  SPEAKER_00: And so a couple of things.
• 7:46
  SPEAKER_00: So with iron infusions, um, again, if we go back to the inflammatory picture, if there's inflammation around, they're more likely to be a poor responder to the iron infusion.
• 7:55
  SPEAKER_00: And there are those people that will say, either I had an iron infusion and I didn't feel any different.
• 8:00
  SPEAKER_00: My on paper, my blood work looks better, but I just still feel the same.
• 8:04
  SPEAKER_00: Or they'll say, My ferritin peaked and then it just fell off a cliff again.
• 8:08
  SPEAKER_00: And it's because the body is just rejecting the iron for the same reason we spoke about last time.
• 8:13
  SPEAKER_00: But I think, as you mentioned, it's also really important to understand what ferritin actually is because I think it's quite misunderstood.
• 8:20
  SPEAKER_00: So there's probably two big misconceptions that I see around ferritin.
• 8:25
  SPEAKER_00: The first one relates to what it actually is.
• 8:27
  SPEAKER_00: So often I hear people talking about ferritin as stored iron, but uh ferritin is actually a like a self-assembled protein cage and it's found throughout the body.
• 8:38
  SPEAKER_00: So it's in the cells and it's in the blood.
• 8:40
  SPEAKER_00: And iron is what's is stored within the ferritin cage.
• 8:44
  SPEAKER_00: So they're two separate things.
• 8:46
  SPEAKER_00: What I find really fascinating is that the just not to go into the um the detail too much, but the ferritin that we have in our cells contains around 1,000 to 4,500 iron atoms.
• 9:02
  SPEAKER_00: When we look at that same iron in the blood, which is where we're obviously testing it when we do a blood test, we only find about 150 iron atoms.
• 9:10
  SPEAKER_00: So it raises a really big question, right?
• 9:13
  SPEAKER_00: Like where did all the where did all the iron go?
• 9:16
  SPEAKER_00: And we don't actually know.
• 9:18
  SPEAKER_00: We don't know.
• 9:19
  SPEAKER_00: So there are theories around what happens.
• 9:22
  SPEAKER_00: There's theories around how the ferritin goes from in the cell to in the blood.
• 9:26
  SPEAKER_00: And the the working theory at the moment is that it's actually happens through cellular damage.
• 9:31
  SPEAKER_00: So it's this uncontrolled leakage of ferritin um into the bloodstream, which makes sense when we think about ferritin being an inflammatory marker.
• 9:40
  SPEAKER_00: So that's the first part.
• 9:41
  SPEAKER_00: Um, and then the second misconception, which we briefly touched on before, is well, where should our ferritin actually be?
• 9:47
  SPEAKER_00: Like what is the optimal range?
• 9:49
  SPEAKER_00: Because as you know, naturopaths and natural medicine clinicians, we often talk about, well, you know, the reference range says this, but we really want it up here.
• 9:58
  SPEAKER_00: With ferritin, what I've found in the research, and there's been large-scale populations that have looked at this.
• 10:05
  SPEAKER_00: For somebody, let's take somebody who's having, you know, a fairly regular period, it's not super heavy, um, and they have a fairly typical diet, their ferritin value will quite happily sit somewhere between 30 and 50.
• 10:18
  SPEAKER_00: And that is okay.
• 10:20
  SPEAKER_00: We don't need our ferritin be pushing up to 100.
• 10:23
  SPEAKER_00: Um, because as I said, ferritin is it's a protein cage.
• 10:27
  SPEAKER_00: The iron goes in there, and once the iron is in there, the body's not actively using it.
• 10:31
  SPEAKER_00: It's quite literally stored away.
• 10:33
  SPEAKER_00: And the analogy that I like to use is if you think about, you know, if you have winter coats and it's coming into summer and you don't need all of your winter coats, so you put them all into storage, you're not using them through summer, it starts to cool down again.
• 10:46
  SPEAKER_00: You think I might just pull out one of my coats.
• 10:48
  SPEAKER_00: You really only need two or three coats maximum in storage.
• 10:52
  SPEAKER_00: Having 150 coats in there is not going to keep you any warmer.
• 10:55
  SPEAKER_00: So I think about iron in ferritin that way.
• 10:57
  SPEAKER_00: As long as you've got enough that your body can draw on it when it needs it, we don't need massive amounts of excess iron being stored in ferritin.
• 11:05
  SPEAKER_00: So they're the two things that I'd really like to, yeah, kind of just clear up today.
• 11:11
  SPEAKER_01: Um okay, so the sweet spot is that 30 to 50.
• 11:16
  SPEAKER_01: And you were talking about a woman with a normal period.
• 11:18
  SPEAKER_01: What about men?
• 11:19
  SPEAKER_00: Yeah, so men, it will definitely be higher.
• 11:22
  SPEAKER_00: But if I was to see somebody, if I was to see a male um or someone to sign a male at birth in their 30s and their ferritin was in the 200s, I would be that would be a red flag for me that potentially there's hemochromatosis here.
• 11:34
  SPEAKER_00: So it will be higher, but usually somewhere in the hundred, between hundreds and it will naturally increase with age because they don't have that regular blood loss, um, which is the same mechanism that we see um when someone goes through menopause, their ferritin will then gradually start to rise.
• 11:49
  SPEAKER_01: Yeah.
• 11:50
  SPEAKER_01: Okay.
• 11:51
  SPEAKER_01: So uh do we need to in um discuss uh the markers, uh like how you use them in combination?
• 11:59
  SPEAKER_01: Do we you know, this is up, that's down, that's equivalent.
• 12:02
  SPEAKER_01: Do you do you want to I've seen tables and I look at them and go, uh there's a lot going on.
• 12:09
  SPEAKER_00: So I mean, I guess the basics are that the first thing that I'll always look at, even ahead of ferritin, is transferrin, because transferrin is really telling us the bot how hungry the body is for iron.
• 12:19
  SPEAKER_00: You know, Rachel Arthur um talks about this a lot, that your the liver makes more transferrin and sends it out when the liver decides that the body doesn't have enough iron.
• 12:29
  SPEAKER_00: So if we see a ferritin and it's 29, for example, but the transferrin is sitting at an optimal level, which I would say is below 2.6, I typically won't um, you know, I won't supplement.
• 12:42
  SPEAKER_00: We might do a little bit of dietary strategies just to make sure their ferritin doesn't continue to drop.
• 12:45
  SPEAKER_00: But at that point, their body is telling me based on their transferrin, they're not hungry for iron.
• 12:50
  SPEAKER_00: If I saw that same ferritin value at 29 in someone whose ferritin someone whose transferrin was three, 3.1, 3.2, it would be a very different picture because for that person, their body is saying, actually, hold on, I don't have enough iron for all of my needs, so we need to address it.
• 13:06
  SPEAKER_00: So that's the first thing I look at.
• 13:08
  SPEAKER_00: And then I look at the saturation level, how much iron is actually being moved around the body on that transferum?
• 13:14
  SPEAKER_00: Because this is when we start to get into, okay, you've got enough iron stored away.
• 13:18
  SPEAKER_00: How come you still feel iron deficient?
• 13:20
  SPEAKER_00: Or how come your red blood cells are showing signs of anemia?
• 13:23
  SPEAKER_00: Um, and this is where if I see somebody's transferrin saturation is a bit low, um, I'll consider using things like copper or other nutrients that we need to help the um the iron basically get onto the transferrin.
• 13:38
  SPEAKER_00: Because if we go back to the ferroportin door on the enterocyte, once that ferroportin door opens and the iron's now in the bloodstream, we need um good levels of copper in order to get that iron onto transferrin.
• 13:50
  SPEAKER_01: Has that got something to do with superoxide dismutase at all?
• 13:54
  SPEAKER_01: The copper?
• 13:55
  SPEAKER_00: Yeah, it's to do with um ceruloplasmin and ceruloplasm, forgive me.
• 13:59
  SPEAKER_00: Yeah, ceruloplasmine, yeah.
• 14:00
  SPEAKER_00: That's what you meant.
• 14:00
  SPEAKER_00: Yes.
• 14:01
  SPEAKER_01: Yeah, no, it's not I was wrong.
• 14:05
  SPEAKER_00: So yeah, so um ceruloplasmin and hepastin, they both require um copper, and that's what you need in order to get the iron to um then basically jump onto the transferrin.
• 14:15
  SPEAKER_01: Okay.
• 14:16
  SPEAKER_01: And what do you think about this notion of the sort of golden ratio if you if you like, you know, like 10 to 1 or something like that with copper, iron to copper?
• 14:24
  SPEAKER_01: Yeah.
• 14:25
  SPEAKER_01: Have you heard about this?
• 14:26
  SPEAKER_00: No, no, I haven't.
• 14:27
  SPEAKER_00: I haven't.
• 14:27
  SPEAKER_00: I I just usually, you know, I'll do a blood test and I'll make sure they have enough.
• 14:30
  SPEAKER_00: Um, and then I'll obviously look at it in relation to zinc, but no, I'm not familiar with the golden ratio.
• 14:34
  SPEAKER_00: You have to fill me in.
• 14:35
  SPEAKER_01: No, no, look, it's an old it's an old um concept.
• 14:39
  SPEAKER_01: And there was like zinc, iron, and copper trying to get into the same keyholes and you know, too much zinc and you go on.
• 14:45
  SPEAKER_01: Yeah.
• 14:46
  SPEAKER_01: And and I've I've I've utilized that with treating hemochromatosis, hereditary hemochromatosis, where we where we have to give massive amount amounts of zinc, but we have to also look at making sure they don't have a copper deficiency and end up with cardiomyopathy from that.
• 15:02
  SPEAKER_01: You know, so um but um so can I ask then with regards to copper, do you um are you concerned with the type with the form of copper?
• 15:15
  SPEAKER_00: Copper, is it chloride or um I haven't found it's mattered that much, to be honest.
• 15:21
  SPEAKER_00: Um, I mean I have my go-to um, you know, supplements that I'll use in clinic, but they're usually just practitioner um straight copper supplements.
• 15:27
  SPEAKER_00: I haven't noticed there's too much of a difference.
• 15:30
  SPEAKER_00: Um, and because we don't need to go super high dose, we don't need to do it for that long.
• 15:34
  SPEAKER_00: We really just need to get a little bit in in there to help with these processes.
• 15:38
  SPEAKER_00: Um so no, I haven't found there to be much difference.
• 15:41
  SPEAKER_01: And you know, there was a big um shift, if you like, in in practice where copper was labelled as the bad guy, a copper overload.
• 15:50
  SPEAKER_01: And I understand in West Australia, I get it, different types of pipes and things like that, but I've never seen it over here.
• 15:57
  SPEAKER_01: Have you have you seen copper access?
• 15:59
  SPEAKER_00: No, I haven't either, except for as you said, I have a few, I have a few clients who work in um kind of mining um roles and that kind of thing.
• 16:06
  SPEAKER_00: But yeah, unless you're actively being exposed to it through usually through industry or yeah, as you said, through um particular types of water pipes, um, it's more often that I'll see copper on the low side.
• 16:16
  SPEAKER_01: Gotcha.
• 16:17
  SPEAKER_01: And uh just along that line, zinc, zinc issues.
• 16:21
  SPEAKER_01: Do you find that either too much supplementation, for instance, with meals?
• 16:25
  SPEAKER_01: Or are you seeing any other aberrations where A, you might need zinc along with the iron or at a different time from the iron to help iron absorption, or is it mainly copper that you find works?
• 16:38
  SPEAKER_00: Uh no, it's both.
• 16:39
  SPEAKER_00: And zinc's an interesting one because um, again, this I feel like this was very oversimplified.
• 16:44
  SPEAKER_00: Uh, well, I had it very oversimplified in my mind before I started looking into it.
• 16:48
  SPEAKER_00: Um, that well, zinc and iron um interfere for absorption, they, you know, they compete, and so you shouldn't have them together.
• 16:54
  SPEAKER_00: But there's actually not really consensus in the research about what is going on in the small intestine with zinc and iron, and they seem to have um a bit of a push-pull relationship.
• 17:05
  SPEAKER_00: So we used to think that they competed because they both use the DMT-1 to get into the interacite.
• 17:11
  SPEAKER_00: But zinc actually uses the zip 14 transporter, not the DMT-1.
• 17:15
  SPEAKER_00: Um, and we do actually have research that shows that um the zinc level, if you have adequate zinc levels, it actually helps with the expression of DMT1.
• 17:26
  SPEAKER_00: So you can increase the uptake capacity of iron.
• 17:30
  SPEAKER_00: I think, as you said, where you run into trouble is if you're supplementing with really high doses.
• 17:35
  SPEAKER_00: From a dietary perspective, it's fine.
• 17:36
  SPEAKER_00: And if you think about the sorts of foods that are really high in iron, red meat, it's also really high in zinc.
• 17:42
  SPEAKER_00: So, you know, when we have it in a dietary um meal, it's it's okay.
• 17:46
  SPEAKER_00: It's just when we're going in, you know, with too much of it that I think we can destabilize things.
• 17:52
  SPEAKER_01: Yeah.
• 17:52
  SPEAKER_01: Um, so let's talk about this supplementation strategy.
• 17:56
  SPEAKER_01: Um, what's the latest evidence with regards to iron?
• 17:59
  SPEAKER_01: Because I remember forgive me.
• 18:02
  SPEAKER_01: I remember um what was it back in 2022, say, there was this shift in how we're looking at iron supplementation, the dosages that we're using because of hepsidin, they're they're talking about.
• 18:15
  SPEAKER_01: There was no mention of inflammation or anything like that.
• 18:18
  SPEAKER_01: It was only that hepsidin blocking the transporter.
• 18:22
  SPEAKER_00: Yeah.
• 18:23
  SPEAKER_01: Yeah, can we discuss that?
• 18:24
  SPEAKER_00: Yeah, definitely.
• 18:25
  SPEAKER_00: So yeah, you're 100% right.
• 18:27
  SPEAKER_00: Um, we, you know, as um naturopathic clinicians, we now use alternate day dosing primarily and much lower doses.
• 18:36
  SPEAKER_00: So around that 24 milligram equivalent iron seems to be the sweet spot.
• 18:40
  SPEAKER_00: Um, and doing it every second day, I usually recommend in the morning, but you can do it late at night before bed as well.
• 18:47
  SPEAKER_00: And we do it every second day, a from a um a tolerance perspective, um, because it helps people if they have digestive issues going on, you know, a bit less iron and giving them a you know 48-hour break from it can help, but it also helps with absorption because as you said, um hepsidin is going to be um blocking the iron from being absorbed if there's too much inflammation.
• 19:08
  SPEAKER_00: The other reason why hepsidin will block iron being absorbed is if you take too much iron.
• 19:13
  SPEAKER_00: So the liver will also send hepsidin out if you um flood, you know, if you take a whole lot of iron supplements because it thinks, hang on a second, we don't need too much iron.
• 19:22
  SPEAKER_00: Let's shut the gates until we figure out what's going on, and then we'll open them up again.
• 19:26
  SPEAKER_00: And so once hepsidin becomes active, it stays active for about 36 hours.
• 19:31
  SPEAKER_00: Yeah.
• 19:32
  SPEAKER_00: Yeah, about two days.
• 19:33
  SPEAKER_00: And so with this alternate day dosage strategy, we essentially sneak a little bit of iron through before the gates shut, we wait for them to reopen again and we repeat the process.
• 19:41
  SPEAKER_00: And yeah, I get far greater success with that than the old, we'll just give them more and more iron, you know, twice a day, really high doses.
• 19:49
  SPEAKER_00: Um, just doesn't get you anywhere except for concentrated.
• 19:52
  SPEAKER_01: Yeah, yeah.
• 19:53
  SPEAKER_01: And nausea and blah, blah, blah.
• 19:55
  SPEAKER_01: Um, and horrible smelling iron smelling poos and the whole getting cabidal.
• 20:00
  SPEAKER_01: But um, so two things like one is um, forgive me, I forgot to mention before that was a medical change in 2022 where the medical guidelines were were changing.
• 20:12
  SPEAKER_01: And there were I remember there was an RAC GP, but it was a newspaper thing that I saw.
• 20:17
  SPEAKER_01: That was probably the one uh that was the best explanation.
• 20:20
  SPEAKER_01: But then I saw more and more things, and now I think the guidelines have changed.
• 20:25
  SPEAKER_01: Having said that, um, naturopaths have been doing that for 10 odd years.
• 20:31
  SPEAKER_01: Yes.
• 20:31
  SPEAKER_01: So it's like I was telling somebody else that we've podcasted with that medicine's finally caught up to what to the science.
• 20:38
  SPEAKER_01: It's it's really dogma, you know.
• 20:41
  SPEAKER_00: Yeah, yeah, that's right.
• 20:43
  SPEAKER_00: And I mean, you know, we saw the same thing happen with probiotics, right?
• 20:46
  SPEAKER_00: Like we've been recommending them for decades and you know, now they're they're um becoming more accepted.
• 20:50
  SPEAKER_00: So um, yeah, and I think just to add a little bit more nuance that that conversation around alternate day dosing, there are exceptions to that, right?
• 20:58
  SPEAKER_00: You know, if somebody comes to me and you know, they're maybe they're they're following a vegan diet and they're not necessarily um uh eating enough different varieties of iron uh rich foods or you know, whatever's going on for them, occasionally I will do daily supplementation.
• 21:14
  SPEAKER_00: If it's a fact of you're just not getting enough iron in and we can't fix that at the moment, I will do daily, but 99% of the time it's alternate day because people just respond so much better.
• 21:24
  SPEAKER_01: Yeah.
• 21:25
  SPEAKER_01: I've also uh when I was researching this, I read a paper, and I all I remember is that it was like an Iranian researcher, Iraqi researcher.
• 21:34
  SPEAKER_01: Um, but they had what I thought was a rather arbitrary dose of uh 60 milligrams per day.
• 21:40
  SPEAKER_01: And I went, what, based on body weight?
• 21:43
  SPEAKER_01: Like what are we basing that on?
• 21:45
  SPEAKER_01: But so I thought it was rather arbitrary.
• 21:47
  SPEAKER_01: You've gone rather lower than that though.
• 21:50
  SPEAKER_00: Yes.
• 21:50
  SPEAKER_00: Well, because if you think about what you're getting from your diet, you know, the average Australian would get somewhere between 10 and 15 milligrams of total dietary iron, and of that can absorb absorb about one to two milligrams a day.
• 22:02
  SPEAKER_00: And so having 24 milligrams for a lot of people, that's double what they would get through their diet anyway.
• 22:09
  SPEAKER_00: And so if you just think about how the body is working, it's just not going to let you absorb more than that.
• 22:14
  SPEAKER_00: So if you can get it closer to what you know what you would get from your diet, we're less likely to cause the body to freak out and block it all from being absorbed.
• 22:23
  SPEAKER_01: Yeah, but but I'm also impressed with the way you're thinking from a safety standpoint because as you were saying, if your body takes it in and your liver says nah it's too much, it's already in there.
• 22:34
  SPEAKER_01: Where to now?
• 22:35
  SPEAKER_01: Spleen, brain, heart, what?
• 22:37
  SPEAKER_00: Well, yeah, that's right.
• 22:38
  SPEAKER_00: And that's where you can potentially run into an issue with oxidative damage and are we contributing to an inflammatory picture?
• 22:44
  SPEAKER_00: The other way that it can cause problems a little bit more indirectly is if you put in, say if we go in with a 300 milligram iron supplement that has 100 milligrams of equivalent iron, there's far too much for the small intestine to absorb.
• 22:58
  SPEAKER_00: And so what happens then is that iron has to go somewhere and it gets dumped into the colon where obviously all of the gut bacteria live.
• 23:06
  SPEAKER_00: And as we talked about before, if you have less friendly bacteria living there, if you've got pathobionts or potentially a pathogen, they're going to use that iron to replicate.
• 23:16
  SPEAKER_00: And what those pathobionts do is create inflammatory substances.
• 23:19
  SPEAKER_00: And so now you're feeding into this inflammatory cycle where that inflammation blocks you being able to absorb it.
• 23:25
  SPEAKER_00: So you take more iron supplements you create more inflammation and the cycle just goes on and on that's such a brilliant answer.
• 23:33
  SPEAKER_01: The other thing of course is um horrible foul smelling wind yes yeah yeah because the iron the the bugs are just eating up the iron in the in the distal collar um okay so role of cofactors it's you we've mentioned iron and copper but you know there was I remember back in the years the years when he brushes his gray hairs away um you know there were some uh anemias that weren't responsive to iron and they were responsive to several of the B vitamins for instance yeah we've now got a uh an unfortunate situation in the Australian um market where B6 is being restricted.
• 24:12
  SPEAKER_01: Yeah take us through this what do you use how much do you need what's safe what do you look about what do you look out for?
• 24:19
  SPEAKER_00: Yeah so I use a lot of testing in my clinic blood testing um to work out well you know do we need particularly B12 and folate often people are deficient in those um so that'll be usually where I'll start from a B vitamin perspective in particular.
• 24:34
  SPEAKER_00: So B vitamin B12 vitamins as we know are really needed for red blood cell production.
• 24:39
  SPEAKER_00: So they make the red blood cells and then we need iron to make sure that those red blood cells have good levels of hemoglobin to transport oxygen.
• 24:45
  SPEAKER_00: So they really go hand in hand.
• 24:47
  SPEAKER_00: So this becomes really relevant if someone's iron deficiency has got to the point where it's starting to cause anemia I'll always make sure that we know what's going on with their B12 in that scenario.
• 24:57
  SPEAKER_00: And then of course folate because it helps to ensure that those red blood cells you know divide and mature correctly.
• 25:03
  SPEAKER_00: So they all really work in kind of symphony with each other when it comes to red blood cells and oxygen transportation.
• 25:10
  SPEAKER_00: But then we have things like vitamin C, of course, you know good old vitamin C, right?
• 25:14
  SPEAKER_00: So it does a few things.
• 25:16
  SPEAKER_00: It actually helps to increase the acidity in the stomach and this is really important um particularly if you're consuming your non-heme like plant-based types of iron because it helps to cleave the um iron apart from the food so that then when it goes to the small intestine you've got a better chance of it being converted so you can absorb it.
• 25:35
  SPEAKER_00: And it also helps the actual iron be absorbed through the enterocyte and it can help reduce some of those symptoms that we talked about that you can get from iron supplementation.
• 25:46
  SPEAKER_00: So I love vitamin C alongside of iron um they'd be the main ones that I consider.
• 25:54
  SPEAKER_00: Yeah we've already talked about zinc, um copper so zinc copper B12 folate um and vitamin C would be the the key ones that I'm always looking at.
• 26:03
  SPEAKER_01: Okay and particular forms like B B12 do you look at methyl cobalamin or you don't care or it depends depends on the client depends what I know about their methylation status.
• 26:15
  SPEAKER_00: I have some clients who um just can't tolerate methylated B vitamins at all because of what's going on with their methylation pathways it causes extreme irritability.
• 26:25
  SPEAKER_00: So if I'm concerned about that I'll go in um with a hydroxycobalamin you know B12 potentially um yeah I I really determine it on a client by client basis.
• 26:36
  SPEAKER_00: If there's someone who I know has taken you know stacks of B vitamins in the past then then we can be a little bit more um adventurous with the types we use but yeah it depends.
• 26:46
  SPEAKER_01: Can can I ask about B6 do you ever worry about it?
• 26:48
  SPEAKER_01: You you said you didn't mention it.
• 26:50
  SPEAKER_00: So yeah I don't worry about it.
• 26:53
  SPEAKER_00: Um I the reason why I don't worry about it is because when you know when someone comes to me if they're taking a whole lot of different supplements you know that they've sourced themselves the first thing I'll always do is go through them and we'll find out do we even need them?
• 27:05
  SPEAKER_00: If so can we consolidate some of them down?
• 27:07
  SPEAKER_00: And that usually eliminates any B6 over overload overdosing.
• 27:13
  SPEAKER_00: And through the supplements that I'm recommending um I'm not usually not multi-dosing a whole lot of different things that all have B6 in them.
• 27:22
  SPEAKER_00: So as you would know the sorts of products that we have access to they often do have B6 but it's at lower levels sometimes we'll use P5P forms and I know there's a bit of conjecture about is that better is it not depends who you talk to um I just yeah you know use a bit of caution but I I think it's not that the um downsides of B6 toxicity have been overblown but I think the amount that it's happening and the risk of it happening is has probably been a little bit um overblown.
• 27:51
  SPEAKER_01: Yeah yeah yep and forgive me the other thing that we haven't even discussed we've talked spoken about the the forms that are commonly used in in massive amounts the sulfates but we haven't talked we haven't spoken about um the doses and the forms that you use.
• 28:08
  SPEAKER_00: Of iron yeah um so I use iron bisglycinate pretty much exclusively um I find it's better tolerated it's better absorbed um it's usually the type that will come in those lower dose supplements um they'll always be iron bisglycinate or not always but predominantly so anyone with a sensitive gut it's better for them um I find that ferro sulfate tends to be quite rough on the digestive system you know all those things we talked about the bloating the nausea the smelly farf the like black poo like all of that polymultose it does seem to be a little bit gentler but I just don't find that it increases iron levels as predictably as um like a bisglycinate form does so yeah it's my go-to yeah interesting I remember um what was it Argentina I think Argentina Chile uh was uh using iron bisglycinate as a um fortification in food oh right yeah yeah this was from Albion laboratories the people used to make it or make make it still I don't know but uh yeah it was a it was like a a whole national fortification thing so it's interesting yeah okay and do you know if they did any um like population studies to see if it changed wouldn't have a clue no I've never never tracked it never never tracked it that much um okay so clinical applications so if we look at the classic one is going to be women who are constantly flooding.
• 29:35
  SPEAKER_01: So they've got another issue over here endometriosis polycystic colyps something like that um dysfunctional uterine bleeding where they're losing blood.
• 29:46
  SPEAKER_01: There's also both males and females you've got blood loss out of the GIT so whether that be anything from overuse of NSAIDs to ulcers to hemorrhoids to obviously something sinister a tumor that's sinister it's something like that um maybe a meekled diverticulum something weird yeah um and malabsorptive syndrome so IBS celiac blah blah blah I mean you've got a lot on your plate just with iron forgive I know yeah I know I often think maybe I should have gone into a different clinical speciality what have I done hematologist so so how do you wend your way through other causes of the iron deficiency if that's what you see?
• 30:33
  SPEAKER_00: Yeah so it's a lot of case taking a lot of questions um I'll often start with a digestive system because I mean that's an area a lot of people who come to see me also have IBS or other digestive things going on.
• 30:46
  SPEAKER_00: So typically that's where I'll start because what I find for most people is there's some kind of digestive dysfunction whether or not it's the main thing that's causing the iron deficiency or if it's just contributing to it, it's usually there in some capacity.
• 30:58
  SPEAKER_00: So start from the top so what are you eating number one?
• 31:02
  SPEAKER_00: Are you chewing your food properly?
• 31:04
  SPEAKER_00: What's going on in your stomach?
• 31:06
  SPEAKER_00: Do you have H.
• 31:06
  SPEAKER_00: pylori are you taking NSAIDs?
• 31:08
  SPEAKER_00: Is there something that's preventing your stomach acid from being able to do the first step of that iron breakdown process?
• 31:15
  SPEAKER_00: And then what's going on in the small intestine?
• 31:17
  SPEAKER_00: Do you have a bacterial overgrowth there?
• 31:20
  SPEAKER_00: Do you have celiac disease?
• 31:22
  SPEAKER_00: The amount of people who have celiac disease and don't know about it, it's something like 70% of people with celiac disease they don't know.
• 31:28
  SPEAKER_00: And so whenever anyone says particularly in children been iron deficient for years and no one knows why like we have to rule out celiac disease is a number one because you know even if they don't have obvious digestive symptoms um yeah chronic iron deficiency with no other known cause celiac disease um so we look at that environment um and then from there as I talked about is there are there signs that they have some um imbalances in their microbiome so do they have pathobionts or other things there that they're contributing to it so I kind of work top to bottom from that perspective.
• 32:02
  SPEAKER_00: And then yeah if there's someone who's having a regular period well what does that look like as you said is is there heavy bleeding contributing to it um and I just piece it all together.
• 32:13
  SPEAKER_00: You know if I've kind of ruled all that out and I think well okay so the digestion seems okay their periods are fairly you know regular nothing's going on there then I'll usually look at the thyroid because the thyroid can you know interact with iron deficiency as well and often um if somebody has hypothyroidism those symptoms mirror iron deficiency.
• 32:31
  SPEAKER_00: So I guess that's the other really important thing is I'm never just assuming it's only iron deficiency um or it's iron deficiency at all because it could be it could be something else.
• 32:40
  SPEAKER_00: So yeah it's a bit of a kind of just follow the just pull the thread I guess and see where it goes.
• 32:46
  SPEAKER_01: Yeah.
• 32:47
  SPEAKER_01: Well following on from that changes in metabolism you spoke about thyroid what about uh perimenopausal and menopausal women you know they're they're hopefully no longer having that blood loss that they had during their reproductive lives.
• 33:00
  SPEAKER_01: Yeah um but they may have other issues where their thyroid goes down their digestive processes are slower now da-da-da-da-da.
• 33:07
  SPEAKER_00: Tell me how you approach this this group of women yeah so it gets tricky particularly when you're using blood tests to see what's going on from an iron perspective.
• 33:17
  SPEAKER_00: So obviously as we know in perimenopause estrogen kind of goes like this.
• 33:21
  SPEAKER_00: And that's really relevant for iron because um we actually have an iron estrogen axis.
• 33:27
  SPEAKER_00: So just to add another axis to our collection um we have an iron estrogen access and so what estrogen does is as it increases it basically reduces the production of hepsidin.
• 33:38
  SPEAKER_00: So and this happens throughout the menstrual cycle and you know we have a little temper like a little lesser um uptick in our estrogen in the luteal phase and it's thought that that's happening to help prepare for the blood loss.
• 33:51
  SPEAKER_00: So it's keeping the iron in the body it's letting more of it in.
• 33:54
  SPEAKER_00: So there's this really beautiful relationship between estrogen and iron in the menstrual years.
• 34:00
  SPEAKER_00: And then when we get into perimenopause it can be a bit all over the place.
• 34:04
  SPEAKER_00: So it starts to get harder to get a true understanding of what's you know what's actually going on from an iron deficiency perspective.
• 34:10
  SPEAKER_00: And then as you said we also need to consider I guess it's more lifestyle things in that group because often these are people who have potentially still have young kids at school maybe now they're looking after their parents they're also in the peak of their careers and so the last thing they're doing is making sure they're eating iron rich foods to begin with that you know they're not sitting down to chew their food properly.
• 34:30
  SPEAKER_00: Maybe they've had IBS for 15 20 years and it's just always kind of been put on the back burner and so it can again it's it's about what's going on for that individual person.
• 34:42
  SPEAKER_00: But it needs to be looked at under a different lens you know even just the ferritin level that we were talking about before once somebody is in now in menopause or maybe they're still in periomenopause but they're only getting one period every kind of six months we would expect to see their ferritin start to gradually increase.
• 35:01
  SPEAKER_00: Where it gets more complicated which I think is what you were alluding to is if somebody has a metabolic picture starting to develop around that time as well, that can start to drive up inflammation.
• 35:10
  SPEAKER_00: So that increasing ferritin might actually be a sign of something more sinister.
• 35:14
  SPEAKER_00: So again this is where I really use a lot of um blood testing pathology markers just to see well what what is actually going on here?
• 35:22
  SPEAKER_00: Is this to be expected this rise in ferritin or is it you know pointing at something a bit that we need to look into this is awesome I've got to say we need to I wish I could have a seminar with you.
• 35:33
  SPEAKER_01: This is a um okay so um I've got a question and this is more of a personal sort of eyesore right so forgive me this sort of example but um I've been a long-term advocate of lower to reasonable doses um of iron but I do remember a case where somebody was on like three four tablets of a 24 milligram per day and wasn't getting anywhere and yet one tablet once per day of high dose iron 108 milligrams of a sulfate form and within a and it within a week pick this woman up.
• 36:13
  SPEAKER_01: Now she was exhausted and and my guess was you were so low in iron that your body was just sucking up out of desperation whatever it could before the hepcidin rose.
• 36:25
  SPEAKER_00: Picked in yes yeah I would say so and it's a similar thing that we see with iron infusions because um we have as you would see as well and we talked about at the start we have really good responders with iron infusions and poor responders and often it comes down to how hungry their body is for iron.
• 36:42
  SPEAKER_00: So if someone's ferritin has dropped below 15 and it's true iron deficiency and their transferrin has jumped up to 3.1 3.2 then they're going to be a really good candidate typically for an iron infusion.
• 36:55
  SPEAKER_00: Whereas if your ferritin is you know around 23, 24 and you maybe your transfer is around 2.9.
• 37:03
  SPEAKER_00: So you're still technically iron deficient but you're not as iron deficient as that person, you're far less likely to get the benefit from the iron because as you said once you get to such a low point your body just says that just give us the iron and we'll deal with any fallout that might come from you know too much of it.
• 37:19
  SPEAKER_01: Right.
• 37:20
  SPEAKER_01: So there's so there's almost like a cutoff of ferritin where it's like no more.
• 37:24
  unknown: Yes.
• 37:25
  SPEAKER_01: No more iron gotta watch it.
• 37:26
  SPEAKER_01: Yeah yeah yeah there definitely is yeah this is this is so interesting like I feel like such an ignoravus anyway could you could you as a last thing for us Laura would you mind just summarizing if you wanted three do I limit it to three three or four practical must to must do's for practitioners to learn from today's topic.
• 37:57
  SPEAKER_00: Forcing me to be succinct um so always interpret ferritin in the context of other pathology markers nutrient levels um and what's going on for that person because as I said one fer a ferritin for one person means something vastly different to somebody else so um so that um not just assuming that the person's symptoms are all from iron deficiency they could be something like hypothyroidism or you know chronic fatigue there's a lot of other things that that have similar symptoms so don't just blame low iron.
• 38:28
  SPEAKER_00: Fix the gut first if there's something going on with the absorption if there's something going on with the microbiome no amount of supplementation in iron-rich foods is really going to get them anywhere.
• 38:38
  SPEAKER_00: Even if you do see their levels increase temporarily it's not going to hold because that underlying dysfunction hasn't been addressed.
• 38:45
  SPEAKER_00: And then I think going gently with iron supplements we don't need to go in really heavy handed.
• 38:51
  SPEAKER_00: If we use a you know an alternate day dosage strategy with a nice low form of iron we use those cofactors make sure that they're not deficient in the other cofactors for once the iron's in the body um using things like vitamin C, um using certain probiotic strains, all of these things can help ease the iron into the body.
• 39:11
  SPEAKER_00: So yeah I don't know if that was three or four but no that's good.
• 39:15
  SPEAKER_01: I said last question but I can't do it very so can I ask though and this is something I forgot earlier with regards to dietary stuff and anti-nutrients so fitic acid for instance that taking an iron tablet and they're taking it with their wheat bicks or their all brand in the morning or whatever.
• 39:33
  SPEAKER_00: Do you find that this is a common issue with patients about how to take their iron supplements, when to take them yeah it is for some people um you know if they're having like maybe they're having a coffee with a whole lot of cow's milk in it and they're having their iron supplement at the same time and they're not getting any results and I can't see anything else that could be going on, then I'll get them to change it.
• 39:55
  SPEAKER_00: I think for most people it's less about those factors.
• 40:00
  SPEAKER_00: Like that that helps but that's kind of the 1% is right like the tweaking it getting a little bit more of it in it's the other things.
• 40:07
  SPEAKER_00: It's what's happening once the iron is in the small intestine and that we really need to worry about um in terms of dysfunctions there.
• 40:14
  SPEAKER_00: So yes it's important and yes I will guide people on it but I don't get too full on about it because what I've found has happened if I say to somebody you need to avoid dairy with your iron supplement they come back and they you know in a month's time they say I didn't take it because the only time I can take my supplements is in the morning and I always have a coffee and so I just didn't take it and I'm like well now okay well that didn't achieve anything.
• 40:33
  SPEAKER_00: I'd much rather you take it imperfectly than not take it at all.
• 40:37
  SPEAKER_01: Yeah.
• 40:38
  SPEAKER_00: And you're obviously somebody that keeps up with the research what's what's new in the research with um iron metabolism let's say hemodynamics yeah well so I think um the area that I'm keeping the closest eye on which we touched on at the start is really um understanding what what is actually going on with ferritin because it is such a gaping hole in our understanding of iron um and it once we I can understand that and unlock this um understanding of well what is what is ferritin and how come where does all the iron go?
• 41:11
  SPEAKER_00: Because we don't see it in the blood.
• 41:12
  SPEAKER_00: It's not in the cell anymore.
• 41:13
  SPEAKER_00: So where did the other 4000 iron atoms disappear to you know that's the research that I'm really most interested in.
• 41:21
  SPEAKER_00: You know I've got my PubMed alerts for clinical you know applications and things but that I that there's such a missing link in our understanding of iron and I think that's it.
• 41:30
  SPEAKER_00: If someone you know someone with a much smarter brain than me if they can figure that out that would be really helpful.
• 41:34
  SPEAKER_01: No no I think it's your PhD topic.
• 41:37
  SPEAKER_01: There we go.
• 41:37
  SPEAKER_01: We've settled it I'll introduce you love it.
• 41:42
  SPEAKER_01: Laura thank you so much for taking us through this today there's so much I think that we could learn more than what we've discussed here.
• 41:49
  SPEAKER_01: This is just the tip of the um iceberg so I I just can't thank you enough for enlightening me certainly but enlightening us today uh because this is a truly practical application of iron and and how to utilize it how to test for it how to see what's going on always in your patients and I love that about you you're always looking to the patient's picture to guide you to see what you do.
• 42:14
  SPEAKER_01: Yeah well done thank you so much for joining us today thanks for having me and thank you everyone for joining us remember we're going to be putting up again a whole heap of information Laura please uh on iron hemodynamics so please access that and so that we can learn I do believe I hope that you will be doing a webinar in the future for designs for health so look out for that one and obviously there's all the other podcasts on the designs for health website thanks so much for joining us I'm Andrew Whitfield Cook