We have seen that iron acts on many processes of the organism: oxygen transport in the blood, muscle activity and protein metabolism. This explains why the symptoms of iron deficiency can be multiple and often nonspecific. The most common symptoms associated with iron deficiency are:

• Asthenia: feeling of tiredness, weakness or lack in energy/strength, easy fatigue and exertional dyspnoea
• Hair loss and brittle nails
• Restless leg syndrome: a disorder that causes an urgent and uncontrollable need to move the legs, often accompanied by “unpleasant feeling in the legs”. Symptoms are relieved only by moving the legs
• Impaired thermo-regulation: cold intolerance. Iron seems to be involved in the body temperature-regulating mechanism
• Headache, angina, cardiac decompensation
• Pallor
• Increased predisposition to infections

What are the biochemical signals of an iron deficiency?

• Serum ferritin value less than 15 mg/dL
• Serum iron (concentration of iron transportation in the blood) less than 60 mg/dL

Iron deficiency can lead to iron-deficiency anemia. This occurs when, in addition to a lack of ferritin and serum iron, there is also a decrease in haemoglobin levels (values less than 12 gr/dL for women and 14 for men).

Anemia is a very frequent complication in patients suffering from oncological pathologies, both at the time of diagnosis and during therapeutic treatment. The ECAS (European Cancer Anemia Survey) investigated the prevalence, incidence and treatment of anemia in cancer patients. It was observed that 39% of patients had anemia at the time of diagnosis, while 67% developed it during chemotherapy. The cause of anemia in these patients is multifactorial and for many of them the dominant mechanism is iron deficiency.

Iron deficiency and iron-deficiency anemia can be treated with existing iron-based drugs that can be administered by mouth or by intravenous injection. Oral iron administration is the most common and makes use of iron salts including iron sulphate, gluconate and fumarate. Therapy may have some side effects, such as nausea, vomiting, constipation and “metallic taste”.

Intravenous administration is more effective than oral therapy and it increases iron and haemoglobin levels more rapidly. This method may cause some side effects such as nausea, vomiting, itching, headaches, myalgia and chest/back pain.

The doctor will determine whether drug therapy is necessary and, if so, the appropriate route of administration. Keep in mind that proper nutrition can have a positive effect by increasing iron intake and absorption. Proper nutrition does not substitute prescribed drug therapy but can effectively integrate it.

DIETARY IRON

The iron in our body comes from dietary intake, which allows us to maintain a balance between absorption and daily losses. After iron has been absorbed by the intestine, it is distributed to various body compartments for synthesis, storage and transport processes. Since it is not possible to control its elimination, the amount of iron in the body is regulated by controlling its absorption. About 1-2 mg of iron per day is lost by skin, gastrointestinal tract and genitourinary tract mucosae exfoliation.

Iron is present in many foods, but the amount of iron that can actually be absorbed and utilized varies according to its source. There are two forms of food iron:

1. HEME IRON, also called “animal iron”, is bonded to a molecule of haemoglobin or myoglobin. It makes up about 40% of the iron contained in animal source foods (meat and fish). This type of iron can be easily absorbed (from 20 to 40% is absorbed in healthy subjects).
2. NON-HEME IRON, also called “vegetal iron”, is hardly absorbed by the organism; it makes up about 60% of the iron in animal tissues and the total amount of iron found in plant foods. The amount of iron that can be absorbed from plants is less than 5% owing to the presence of substances that interfere with the utilization of mineral salts (especially tannins and phytates). This percentage rises to 10-20% if certain substances are present that positively affect absorption as described below. As a result, the absorption of non-heme iron is strongly influenced by the rest of the diet.

IRON IN FOOD

The table lists foods rich in iron and for each group they are listed in descending order, from richest to poorest.

AROMATIC HERBS
Dried thyme, marjoram, cumin, dry bay leaf, dried basil, cinnamon, dried oregano, dried parsley, fresh thyme, paprika, black pepper, dried rosemary, dried sage, fennel seeds, saffron

MEAT AND FISH
Beef (spleen), canned clams au naturel, bottarga, caviar, sheep (liver), pork (liver), clams, anchovies in brine, beef (liver, lung, kidney), horse (heart, liver), rabbit (offal), mussels, and oysters

GRAINS AND MISCELLANEOUS
Wheat bran flakes, cocoa powder, wheat germ, dark chocolate, brewer’s yeast

DRIED PULSES
Dried beans, dried chickpeas, chickpea flour, dried lentils, dried broad beans, dried peas

FRUITS AND VEGETABLES
Dried mushrooms, dried tomatoes, green radicchio, dried peaches, dehydrated apricots

It is generally thought that the best food to ensure a good dose of iron is red meat. In fact, the greater content of iron is mainly found in bovine, pork and horse offal liver, spleen, kidney, lung and heart. Some meats containing good amounts of iron are pheasant (8.1mg/100gr), hare (6.2mg/100gr), and horse (3.1 mg/100gr) meat. White meat (poultry meat) contains on average a little less than 1mg of iron per 100g, but it depends on the cut you choose. Muscle tissues such as the thigh are richer in iron.

Taking into account the recommendations of the WCRF (World Cancer Research Fund) red meat intake should be limited.

What are alternative sources of iron? If we consider animal foods, clams are a good source providing as much as 14 mg per 100 g. The iron content in mussels and anchovies in brine 5.8 and 6.9 mg per 100 g of product respectively should not be underestimated. Due to their animal origin, these foods contain a good amount of heme iron, that can be easily absorbed by the organism. However, you must pay attention to the quantity of clams and mussels you eat because of their cholesterol content (50mg/100gr for clams and 121mg/100gr for mussels).

As you can see from the table, many foods containing iron are of plant origin. Vegetal iron is non-heme iron and barely absorbed by the human organism. As previously illustrated, phytates and tannins interfer with the digestion of food, with metabolic functioning at the gastrointestinal, cerebral or hormonal level.  Phytates and tannins also interfer with iron absorption.

Phytates are compounds that capture mineral salts, making them unavailable for absorption, through a chemical mechanism called chelation. They are found in legumes, cereals and cocoa powder. To try to reduce the amount of phytates in food, you should follow some indications.  As regards dry legumes, the long soaking of the seeds ensures the removal of most of the phytate.  Therefore, it is better to soak the legumes overnight, changing the water at least once or twice. While cooking, skim off any “foam” that is formed to remove the phytates. For this reason, legumes should be cooked for a long time (this also applies to whole grains).

Tannins polyphenol are substances which are synthesized by plants, in particular the bark. They are mainly contained in tea, coffee, grapes, unripe persimmons and wine. Hence, it is not recommended to drink tea, coffee and wine during a meal of foods rich in iron, to prevent these antinutrients from seizing iron and making it insoluble.

Thankfully, there are some substances that can increase iron absorption at the intestinal level. The introduction in the same meal of small amounts of fermented sauces (e.g. homemade sauerkraut or miso), citric acid (lemon), ascorbic acid (vitamin C of vegetables) or even organic acids contained for example in tamari (soya sauce), increases even the absorption of non-heme iron up to 20%.

Herbs and spices are very rich in iron. When dried they contain 30 to 120mg per 100g of product, whilst when fresh they contain an average of 10-20 mg per 100g of product. Although eaten in minimal amounts, their constant use can be a valid source. They can be used to season dishes, with the aim of limiting the use of kitchen salt. Another source of iron is brewer’s yeast (4.9mg/100gr) which can be used for example to season salads or cooked vegetables, again as an alternative to salt.