Ep. 112: Why You're Not Absorbing Iron (Even If You Are Supplementing) [PART 1 of Iron & Ferritin Series]

If you've been taking iron consistently and your ferritin still won't move, this episode is going to help you understand why. 

This is Part 1 of a three-part series on iron, and it starts where most ferritin problems actually begin: absorption. Dr. Heather walks through the case of her client Ashley, whose years of stress, grief, antibiotics, hormonal birth control, and mold exposure created a gut environment that couldn't absorb iron no matter how much she took. Dr. Heather also  breaks down exactly why iron intake is only one small piece of a much bigger system.

In this episode:

• Why iron absorption depends on stomach acid, pancreatic enzymes, bile flow, mineral status, and nervous system regulation, not just how much iron you're taking
• What Ashley's GI Map revealed, including H. pylori, C. diff, pathogenic E. coli, and a depleted four-lows mineral pattern on HTMA
• How chronic stress physically changes digestive function and blocks absorption
• Practical starting points to support absorption, including meal hygiene, stomach acid and bile support, and minerals
• Why iron supplementation needs to be timed to where your body actually is and what to look at if ferritin still isn't moving

Next week: Part 2 covers iron transport: ceruloplasmin, copper, and why ferritin can stay low even when your iron looks normal on a blood panel.

Ready to fix your low (or high) ferritin? 

Join me live on May 31st for my live training "Why Iron Isn't Enough" (you'll also receive my ferritin troubleshooting guide)

Taking iron but your ferritin won't budge? Join me LIVE for "Why Iron Isn't Enough" 

Early bird pricing if $27 is available through Sept 24th! Sign Up Here! (replay available for registrants) 

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Transcript

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Dr. Heather Finley 1:13

Welcome to the Love Your Gut Podcast. I'm your host, Dr. Heather Finley, registered dietitian and gut health specialist. I understand the frustration of dealing with GI issues because I've been there and I spent over two decades searching for answers for my own gut issues of constipation, bloating, and stomach pain. I've dedicated my life to understanding and solving my own gut issues. And now I'm here to guide you. On this podcast, I'll help you identify the true root causes of your discomfort. So you can finally ditch your symptoms for good. My goal is to empower you with the knowledge and tools you need so that you can love your gut and it will love you right back. So if you're ready to learn a lot, gain a deeper understanding of your gut and find lasting relief. You are in the right place. Welcome to the love your gut podcast.

2:05

Have you ever taken iron supplements consistently? Maybe you've eaten all the iron-rich foods, steak, spinach, cast iron skillets, all the things. Maybe you even got an iron infusion, and your ferritin barely moved. Or the second that you stopped doing that, it went right back in the tank. Maybe it crept up a little bit, you felt really hopeful, and then your next lab showed that you were right back where you started. You're still exhausted. You're still losing your hair in the shower. You're still cold all the time, still bloated, constipated, wondering what is going on. I get it because I have been there too, and so have all of my low iron clients. This was the case for our client, Ashley, and I am really excited today to help you understand that there's a reason for this. The reason your ferritin isn't moving actually has almost certainly nothing to do with how much iron you're taking. Today is part one of a three-part series on iron. This is probably the most requested topic I've ever gotten, and after the response to our iron webinar earlier this year in February, I knew I wanted to do a whole series on this. So the structure that we're gonna have for the next three weeks, part one, which is what you're listening to right now, is about absorption. Part two is about transport, and part three is about storage. And you need all three working for ferritin to actually build, for ferritin to actually be within a normal range. And also, we're gonna talk too about high iron and high ferritin as well. So don't automatically tune out if you're thinking, "Well, low ferritin is not my issue." In part two of this series, I'm actually gonna talk a lot about high ferritin, so that will be next week if you are listening to this on the week that this comes out. So most women that we work with at Gut Together Have been thinking about iron as just a one-step process. Your iron is low, your ferritin is low, take iron. And they don't realize that there are two more critical steps that iron has to make it through before it even becomes ferritin. So let's start at the beginning. I wanna introduce you to our client, Ashley, because her story is probably going to sound very familiar to many of you listening. Ashley came to us with some pretty significant symptoms. I remember talking to her on a discovery call, and she was just super defeated, and honestly, she was really skeptical because she had worked with several practitioners, and she had kinda reached the point where she's like, "Either I'm just gonna be like this forever, or maybe I'll just give it one last hard college try." And I am so glad that she did. She was dealing with severe bloating, distension, constipation, that brick-in-the-stomach feeling after meals, a lot of burping, and really clear signs of malabsorption and poor digestion. Ashley had a history of SIBO, or small intestinal bacterial overgrowth. She had lots of stress around food that had just built up over the years, especially just because her digestion was feeling so unpredictable. She described it as feeling like her digestion was just shutting down. Now, if you've ever been there before, you know what that feels like, where you're thinking, "I don't know what this meal is gonna do to me. It might feel like it's gonna just sit there for hours, and I'm just getting more and more reactive over time." The important piece of context here is when this all started escalating for her. Her symptoms got significantly worse during a pretty stressful life event involving a ill family member that she was the primary caregiver for. And the reason that I bring this up is because you cannot isolate your gut issues. Your body works together, and your body is greatly affected by stress. And sometimes we can't control having a sick family member or experiencing grief or experiencing trauma. And so I just wanna point that out because this is that moment in time of her family member getting sick and eventually passing away is what really started this snowball effect. Then COVID happened. So years of just things stacking on top of each other, stress, pregnancy, breastfeeding. She had an episode of food poisoning, antibiotics- hormonal birth control. She had mold exposure. Layer by layer by layer, her body had just been slowly depleted over time, and her gut was just trying to hold it together. It was, like, trying to hold it together with duct tape, and eventually it just couldn't hold it together anymore. So that's why when I say when Ashley came to us, she actually really already had a sense of all of this. She told us she suspected that her body had just been really depleted from all the events over the years, and she suspected that all these things, the grief, the infections, the hormones, antibiotics, had just left her system without the resources it needed to function. Ashley was a very highly educated person like you. She had a lot of knowledge about health. She had a lot of knowledge about what she should do from a digestive health standpoint, but there were just a few key missing pieces that were really holding her back, even though she had already done some functional testing and working with some other providers. Ashley was right. She had a clearer picture of her own body and this is part of what made her such a really remarkable client to work with. She specifically worked with Hannah on our team, and Hannah would just rave about how well she was doing and what a great client she was and what a joy she was to work with because of how receptive she was of just, like, wanting to give it a try and see what we could uncover because she really just wanted to feel better. So one thing I wanna point out is knowing your body is depleted and knowing exactly what to do about it in the right order are two different things, and that is where the work began. And Ashley was self-aware enough to know, like, she knew enough to be dangerous, but she wanted somebody to help her put the pieces together, and what an honor for us to be able to help her to do that. It is really such a joy when we have clients that come to us that are like, "I am aware of all of these things, and I'm so excited to have you help me put this together." It's a team effort. It's a group effort. It's really a partnership whenever we're working with clients. So before I walk you through what we found with Ashley specifically, I wanna just lay some groundwork on how iron absorption actually works. Because most of us, including dieticians, which is my specialty, we were taught a pretty simplified version of this, and I think it's really important to understand that it's actually not as simple as we were taught. So the version that most people believe is you eat iron, you take iron, and it absorbs. It's simple, right? But that's really only true if everything else in your digestive system is working the way that it's supposed to. And for a lot of women, especially women who have been through significant stress, and honestly, who hasn't? If you are living in the twenty twenties, there is likely some level of stress that you have dealt with within the last couple years. Maybe you've had multiple pregnancies. Maybe you've had gut infections, food poisoning, long-term birth control. Maybe you've had to use antibiotics. Maybe you've had COVID a couple times. Maybe you have had surgeries. There's so many things that can cause stress on the body. So iron absorption is like a relay race. Now, you can have the fastest runner at the starting line, but if the second runner isn't ready or the baton gets dropped or they never show up, the race is not gonna finish. You're not gonna win. It does not matter how strong your first runner is. It's a group effort. So true iron absorption depends on stomach acid being adequate. It depends on pancreatic enzymes doing their job. It depends on bile flowing properly. It depends on your gut lining being intact. It depends on your microbiome not being in a state of chaos. It depends on your mineral status being sufficient. And most importantly, it depends on your nervous system being in a state where digestion is really even a priority. So if any of those things are off, you can take all the iron in the world and still struggle. Your body just simply cannot absorb what the terrain isn't allowed or set up to receive. So when we really dug into Ashley's history and testing and symptom patterns, we ran a GI map stool test. The first thing that jumped out was evidence of really poor digestive function upstream. So that was key before we got into anything related to infections or inflammation. Her elastase was borderline low. Um, elastase is a marker of pancreatic enzyme output. So basically, it just tells us how your pancreas is equipping your digestive system to actually break down food. Her steatocrit, which reflects fat digestion, was toward the higher end. Now together, those two things pa- painted a pretty clear picture that her body wasn't breaking down food efficiently. Proteins, fats, carbs, all of this was being incompletely processed. And this matters a lot for iron because iron absorption doesn't start in the colon. It doesn't even start in the small intestine. It starts way upstream. So you have to be able to Actually digest food, starting with stomach acid. You have to be able to release iron from the proteins it's bound to in food. You have to be able to stimulate bile flow, which is important for fat digestion and for absorbing the fat-soluble vitamins that support iron transport, like vitamin A, downstream. So if any of that isn't happening, iron never actually gets to the point of being absorbable, and this is why, partially, Ashley felt like she had a brick in her stomach. This is why she was burping. Her upper GI was laboring. The-- it did not have the resources that it needed to break down food. And then on top of that, Ashley had a- infections that were working against her. So her GI map showed H. pylori, virulence factors were positive. She had C. diff toxins. She had E. coli. She had strep overgrowth. So I wanna talk about H. pylori specifically for a second because this is one that we often see in clients with low ferritin and iron issues, and I don't think it gets enough attention. H. pylori is the most common bacterial infection in the world, and it's passed really easily through saliva, water, casual contact. A lot of people carry it without knowing it. And what it does in the gut is it impairs stomach acid, and it also can inflame the stomach lining, which directly interferes with iron absorption at that very first step. But the part that really matters for Ashley's picture is H. pylori doesn't just block iron absorption, it actually competes for iron. So it's kind of a double whammy here. It feeds off of iron. So she was in a situation where she's taking iron and... or if she was taking iron, then there's a pathogen in her gut essentially stealing it before her body can actually use it. The same is true for other infections like candida overgrowth, which we see in clients with nearly identical pictures. Candida will feed off of iron. This is part of why some women feel worse and more bloated, more foggy, more inflamed when they start increasing their iron intake, or they start taking supplemental iron because their gut infections are like, "Yes, we have some better fuel here. This is awesome. Keep it coming." So the C. diff, the E. coli, the strep, all of those were definitely creating more inflammation, just damaging the gut environment, making nutrient absorption across the board just overall hard. So when you have H. pylori, C. diff, E. coli, strep all running at the same time, that's not just one problem. That's like a circuit with too many things plugged in. Eventually, something's gonna trip the breaker. And absorption is one of those first things that can go offline. So that overloaded circuit feels the most clinical and specific to what's actually happening with Ashley's gut with multiple infections running simultaneously. So the flooded basement is kind of the, the analogy here of like, okay, we really have to stop the water from leaking before we can actually, like, dry it out, if that makes sense. Then there's a mineral piece, which really just makes this whole situation really fascinating, and I also think ties everything together, and it can be frustrating for people as well. So Ashley also ran some mineral testing with us HTMA, hair tissue mineral analysis, and that is a test that shows us the tissue level state of minerals in the body over the past several months. And what it showed was a just overall really depleted pattern. She had low calcium, low magnesium, low sodium, low potassium, just low trace minerals across the board. Her HTMA just visually looked like her body was running on empty. This is what's classified as, like, a four lows pattern, if you're familiar with HTMA testing. But why does this matter for absorption? Because you need minerals to absorb iron, and you need copper to move iron through the body. You need adequate sodium and potassium for gut motility and cellular function. You need magnesium for so many things in the body, including digestion. You also need minerals to make stomach acid in the first place. So low iron will also worsen your ability to do all of those things. Low iron is going to impair energy, which impairs your stress resilience, further lower stomach acid, further impairs mineral absorption. So you can see why this is just genuinely a cycle that can be really difficult to break without understanding the correct order of operations. Low minerals will lead to poor digestion, which leads to poor iron absorption, which leads to more mineral depletion. So you can see how the cycle just goes around and around and around. So this is not just like, "Oh, we'll just take more iron." This is like, we have to look at minerals as a whole and support all minerals across the board while we're also supporting digestion so we can break the cycle. Now, there's one more piece of Ashley's picture that I wanna spend some time on because I think it's the piece that is the hardest for people and that gets dismissed the most. And for a lot of women, it's the biggest driver of why their absorption is stuck. So as a reminder, Ashley's symptoms escalated significantly after a stressful life event of caregiving and grief and nervous system overload. So I wanna say something really clearly because I don't want this to land wrong. This does not mean that it's, like, all in your head or I'm not telling you that your symptoms are just from stress. I'm telling you that stress changes the physiology of digestion in ways that are measurable and significant. So when your nervous system is in a stress state, real stress, grief, survival mode, that, like, low-grade activation that a lot of women are running on without even noticing, your body physically reduces stomach acid production because why does it need to digest a steak if your body thinks it's constantly being chased by a tiger, right? So it's gonna pull back on enzyme output, it's gonna slow motility, it's gonna change your microbiome. It reduces blood flow to your digestive organs because that blood is being redirected to your limbs to help you deal with that perceived threat, even if there's not an actual threat. So you cannot fully digest and absorb in survival mode. This is not like, "Oh, you just need a better mindset." It's just physiology. So for Ashley, that stress response had been running for years through grief, pregnancy, COVID, all the things that were stacking up on her body, and her body had been in just this chronic state of protection for a long time. And the gut absorbs what the system has the capacity to. When that system is in protection mode, absorption is gonna go offline. So here is something that a lot of people have backwards, and I think it's worth discussing or straightening out. Most people think that bacterial overgrowth in the gut, whether it's in the large intestine or SIBO, any kind of imbalanced microbiome causes poor digestion. And while sometimes that is true, a lot of the time the sequence actually runs the other direction. So poor digestion upstream is going to create this perfect environment for dysbiosis to take hold, and here's how it works. When your stomach acid is low and your enzymes aren't keeping up, food does not get fully broken down in the upper GI. So incomplete broken down food then travels further into the small intestine in a form that it should not. So it's sitting, it's fermenting. Bacteria that shouldn't be colonizing in the small intestine find food sources and start to grow. That's where SIBO can happen. You get bloating, distension, that classic belly that shows up in the afternoon when you haven't eaten much. So Ashley had a prior SIBO history. She had the bloating and the distension. Her GI map showed some significant dysbiosis patterns. But all of that downstream was a result of the upstream upper GI dysfunction that we were seeing, and this is what no one had addressed for her. So her SIBO was not the starting point. It was the result of the poor conditions upstream. And another thing that I wanna mention just on the stress piece is this does not mean that we were telling Ashley she needed a four-hour morning routine and to be meditating for eight hours a day or anything like that. What this involves is just bringing in little moments of safety, whether it's like a quick breathing exercise before eating or a gratitude journal or... Nervous system regulation does not have to be complicated, and we like to find the tools that are gonna work best for our clients. So I wanna just make that really clear. So you can do a SIBO protocol, you can get some relief, but if the conditions that created SIBO haven't changed, same thing with iron, if stomach acid is still low, if motility is sluggish, m- minerals aren't supporting the system, it's always gonna come back, and that's kinda that vicious cycle that we're talking about. So what did we actually do here? I wanna be really specific because I think the instinct when you hear all of this is to assume that the solution is so complicated, and it's really not. It's just sequential and specific. So the first thing we focused on was actually not iron. It was not an antimicrobial protocol. It was not even minerals right away. It was digestion support and foundations. Meal hygiene was a big starting point for Ashley. This means slowing down before eating, taking deep breaths, not eating while rushed or stressed, chewing. I know that sounds almost like insultingly simple, but like I said, when your nervous system is dysregulated and your body is in protection mode, how you eat is way more impactful than what you eat. Your digestive system literally needs a signal that it is safe. Then we added some digestive support to support stomach acid and bile flow, and these were just things that were specific to her and her testing and her history. We focused on hydration and mineral take, mineral intake, not with just this complicated supplement stack, but gradually in the right sequence. We worked on gut motility because constipation is gonna compound everything. Slow transit means more fermentation, more dysbiosis. We also worked on reducing food fear, which had built up over the years of her gut reacting to things. Ashley had gotten to a point where she was really anxious around food in a way that further dysregulated her nervous system. So we had to rebuild her sense of safety, uh, which is part of the work. And then most importantly, we did not start high-dose iron supplementation. Her system was not ready to absorb it. So adding in more iron before her body was ready to absorb it would've likely been just adding more fuel to the fire. So Ashley had already done a lot of things right. Like I said, she tried protocols. She had worked with practitioners. She had done her research. The missing piece was sequence and doing things in the right order based on her specific physiology, her specific testing, her specific life scenario. So let me give you some concrete things to start on if you're hearing Ashley's story and you're recognizing yourself in it. First of all, I want you to start by prioritizing meal hygiene. This is a thing that you can start today. Before you eat, take two or three slow breaths, four, seven, eight breathing, where you breathe in for four, you hold for seven, you breathe out for eight. Put your phone away. Give your body the signal that digestion is a priority. This is essential. You need to be in a state of rest and digest so that you can digest your food. Secondly, support stomach acid. Digestive bitters are one of the most underused tools. There are a few brands I like, but bitter foods also work well as a starting place: arugula, radishes, artichokes, grapefruit, dandelion greens, even cacao. So make sure you're eating enough protein, healthy fats. That's also essential for bile flow. Number three is address your constipation. I know that's probably not what you expected in an episode about iron absorption, but slow motility makes everything worse because everything backs up. So if you're not having complete bowel movements, that is something that needs to continue to be worked on. Number four is support your minerals. If you haven't downloaded our free mineral guide, the link will be in the show notes. But you can just start with the basics. A simple adrenal cocktail each day can be great, sodium, potassium, magnesium. You can also just really heavily emphasize mineral-rich foods, things like avocados, things like coconut water, pumpkin seeds. Those are all really mineral-rich foods that you can include. And then number five, if you've done all of the above and your ferritin still isn't moving, this is where it can be really helpful to get some specific data. The specific data that you want is a stool test and a mineral test. This is what's gonna help you understand the patterns and where iron is getting blocked. We love an HCMA. We love a GI map. It gives you actual answers- Then we know exactly what we need to address, whether it's gut infections, whether it's specific patterns of depletion, et cetera. So I wanna take just one more minute to talk about iron supplementation specifically, because I'm actually not anti-iron, even though it might sound like that. I wanna be super clear that there are absolutely situations where iron supplementation is appropriate and necessary. But there are also a lot of situations where it is not necessary, and it's creating more problems like constipation, bloating, nausea, where there's active gut infections and it's feeding pathogens. So the form of iron is gonna matter, the timing is gonna matter. But more than those things, the state of your gut and your other minerals matters. So for a lot of women, the sequence needs to be stabilize digestion, improve motility, rebuild minerals, reduce inflammation, address underlying of infections. And then if iron is still needed, you can introduce it strategically, not the other way around. So that's why I always say I'm pro-iron at the right time, not anti-iron, just in favor of actually asking whether the body is set up to actually use the iron correctly. So I wanna share where Ashley is now, because I think outcomes are what make all of this real. When Ashley started working with us, she rated her constipation an eight out of ten. Her bloating was an eight out of ten. She felt like she never had a complete bowel movement. Couple months later, about three months by May, her constipation was a two out of ten. Her bloating was a three out of ten. But the wins that she was most excited about weren't just, like, the lab numbers. It was that her quality of life was so much better. She traveled without constipation for the first time in years. She ate dairy again. She ate gluten at a wedding without panicking. She started trusting her body around food in a way that she really hadn't in a long time. And that's what happens when digestion starts working again. The body can finally start absorbing. The system can finally do what it's capable of doing once the conditions are right. So before you go, I wanna tell you about something coming up on May 31st. I'm hosting a live webinar called Why Iron Isn't Enough, and it is such a great training. I ran it in February, and it was by far the most popular training I have ever done. So if you have iron issues of any kind, you need to be there. We're going through all these steps in much more detail, how you can optimize your iron, your transport, your storage. You'll also get access to my ferritin troubleshooting guide. So if you've been piecing this together on your own and you're finally ready to get to the point where you actually wanna fix this, you need to be there. So the link is in the show notes. We are in early bird pricing right now if you're listening to this at the time that it is live. And make sure you come back next week for part two, because we're going into transport, which is where things can get really interesting. Now that you can absorb iron, how's your body actually gonna transport it so that your body can store it? So I'll see you next week, and thanks for joining this episode of the Love Your Gut podcast