Here’s some good news.

In March of 2012, a vegan woman wrote me saying that her serum ferritin levels were 8 ng/ml. The reference range for her laboratory was 10-232 ng/ml. Generally, a healthy level is above 18 ng/ml with levels as low as 12 ng/ml being associated with complete depletion of iron stores.

Instead of supplementing with iron, she:

• Increased beans and spinach from once every two weeks to two to three times a week (yes, she had been eating surprisingly few beans for a vegan)

• Replaced brown rice with quinoa (which has about twice the amount of iron)

• Stopped drinking coffee with meals

• Added a 500 mg vitamin C tablet or an orange to a couple of her high-iron meals a week

She just got her iron tested again and it was 28 ng/ml. A big increase which puts her well above iron deficiency!

As fate would have it, Ginny Messina has also written an article today about iron in vegan diets, Iron Nutrition: Why the Rules are Different for Vegans.

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Question:

Have you found women with iron absorption issues? For example, too many other minerals or not enough vitamin C? Or is absorption usually OK, and just the amount of iron the issue?

Answer:

Yes, many women have iron absorption issues. Almost all vegans get enough iron and enough vitamin C, so if they have iron issues, it’s probably from poor absorption. This is usually not a problem for men, but is for women who menstruate due to blood loss.

Someone might not be eating vitamin C at the optimal times for it to increase iron absorption – eat foods with vitamin C with whole grains, leafy greens, legumes and other high-iron foods. I often eat a small orange or two with my meals to increase iron absorption.

And you also need to remember that many people drink tea with all their meals, which inhibits absorption. Coffee does the same thing.

A reader pointed out a paper that will be published in the May issue of Food Research International on tea and iron absorption.

The study tested black tea and green tea (1 liter per day with meals), independently for four weeks each, on both vegetarian and omnivore women. It found:

• Black tea lowered serum ferritin levels in omnivore women, but not vegetarian women.
• Both teas lowered serum ferritin levels in both omnivore and vegetarian women who began the study with serum ferritin levels below 20 µg/l.
• Male vegetarian and omnivore ferritin levels were not affected, but none started with serum ferritin levels below 20 µg/l.

This study supports my suggestion from earlier this month:

“If your iron status is always fine when tested, then I don’t see a need to change your tea drinking habits; but if you have a tendency towards iron deficiency, it’s probably a good idea to avoid drinking tea with meals.”

Reference

Schlesier K, Kühn B, Kiehntopf M, Winnefeld K, Roskos M, Bitsch R, Böhm V. Comparative evaluation of green and black tea consumption on the iron status of omnivorous and vegetarian people. Food Research International. 2012 May;46(2):522-27. | link

Breaking news from 1999:

Many herbal teas inhibit iron absorption. I hate to hear bad news about people’s good habits, and I particularly don’t like it when it’s from 1999 and I’m just finding out about it now! As I’ve mentioned before, I have been working on an iron article for the Vegetarian Nutrition Practice Group and one of the reviewers pointed me to the study below showing that herbal teas inhibit iron absorption. In the past, I had thought herbal tea did not inhibit iron absorption. Sadly, I was wrong.

The herbal teas tested were camomile, vervain, lime flower, pennyroyal, and peppermint. Cocoa also inhibited iron absorption, as did coffee and black tea. The iron absorption was tested against iron-enriched white bread with only water, and these beverages reduced iron absorption by 50% or more (usually more), with black tea being the worst offender cutting iron absorption by about 80%+.

The good news is that this study pinpoints a benefit of iron-enriched white bread! Who would have thought that white bread could be healthier than herbal tea? Guess it all depends on your perspective.

If your iron status is always fine when tested, then I don’t see a need to change your tea drinking habits; but if you have a tendency towards iron deficiency, it’s probably a good idea to avoid drinking tea with meals.

I have updated the Iron section of VeganHealth.org to reflect this study.

Reference

Hurrell RF, Reddy M, Cook JD. Inhibition of non-haem iron absorption in man by polyphenolic-containing beverages. Br J Nutr. 1999 Apr;81(4):289-95. | link

I have been reviewing the research on iron and vegetarians (lacto-ovo and vegan). It appears that the iron status of vegetarian men is fine, but that, roughly, about 10% of vegetarian women have iron deficiency anemia and another 15 to 40% have low iron stores. These rates are not much different than the meat-eating women in the same studies.

From the research I’ve reviewed, vitamin C appears to be the most important factor in absorbing plant iron. I have added a few paragraphs to the Iron page at VeganHealth.org and am reproducing that section here:

“In meat, 65% of iron is bound to the heme molecule (from hemoglobin and myoglobin), which is relatively easily absorbed. The rest of the iron in meat and all iron in plants is non-heme iron. Non-heme iron requires being released from food components by hydrochloric acid and the digestive enzyme pepsin in the stomach. Non-heme iron also needs to be shuttled from the digestive tract into the bloodstream by a protein called transferrin.

“The phytates, found in legumes and grains, and polyphenols (including tannins found in coffee and green and black tea), can inhibit the absorption of plant iron. On the other hand, vitamin C is a strong enough enhancer of plant iron and can overcome the inhibitors in plant foods.

“One study found that various doses of phytate reduced iron absorption by 10 to 50%. But adding 50 mg of vitamin C counteracted the phytate, and adding 150 mg of vitamin C increased iron absorption to almost 30%. Similarly, in the presence of a large dose of tannic acid, 100 mg of vitamin C increased iron absorption from 2 to 8% (13).

“In another study, vegetarian children with iron deficiency anemia and low vitamin C intakes in India were given 100 mg of vitamin C at both lunch and dinner for 60 days. They saw a drastic improvement in their anemia, with most making a full recovery (2).

“Researchers used 500 mg of vitamin C twice daily after meals to increase hemoglobin and serum ferritin in Indian vegetarians. They concluded that vitamin C was more effective at increasing iron status than iron supplements (12).

“Vitamin C is found in citrus fruits, strawberries, green leafy vegetables (broccoli, kale, collards, Swiss chard, Brussels sprouts), bell peppers (yellow, red, and green), and cauliflower.

“Calcium supplements, coffee, and black and green tea inhibit iron absorption if eaten at the same time as iron, so avoid them at meals in which you are trying to increase iron absorption.”

References

2. Seshadri S, Shah A, Bhade S. Haematologic response of anaemic preschool children to ascorbic acid supplementation. Hum Nutr Appl Nutr. 1985 Apr;39(2):151-4. (Link)

12. Sharma DC, Mathur R. Correction of anemia and iron deficiency in vegetarians by administration of ascorbic acid. Indian J Physiol Pharmacol. 1995 Oct;39(4):403-6. PMID: 8582755. (Abstract only)

13. Siegenberg D, Baynes RD, Bothwell TH, Macfarlane BJ, Lamparelli RD, Car NG, MacPhail P, Schmidt U, Tal A, Mayet F. Ascorbic acid prevents the dose dependent inhibitory effects of polyphenols and phytates on nonheme-iron absorption. Am J Clin Nutr. 1991 Feb;53(2):537-41. PMID: 1989423.

I am regularly asked by vegans what they should be tested for. Here is a run down:

Vitamin B12

As I say in Should I Get My B12 Status Tested? -

Vegans do not need to get their homocysteine or B12 levels checked merely because they are vegan. Rather, being vegan means that you should get a regular, reliable source of vitamin B12 from fortified foods and/or supplements. (Though if you’ve gone a month or so without a reliable source of B12, you should replenish your stores as described in Step 1 of the Recommendations.)

About 2% of people do not absorb B12 well. While this has nothing to do with being vegan, it is nice to know if you are such a person. You will not be able to tell unless you first have a reliable source of B12 for at least a few weeks before your B12 level is checked. Additionally, there are specific tests that directly measure B12 absorption.

If you get your B12 level checked, please note that eating seaweeds can falsely inflate B12 levels. Methods for determining B12 levels do not distinguish between B12 and some inactive B12 analogues. Many seaweeds contain a variety of inactive B12 analogues. Someone who is eating large amounts of seaweed may have serum B12 levels well above normal, but much of it could be inactive B12 analogues.

Vitamin D

This is probably the one nutrient that vegans really can benefit from getting tested even if they do not have any symptoms of poor health.

Calcium

The body keeps blood calcium levels relatively constant regardless of your diet, so getting calcium levels tested doesn’t tell you much of anything (other than that you are not seriously ill). Getting your bone mineral density tested is the best way to find out what shape your bones are in. I don’t necessarily recommend this, unless you have reason to believe you might have osteoporosis. I’ve said it many times before, but I’ll say it again – most vegans should drink calcium-fortified non-dairy milks (or other foods) or take a calcium supplement.

Omega-3s

If you are taking a DHA supplement, then you are probably fine. If you are not and want to see what your DHA levels are, here are some testing places.

There is a more common test that could shed some light on your EPA status – blood clotting time. Most doctors test for this routinely. If your blood is clotting too fast, you might be lacking EPA. But, I rarely hear from a vegan whose blood is clotting too fast. If blood clotting time is normal, it doesn’t necessarily mean you have enough DHA.

Iron

If a doctor is going to draw blood, getting an iron panel to see if you have enough (or too much) iron is a good idea, especially for menstruating women.

Iodine

There is no direct test for iodine. Like B12, it’s best to just make sure you’re getting enough (but not too much). Iodine deficiency (and excess) can lead to thyroid problems, so getting your thyroid tested would be an indirect indicator. Click here for more on iodine.

And that covers it for any routine nutrients to test for regarding the vegan diet.

On November 10, NPR featured an article on vegetarian children, Raising Vegetarian Kids? Here Are Some Pointers.

As with most nutrition articles on vegetarian children, they make it seem much harder than it actually is. I will only address the scariest statements in the article. It says:

“Iron is the most common nutrient deficient in vegetarians, and especially in vegans, who don’t eat any animal products, the American Academy of Pediatrics’ Pediatric Nutrition Handbook says.”

Reed Mangels, PhD, RD (quoted in the NPR article and an expert on nutrition for vegetarian children) was kind enough to forward me the excerpt from the 6th Edition (2009) of the Pediatric Nutrition Handbook. Reed’s comments are in brackets:

“The iron nutritional status of vegetarian infants and children varies. Iron deficiency is by far the most common of the micronutrient deficiencies exhibited by vegetarian children (62). It is particularly common in children consuming vegan diets [no reference] because plant foods contain nonheme iron as opposed to heme iron in animal sources [it would be more accurate to say a mix of heme and nonheme iron in animal sources]…Recommended iron intakes for vegetarians are 1.8 times those of nonvegetarians because of the lower bioavailability of iron in a vegetarian diet (64), and although vegetarians have lower iron stores their serum ferritin concentration is usually within the normal range (65, 66). Incidence of iron deficiency anemia among vegetarians is similar to nonvegetarians (55). Although many studies have been short-term, there is evidence that adaptation to low intakes takes place over a longer term and involves increased absorption and decreased losses (67, 68).”

Reed commented further:

“Reference 62, the Dietary Reference Intakes for Calcium, Phosphorus, Magnesium, Vitamin D, and Fluoride, is an odd reference to cite for this; it does not provide evidence for iron deficiency incidence in vegetarian children.

“As you can see, they say iron deficiency (not anemia) is the most common deficiency in vegetarian children. This is likely true since iron deficiency is the most common nutritional deficiency in all children and why should vegetarian children be the exception? I don’t think there is evidence that it is particularly common in vegan children. The two studies I know of (Swedish and UK) that look at iron intakes of vegan children and teens actually found higher or similar intakes in vegans compared to non-vegetarians (3, 4).

“Anemia does not appear to be more common in vegetarians and while serum ferritin levels are lower, they are within the normal range. Note that these findings are mainly, if not exclusively, in adults – there just aren’t that many studies of vegetarian children. So, when the article said that iron is the most common nutrient deficient in vegetarians, this should have been qualified to say ‘and in children in general’ or something like that.”

Back to the NPR article. Dr. Jatinder Bhatia, the chairman of the American Academy of Pediatrics’ committee on nutrition is quoted:

“If the child’s pediatrician isn’t aware that the child is a vegetarian, the doctor may not know to test for iron deficiency, Bhatia says…Iron deficiency may not become apparent until the child is older, Bhatia says, and at that point, the child may actually have irreversible cognitive defects.”

Dr. Mangels responds:

“Dr. Bhatia is correct that iron deficiency does affect brain development but this should be a concern for all parents, not just parents of vegetarians. The AAP handbook suggests either universal screening for iron deficiency at 9-12 months and then at 15-18 months for communities where a significant level of iron deficiency exists or selective screening using the same time points and measures for infants believed to be at risk, including those over 6 months not consuming a diet with adequate iron content. Annual screening should also be done for children with a possibly low iron diet who are 2-5 years old. So, I can’t fault him for saying parents should tell their pediatrician about their child’s diet. I can see why parents might not bring it up if they thought they would be discouraged from raising their child on a vegetarian diet. ”

A 1985 study of vegetarian children in India indicated that iron deficiency anemia was not uncommon, at least at that time (1), but this was not the case in the one study that tested vegan children’s iron levels, none of whom had anemia (2). As someone who corresponds with many parents of vegan children, I am not aware of any prevalence of iron deficiency anemia (or any recent cases at all).

Parents of vegetarian children do need to know a few things, but it is not rocket science. A good summary is Vegan Nutrition in Pregnancy and Childhood by Reed Mangels, PhD, RD and Katie Kavanagh-Prochaska, RD.

1. Seshadri S, Shah A, Bhade S. Haematologic response of anaemic preschool children to ascorbic acid supplementation. Hum Nutr Appl Nutr. 1985 Apr;39(2):151-4. (Link)

2. Kim Y-C. The effect of vegetarian diet on the iron and zinc status of school-age children. [master’s thesis]. Amherst: University of Massachusetts; 1988. Cited in: Messina V, Mangels AR. Considerations in planning vegan diets: children. J Am Diet Assoc. 2001 Jun;101(6):661-9. (Link)

3. Sanders, T. A. B. and Manning, J. The growth and development of vegan children. Journal of Human Nutrition and Dietetics,1992 5(1): 11–21. (Link)

4. Larsson CL, Johansson GK. Dietary intake and nutritional status of young vegans and omnivores in Sweden. Am J Clin Nutr. 2002 Jul;76(1):100-6. (Link)

Comment:

While I was leafleting about vegetarianism, someone told me they tried to be vegetarian but got iron deficiency.

Answer:

When someone says this, you might want to ask them if a medical doctor diagnosed them. A lot of people diagnose their own iron deficiency and are likely wrong about it. It’s good to get people to reconsider whether they really had iron deficiency because my suspicion is that a lot of them actually didn’t.

And then you might suggest that they try eating spinach and oranges at the same meal, on a regular basis. The spinach for iron, and the orange for vitamin C which increases iron absorption. Other iron tips:

* Avoiding black or green tea and coffee at meals.
* Adding a source of vitamin C at meals.
* Increasing legume (peanuts, beans, lentils, peas) intake.
* Cooking foods (especially water based acidic foods like tomato sauce)
in cast iron skillets.

More info can be found on the Iron page of VeganHealth.org.