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Iron Deficiency: Symptoms and Treatments

August 18, 2016

Have you been diagnosed with iron deficiency after having bariatric surgery? If so, you’re not alone. Iron deficiency, already the most common mineral deficiency in the United States, occurs at an even higher rate among weight loss surgery patients and is a particular concern for post-operative RNY Gastric Bypass patients. But the good news is that with regular monitoring and supplementation, iron deficiency can be prevented or treated before it becomes a more serious problem.

Iron deficiency may also occur in Gastric Sleeve patients, recent data suggests. Though the flow of food through the GI tract remains unchanged with a Sleeve, there are several factors that are believed to contribute to iron deficiency, including reduced secretion of stomach acid and smaller portion sizes of all foods.

Why We Need Iron and How Much We Need

Iron is an essential mineral that helps transport oxygen throughout the body. If you don't have enough of it, your body can't make enough healthy oxygen-carrying red blood cells. A lack of red blood cells is called iron deficiency anemia. Without a sufficient amount of red blood cells, your whole body can be affected.

How much iron do you need? The recommended dietary allowance for men and for women over age 50 is 8 milligrams per day. For menstruating women, the RDA is 18mg per day (it's higher to make up for monthly blood loss).

If you’ve had bariatric surgery, you should be taking a daily multi-vitamin anyway. But don’t assume that taking a multi-vitamin is enough to keep your iron levels where they should be (especially if you are a woman who still gets a period) and not all multi-vitamins contain iron. That’s why testing and relying on your doctor to prescribe the right course of treatment is so important.

Symptoms of Iron Deficiency

  • Your brain doesn’t function to the best of its ability
  • You generally feel sluggish or tired
  • Shortness of breath
  • Coldness in hands and feet
  • Paleness
  • Brittle nails
  • Restless Leg Syndrome
  • Pica - cravings for nonfood items such as ice, dirt, paint or starch.

Treatments for Iron Deficiency

Even before your surgery, your surgeon will test for vitamin deficiencies, including iron. After surgery, testing is typically done at 3 months post-op and then yearly. But schedules may vary so check with your surgeon. If iron levels are normal, your doctor may or may not have you take an iron supplement.

Some bariatric surgeons suggest patients supplement with iron to prevent a deficiency. This is very important for female RNY Gastric Bypass patients who get a period. For all others at my practice, we typically prescribe iron only when a deficiency is present because iron is known to cause constipation so check with your doctor before selecting your supplement regimen.

If an iron deficiency is found during initial pre-op or post-op testing, expect to be put on a course of treatment and then retested after a few months. Depending on the level of deficiency, your doctor will likely recommend one of the following treatments:

Medicinal iron: Your doctor will prescribe an over-the-counter iron supplement or prescription iron supplement. There are several good over-the-counter products formulated specifically for bariatric patients. Some are formulated with vitamin C to increase absorption. Prescription supplements come in higher dosages and typically contain stool softeners for the prevention of constipation.
Intravenous iron: In cases of severe deficiency, your doctor may refer you to a hematologist for intravenous (IV) iron supplementation. The iron will be delivered directly into your vein at a doctor’s office or a clinic and may take up to several hours. Iron infusions are usually given over the course of several visits until your iron levels are correct.

Iron from Food Sources

Iron is widely available in foods we eat but if you’re a post-op RNY Gastric Bypass patient, you’re at a higher risk of iron deficiency as a result of the changes made to your gastrointestinal (GI) tract, especially if you are a woman who is menstruating.

Since food is routed around the part of the small intestine responsible for absorbing iron and other nutrients, much of the iron in food passes through undigested.

If you find that you are iron deficient, you’re not going to get enough iron in your food to correct your iron levels. But if your iron is normal, including iron-rich foods in your diet can help prevent a deficiency from forming. Iron from whole foods is less likely to cause GI upset, a common side effect of many supplements.

There are two forms of iron in foods, heme, and non-heme.

Heme iron comes from animal foods and is the most well-absorbed form. Plant-based foods contain the non-heme form and absorption is limited to about 30-60 percent of the total iron per serving.

Most foods containing heme iron are naturally low in carbohydrates and should be included regularly in a post-op bariatric diet. However, the plant-based options listed below will provide much-needed dietary fiber, vitamins, and additional minerals.

Some vegetarian options like lentils, beans, nuts, and seeds are great sources of protein, as well. The following are a just a few good sources of iron for bariatric patients:

Animal (heme) sources:

● Beef or chicken liver
● Clams, mollusks or mussels
● Oysters
● Lean beef
● Skinless dark meat turkey
● Sardines
● Skinless dark meat chicken
● Halibut, haddock, perch, salmon and tuna
● Lean ham

Vegetarian (non-heme) sources:

● Lentils
● Beans or split peas
● Tofu
● Pumpkin or sesame seeds
● Broccoli
● Wheat germ
● Peanuts, pecans, walnuts, pistachios, roasted almonds, roasted cashews and sunflower seeds
● Spinach
● Green pepper

Cast iron cookware can also increase the iron content of some foods. Acidic foods high in moisture, like fruits and vegetables, tend to absorb the most iron when cooked in a cast iron skillet or pan. You can also increase the amount of iron absorbed from non-heme foods by eating them with a source of vitamin C. Think broccoli with a squeeze of lemon juice or a lentil and tomato salad.

Many of the early symptoms of iron deficiency are easy to ignore or attribute to other causes so don’t wait for symptoms to visit your doctor. Yearly checkups with your bariatric surgeon can catch deficiencies before they cause too much disruption and are easily treated.



Ajay Goyal, MD, FACS, is founder of the New Jersey Bariatric Center, a medical & surgical weight loss center with offices in Springfield, Somerville and Hoboken, New Jersey, and Director of Bariatric Surgery at Overlook Medical Center. He is a member of the American Society of Bariatric Surgeons (ASBS), the Medical Society of New Jersey, and the Society of American Gastrointestinal Endoscopic Surgeons (SAGES).

Read more articles by Dr. Goyal!