A Tale of Ice, Iron, & Young Women 🧊🩸

A new study finds that almost 40% of women ages 12-21 are deficient in iron — and the range of possible symptoms might surprise you, too

Jul 09, 2023

Hello, dear friends,

This story begins with ice.

For many years, I loved ice in my drinks. Ice water. Iced tea. Iced coffee. Ice, ice, ice. I crunched on it, nibbled on it, crushed it. Some people like spicy food, some like to salt their food, some avoid cilantro. Well, I liked ice.

When I was in my early 20s, I saved up to backpack with friends for a few weeks in Europe. We slept in bunk beds in hostels, washed our clothes in sinks, rode the local trains, visited the Leaning Tower of Pisa and the Vatican and the Musée de l'Orangerie, and ate tons of gelato. It was marvelous.

And: There was no ice.

Europeans don’t generally put ice in their drinks — tap water is room temperature; soda doesn’t come with ice.

I was bereft over this lack of ice, more than I reasonably should have been over such a minor thing. After all, we were in Europe; do as the Europeans do! But I could not put this urge out of my mind.

At one point, I spotted caffè freddo in my travel book of Italian words, defined as “iced coffee” — and eagerly requested the drink at the next cafe, no doubt in mangled Italian.

I still remember the flood of relief when the Italian gentleman behind the counter produced ice out of seemingly nowhere, added it to a shaker with coffee, and shook it up. Eureka! Ice did exist in this country! Thank goodness!

Then, he strained the coffee, tossed the ice away in the sink, and handed me the glass of frigid coffee with no ice.

What!

(It turns out that caffè freddo, which I would learn only in Googling for this very post, means cold coffee, not coffee with ice.)

I frantically tried to signal that I wanted the ice back. I remember his confusion and my desperation. Somehow, I got ice added to the glass. I’m sure he thought I was a ridiculous American tourist, and I was. The compulsion was overwhelming. All for ice! How strange I was!

Then, more then a decade later, I was treated for anemia. I had had anemia on and off since I was a teenager, due to challenges with absorption from a GI illness. I had been prescribed both supplements and infusions, but for for the first time I could remember, my levels catapulted into a more normal range.

I felt better, more energetic, more present, more alert, even warmer.

And the wildest thing happened — my desire for ice completely disappeared.

More than that, I actively did NOT want to crunch ice.

I was stunned.

All this time, I thought I craved ice out of my own personal preferences.

But nope! It was a signal from my body that I was extremely low on iron.

No medical doctor had ever mentioned this to me. I had, at times, brought up my ice craving at appointments, and my physicians only looked at me oddly. It probably seemed like the most bizarre detail to be sharing.

I’ve only ever met one health practitioner who knew about this connection.

Years later, I was at an acupuncture appointment with a wonderful specialist trained in Chinese medicine.

I off-handedly mentioned my past ice craving, and she knew immediately: You were anemic.

Yes.

Iron deficiency is more common than you might think

I thought of this experience recently when I learned about a new study in JAMA, reportedly the first research to look at iron deficiency in young women.

Iron is incredibly important mineral to our health. We rely on it to ensure we have enough red blood cells to transport oxygen throughout our body.

The study, by Dr. Angela Weyand of University of Michigan Medical School and colleagues, examined records of 3,490 women ages 12-21 who were not pregnant. The records looked at both ferritin levels (the longer-term store of iron) and hemoglobin levels (the red blood cell protein that carries oxygen and the marker for anemia). Oftentimes, routine blood work includes hemoglobin but not ferritin, which can lead to iron deficiency getting missed.

The study found that almost 40% of the young women had iron deficiency, with low ferritin levels, yet only 6% would have diagnosed with anemia.

A recent tweet from JAMA lead author Dr. Angela Weyand, aka Shematologist on Twitter.

The study also showed that the likelihood of iron deficiency was significantly linked to race and ethnicity, poverty, and food insecurity. Black and Hispanic young women were more likely to be iron deficient. Young Black women were four times more likely to have iron-deficiency anemia than white young women.

(General study note: Linked means there was some sort of correlation between two metrics, not that X causes Y. There can be underlying factors and causes that aren’t part of the study at all.)

The study excluded records from young women with inflammation or kidney or liver dysfunction, or who were pregnant, so the number of young women in the whole population who are iron deficient is likely even higher.

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Also, as Dr. Weyand notes, the study used the World Health Organization hemoglobin cutoffs for anemia, which are different for women than men and could be problematic. (She points to us to this Lancet article: Sex specific definitions of anaemia contribute to health inequity and sociomedical injustice)

The study didn’t speculate on the reason behind iron deficiency. The authors called for more research on risk factors, as well further evaluation of the recommended frequency of screenings for iron deficiency and iron deficiency anemia.

In general, low iron levels can have many different possible causes, including loss of blood (such as during menstruation or GI bleeding), not enough iron in your diet, inability to absorb iron in your small intestine (GI disorders or removal of your small intestine during surgery), and pregnancy, according to the Mayo Clinic.

Symptoms of iron deficiency can vary widely. I compiled this list of potential symptoms from Dr. Weynard, the Mayo Clinic, Cleveland Clinic, and Penn Medicine:

Extreme fatigue or weakness
Headaches
Dizziness or lightheadedness
Difficulty concentrating
Pale skin
Fast heartbeat
Shortness of breath
Chills
Cold hands and feet
Sore or inflamed tongue
Cravings for non-food substances, such as ice, dirt, chalk (pica syndrome)
Junk food cravings
Poor appetite
Abnormal or increased menstrual bleeding in women
Loss of sexual desire in men
Brittle nails
Hair loss
Restless leg syndrome
Bruises

Not fun.

Detecting and treating iron deficiency

As always, I’m not a doctor and nothing in this newsletter is medical advice. Please see your own clinician for questions and guidance.

An article from the Harvard T. H. Chan School of Public Health describes iron deficiency as the “most common nutritional deficiency worldwide.”

If you think you might have iron deficiency, you’ll likely want to talk to your doctor about blood work that includes an iron panel and ferritin. This will check your blood for both the current amount of iron circulating and your longer-term storage of iron.

Dr. Rachel Bercovitz, Associate Professor of pediatrics at Northwestern University’s Feinberg School of Medicine and a hematologist at the Ann & Robert Lurie Children’s Hospital of Chicago (and not part of the recent JAMA research), describes ferritin as your “iron savings account.”

“The iron we take in every day goes into a checking account where it’s used to make new blood cells and other things that need iron,” she told NBC News. “If any is left over, it goes into the savings account. If you’re living from paycheck to paycheck with iron, you may not be able to keep up and have a surplus for when you’re having your period.”

If your iron is low, your doctor may prescribe iron supplements or an iron infusion. I seem to need an iron infusion every year or two, and I feel a lot better within a few weeks. But each person is different.

At my iron infusion this week, the final of five doses

You can also boost iron intake in your food. Good sources of iron, according to the Cleveland Clinic, Registered dietitian Julia Zumpano, RD, LD, and Harvard T.H. Chan School of Public Health, include:

Legumes: Peas, beans, tofu, tempeh.
Breads and cereals: Whole wheat bread, enriched white bread, rye bread, bran cereals, cereals with wheat, and fortified breakfast cereals, enriched rice
Vegetables: Spinach, broccoli, string beans, dark leafy greens, cabbage, Brussels sprouts and tomatoes, potatoes with skin
Nuts and seeds
Protein: Beef, poultry, eggs, liver, canned sardines, canned light tuna, oysters, clams, mussels
Fruit: Figs, dates and raisins
Dark chocolate

A Tale of Ice, Iron, & Young Women 🧊🩸

A new study finds that almost 40% of women ages 12-21 are deficient in iron — and the range of possible symptoms might surprise you, too

Iron deficiency is more common than you might think

Detecting and treating iron deficiency

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