Okey dokey – who’s ready for a good long rant? I hope you’re comfy in your seat, because this might take a while.
The last week or so, I’ve been elbow deep in research about nutritional deficiencies and supplementation. (For those of you wondering why, a quick refresher: I got quite ill a couple of weeks ago, and my doc identified a couple of nutrient deficiencies that were part of the problem.) As such, it’s been pretty much all that I think about, and thus it’s all that I have to talk about.
Well, okay, that last bit’s not true. I’ve always got more things to talk about. But still, I want to talk about this right now.
Here’s what I’ve learned about what’s going on in my body and what to do about it…
According to the World Health Organisation, iron deficiency is the most common nutritional disorder in the world – I’m depressingly pedestrian in that regard, I’m afraid. Up to one in three Australian women will be diagnosed as iron deficient by age 50. An important thing to note here, too, is that I am iron deficient, but I am not anaemic – Iron Deficiency Anaemia (IDA) occurs when iron deficiency continues so long and levels dip so low that your body is unable to sustain red blood cell production. I haven’t reached that point yet (thank God!), but I’m still pretty worryingly low, and anaemia could result if I don’t get on top of it now. So that’s why I’m getting so worked up :)
Essentially, the causes of iron deficiency can be divided into four broad categories: an increase in iron loss from the body, an increase in iron demand on the body, a decrease in iron intake, and a decrease in iron absorption. There are several groups that are at increased risk: vegetarians, pregnant women, Celiacs, those with chronic renal dysfunction or h.pylori infection (a gut issue), and athletes. Symptoms include fatigue or tiredness, low motivation, muscle fatiguability, trouble concentrating, mood disturbance, hair loss, impaired immunity, and gastrointestinal complaints.
I have had every single one of those symptoms, but – aside from being female and physically active – I don’t really fit into any of the risk groups. I’m certainly not a vegetarian! As I mentioned in my last post, inadequate intake does not seem to be my problem; the doc suspects that the issue for me lies more around problems with iron absorption. The plan, at this stage, is to simply get more iron into me, and re-test – then go from there.
So, food sources of iron are mostly pretty obvious. There are two different types: “heme” iron (generally best absorbed by the body) comes from meat sources (including chicken liver, oysters, beef, clams, turkey, tuna, halibut, crab, pork, prawns, etc.), and “non-heme” iron (not as well absorbed usually) comes from lentils, beans, tofu, spinach, peas, raisins, and fortified foods such as cereals. So can I just load up on the beef and spinach and be done with it? Unfortunately, no – turns out that dietary intake alone is often not sufficient to replete iron stores where deficiency has occurred. Put another way, you can eat enough iron to maintain your adequate stores, but once your stores get too low it’s a bit hard to get them back up to normal with just foods.
Most iron supplements are derived from the non-heme iron sources (non-animal/plant sources), usually in a ferrous form. There are a couple different types of ferrous iron, each of which has a different “strength” so to speak (I’m trying to not get too science-y here). There are other types as well, though (as I have discovered) they are more difficult (read: IMPOSSIBLE) to get your hands on. Polysaccharide iron complex and carbonyl iron are both from non-heme sources as well, but they are 100% elemental iron (so they’re much stronger than the ferrous forms). Heme iron supplements are also hypothetically (ha!) available, in the form of heme iron polypeptide (HIP) – these are more bioavailable, and have repeatedly been shown to be the most effective in the treatment of iron deficiency. Non-heme supplements are typically much cheaper, and definitely more widely available, than HIP, but they are not tolerated as well, they are not absorbed as well, they cause more side effects, and they are more greatly affected by food consumption.
For non-heme iron supplements, you generally need an acidic environment in your gut for optimal absorption, which is why many brands come with additional vitamin C (ascorbic acid). Coffee, wine and fruit all significantly inhibit the absorption of non-heme iron, and there are a variety of drug-drug and drug-food interactions that you need to be wary of. The biggest, though, is that both non-heme and heme iron can be affected by calcium; calcium inhibits the absorption of iron (stops it getting through your gut and into your blood), so the more calcium you consume the less iron you absorb. Massive bummer for me, with my newly rediscovered love of and tolerance for dairy :(
Vitamin B12 Deficiency
Vitamin B12 is bound to the proteins in a variety of foods; it is required for proper red blood cell formulation, neurological function, DNA synthesis, and a bunch of other pretty vital stuff. Put it this way: it’s pretty hard to feel awesome if you’re lacking in the B12 department.
Like with iron deficiency, causes of B12 deficiency can be divided into six categories: inadequate intake, impaired absorption, inadequate utilisation, increased requirements on the body, increased excretion, and increased destruction. Deficiency affects between 1.5% and 15% of the population – it’s difficult to know exactly how many are affected, because it is often not tested for. It is often found in older adults, those with pernicious anaemia, and those with reduced level of stomach acidity or intestinal disorders (e.g., Celiac, Crohn’s). The symptoms are really varied and kind of non-specific – they can include megaloblastic anaemia, fatigue, weakness, constipation, loss of appetite, weight loss, numbness, tingling in hands and feet, difficulty maintaining balance, depression, confusion, dementia, poor memory, soreness in mouth and tongue… the list goes on and on. Luckily, I haven’t had all of these ones, but a few do sound familiar. Permanent nerve damage can occur if the deficiency is not treated, and cognitive declines may be permanent – yikes!
Again, the doc says my intake seems perfect. B12 is naturally found in animal products – fish, meat, poultry, eggs, and dairy. It is not generally present in plant foods. OK, if you want to get technical, there’s a whole thing where it’s like produced by specific bacteria that you can grow in algae or something (which is what vegetarians and vegans rely upon). Still, I’m not eatin’ algae. I’m getting my B12 from blueberry freakin’ liver. Once again, though, the doc thinks the problem lies somewhere in my body’s absorption of B12. The plan of attack is the same as for iron: bump up my intake, see where it gets us.
Another trip down the supplement rabbit hole. B12 is often taken in conjunction with the other B vitamins in a “B complex”. I didn’t want to go down this route, mostly because I have an issue with folic acid supplementation; again, trying to avoid getting to science-y here, but folic acid DOES NOT EQUAL folate. Folic acid supplements are synthetic imitations, that have very different physiological effects on the body. So that puts me off right out the gate.
Speaking of synthetic imitations: vitamin B12 is usually present as cyanocobalamin in supplements, which is a form that the body has to convert to the active forms of methylcobalamin and 5-deoxyadenosylcobalamin. So that’s pretty inefficient, wouldn’t you say? There are (supposedly) supplement tablets containing methylcobalamin available, but usually it only comes in the injectable form (which you have to get a script for and go to the hospital and… it’s a whole thing). The body actually doesn’t absorb the majority of the B12 that you get in a supplement – sometimes only 10mcg in a 500mcg pill. You can bump this up a bit by using sublingual tablets, that you let dissolve under your tongue; it just kind of bypasses the whole absorption-through-the-gut-lining thing. There are a few studies that show no difference, and a few that show a small difference – I figure, why not? It certainly can’t hurt to take it sublingually, instead of chucking it down the hatch; if there’s a small chance it’ll help, might as well, eh?
Generally, we need to take pretty small doses, as absorption decreases with bigger hits (so small doses more often, instead of taking a whole bunch at once). It’s actually pretty hard to take too much B12, because the body has this mechanism – which is pretty darn cool, I think. Ironically, too much vitamin C can actually destroy B12 in the body and impair its absorption and utilisation: you need the C for iron, but it’s horrible for B12 – just my luck! Some more irony: reduced calcium intake reduces your absorption of B12 (which is dependent on the calcium channels) – can’t bloody win!! But on the upside, there are generally pretty much no side effects, and getting your levels back up can work wonders for your vitality and quality of life. So that’s something, at least.
Last but not least, zinc is an essential mineral involved in numerous aspects of cellular metabolism; it plays a role in immune function, protein synthesis, DNA synthesis, wound healing, and cell healing. It is also required for proper taste and smell. You need to consume zinc in some form every day, because the body has no storage system. Zinc deficiency is characterised by growth retardation, loss of appetite, impaired immune function, hair loss, diarrhoea, skin lesions, hair loss, delayed healing of wounds, taste abnormalities, mental lethargy… It’s another really, really long list of kind of non-specific symptoms. Zinc deficiency often goes undetected, because these issues can be attributed to other conditions. Zinc deficiency is usually caused by, you guessed it, either inadequate intake, inadequate absorption, increased excretion, or increased requirements.
Here’s the rub: I’m not actually technically quote-unquote deficient in zinc. I’m right on the borderline between deficient and adequate – which is low enough to make my doctor worried. Thus, I’m going down the route of supplementing on this as well (that said, it’s not as urgent as the other two and I’m a little less concerned).
A wide variety of foods contain zinc; the biggest and baddest are oysters, which contain more zinc per serving than any other food. Red meat and poultry provide the majority of zinc in the standard diet, along with beans, nuts (especially cashews and almonds – yum!!), seafood (crab, lobster), pork and dairy products. Most interestingly – to me, anyway – the phytates found in grains/cereals, legumes and some other foods actually bind to zinc, and inhibit its absorption. God only knows what my levels would be like if I hadn’t transitioned into Paleo and started eschewing these!!
Never tried these – what do you reckon?
(Photo Credit: prostate.org)
There are several types of zinc supplement – and it kind of works the same way as the ferrous iron supplements. The zinc is bound to something else, and the percentage of elemental zinc varies based on what that “something else” is. Zinc sulfate and zinc oxide are the two most common forms, but there’s a lot of controversy about zinc oxide (it’s an alleged carcinogen, and a lot of people are campaigning to have it banned from sunscreens). Zinc is not easily absorbed by the body unless it is first attached to something else, which is why “chelated” varieties are best absorbed – zinc gluconate, zinc citrate, and zinc orotate. Chelating zinc allows it to pass through the cell membranes easily, and carry with it higher amounts of other minerals (which means super happy nutrient-dense cells – yay!).
Zinc supplements need to be taken without food, unless they’re causing some nasty stomach upset (but you need to tell your physician if you start taking them with a meal). Some more irony: large amounts of supplemental iron can decrease zinc absorption – I’ve really chosen some inconvenient and incompatible deficiencies, haven’t I? Black coffee, fiber, and phytates (grains, legumes, seeds, soy) can all significantly reduce zinc absorption, so you don’t want to be taking them with the supplement either.
Another important thing with zinc is to watch that your intake doesn’t get too high – zinc toxicity is nasty (nausea, vomiting, loss of appetite, diarrhoea, cramps, headaches, metallic tastes, altered iron function, copper deficiency, reduced immune function, reduced HDL, kidney damage, stomach damage… a lot of these are also symptoms of deficiency, funnily enough, so you gotta get the balance just right, Goldilocks style). You need to keep an eye out for copper deficiency, and sometimes zinc supplements contain copper as well to guard against this.
So, Where Does All That Leave Me?
Well, I actually went into a lot more detail than I described here – I crafted very specific checklists of exactly what I wanted in each supplement. I knew what I was after, and I was happy to pay for the highest quality.
And here’s where I hit a bum note. Just because I want something and I’m happy to pay for it doesn’t mean it necessarily exists.
I searched high and low, scaring the shit out of some poor pharmacy assistants and emailing pharmaceutical companies, looking for gluten-free (well, all-weird-nasty-crap-free) capsule/tablet form heme iron polypeptide supplements, for sublingual 1000mcg methylcobalamin supplements (again with no other weird crap), and <40mg organic zinc orotate… to absolutely no avail. It’s not that they were too expensive, or on a really high shelf – I actually, literally, could. not. find. them. As you can imagine, this was incredibly frustrating, and I blew my lid more than once.
See, the thing is, even though the medical literature demonstrates pretty conclusively that these supplements would be the most effective for someone in my situation, pharmaceutical companies don’t manufacture them. (Well, generally – some are available in the U.S. or Europe, but pretty much not at all here in Australia as far as I can tell.) It’s harder to produce supplements of the highest quality – it costs a lot more, it’s a lot more time consuming, it’s a lot more labour intensive… and, at the end of the day, not many consumers are freaks like me (i.e., examining the medical literature and drafting checklists). Most consumers want the cheapest supplement they can grab off the shelf and be on their way in a minute and a half. So the supplements don’t get made, and they don’t get distributed, even though they would be the best for us (well, me at least).
This really pissed me off. I hate that free-market capitalism gets to determine for me what I put in my body and how I go about improving my health. It should be my choice whether I take the synthetic-but-easy-and-cheap option or the natural-and-effective-but-expensive-and-difficult option. Instead, some rich suits in a board-room decide that for me, on the basis of their projected growth. It just seems wrong.
I’ve pretty much exhausted this topic with family and friends, and I don’t want to bore you in the same way, dear readers. Just know that it really, really pisses me off, and you don’t want to bring it up with me at a dinner party.
I really think I painted myself into a bit of a corner – I did so much research and dug so deep that it became a bit of a “paralysis by analysis” situation. Rather than just getting the general gist of how each of these conditions worked and what to do about them, I went way off in the deep end picking apart the minutia of every single element. Everything seems sub-optimal, because I know too much. If I had just opted for the ones that the pharmacist grabbed down off the shelf for me, it could have worked out fine and I would have been none the wiser.
Oh Yes, A Fun Anecdote…
Want to hear about how my first supplement-buying trip went? If you don’t, feel free to skip ahead – but for the rest of us, story time!
I wandered down to the chemist that is actually attached to my new GP’s surgery (handy, no?). I spent about twenty minutes walking up and down the supplement aisle, picking things up and examining their contents, reading over the details. I came up with absolute bupkis. Nothing even came close to meeting the checklist (remember, at this point, I still thought ticking everything off would be possible). So, I head up to the pharmacy counter, and ask to speak to someone who could help with selecting a couple of supplements. A very young lady volunteered to give me a hand: “What can I help you with?”, she asked.
“Well,” says I. “I have been diagnosed with iron deficiency…”.
That was as far as I got. Very young pharmacy lady went racing off to the very aisle I had just come from, and grabbed a particular brand down off the wall (that I had already looked at and vetted – contained a laughably small amount of ferrous sulphate, which is the least effective form of iron with the highest risk of side effects).
“Here you go!”, she said, all bubbly and smiley.
I took a breath, smiled, and tried to be diplomatic: “Actually, that’s not really what I’m after – I’m concerned about the bioavailability and side effects of ferrous sulphate. I’m actually looking for a supplement that contains heme iron polypeptide. Could you recommend something of that nature?”.
Well, she stared at me as though I’d suddenly grown two heads and started breathing fire. She appeared to actually be rendered speechless. All I could do was smile apologetically.
“Um, I don’t know. I think you need to speak to our naturopath.”
Here’s what I thought: Darn tootin’ I do, lady!
Here’s what I actually said: “That would be lovely. How do I go about doing that?”.
Oh, well, turns out that the naturopath wasn’t actually there anyway. I was to come back on Thursday. I left the store cranky and disappointed.
What pissed me off about this scenario wasn’t that they didn’t stock the products I was looking for, it was that the salesgirl automatically assumed she knew what I was looking for, assumed that she knew best, and didn’t actually stop to let me finish a sentence, let alone listen to what I was saying in full. She stormed past me and pulled that product off the shelf without stopping to gather any information beyond the words “iron deficiency”. Granted, that might be what most other customers are after, yes – but there was still room for a bit more care and a bit more humility. I’ve worked in customer service to long enough to have some understanding for this girl (she didn’t intentionally piss me off), but also long enough to know that this isn’t the type of service that wins you any loyalty. Very frustrating.
The most frustrating part? I repeated the exact same scenario – young girl doesn’t let me finish speaking before recommending the exact same ferrous sulphate supplement, only to then recommend a naturopath that isn’t actually in the store today – at the very next chemist I tried. Needless to say, I was polite, but I left with steam coming out of my ears.
(Photo Credit: thepenningtonpoint.com)
What Did I End Up Going With?
Well, I did a lot of Googling, pounded the pavement, spoke to some folks, sent quite a few emails… and, I’ll admit it, did a little soul searching. Why was it so important to me to get the perfect supplement? What did it say about me that an adequate supplement, that serves thousands of others perfectly well, would not suffice?
I ended up simply picking the best of a bad bunch. I won’t name products, because I don’t think that’s cool. I got a 200mg ferrous fumarate iron supplement (the highest elemental iron % of all of the ferrous iron supplements), and a 1000mcg sublingual B12 supplement (the cyanocobalamin variety), both gluten-and-other-nasties-free. I haven’t actually settled on a zinc supplement yet; it would seem that our labelling laws don’t require that manufacturers describe what the zinc is bound to, as basically every label simply says “amino acid chelate”. I think I have a front-runner in mind though, and I’ll probably pick up some in the next week. Like I said, my issue with zinc is not that urgent.
So, tomorrow morning, I start my first-ever supplement regimen. I’ll be sure to keep you guys in the loop.
The Take Home Message
Sheree is a crazy person who went way over the top researching her conditions, and she ended up settling for some supplements that are probably perfectly fine but seem sub-par based on the studies she read. :)
Do you take any supplements? How did you choose them? What do you look for in a supplement?