Lethargy. Fatigue. Listlessness. Busy people attribute it to stress. Others are convinced that they need more sleep. But one possible cause is iron-deficiency anemia.

"I'm always tired, but I've gotten used to it," says Kathy, 49, an administrative assistant at a busy health clinic. "I come home from work, cook dinner, usually clean or do laundry. And I'm wiped out. Maybe I should get to sleep earlier, but it never seems to work out that way."

"I thought I was just run down and stressed out," says Julie, 28, a graduate student who admits that she often burns the midnight oil. "I just attributed everything to 'stress.' I had no idea there was a medical cause."

Kathy and Julie both have iron-deficiency anemia. It is a condition that develops because the body's stores of iron are slowly depleted. Women of childbearing age are at risk for this condition because of the blood loss during menstruation. In addition, some women do not get enough iron in their diets to make up for these losses.

Symptoms of iron-deficiency anemia may include:

• Pale skin
• Brittle nails
• Headache
• Weakness
• Heart palpitations
• Hair loss
• Shortness of breath during or after physical activity
• Unusual cravings for substances (such as ice, dirt, or pure starch)
• Restless leg syndrome

Should You Be Concerned About Iron-deficiency Anemia?

Menstruating women lose a significant amount of blood every month. Iron escapes right along with it. Unless iron is replaced, these monthly losses can drain stores over time. While premenopausal women need more iron than men, they generally eat less. This complicates the challenge of getting enough iron from foods.

Iron deficiency is also common among:

• Pregnant women
• People who have certain conditions, like celiac disease, peptic ulcer, H. pylori infection, inflammatory bowel disease, colon cancer
• People who take certain medicines, like antacids, H₂ blockers, proton pump inhibitors, chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, aspirin, ibuprofen), zinc supplements, magnesium supplements
• Teenagers (especially females)

Why Is Iron So Important?

Iron is the central component of heme. Heme is a molecule used to build hemoglobin, the oxygen-carrying part of red blood cells. Oxygen is used by your body to help make energy. When iron stores are low, the body cannot make enough hemoglobin. There is then less oxygen to help generate energy. Iron also allows the normal functioning of the immune system, the production of collagen (wound healing), and the formation of amino acids, which are the backbone of proteins.

As levels of hemoglobin in the blood decrease, the symptoms of anemia start to appear:

• Fatigue
• Weakness
• Apathy or irritability
• Headaches
• Pallor (pale complexion)
• Lowered resistance to infection
• May feel cold
• Wounds may take longer to heal
• Finger nails may become "spoon" shaped

Anemia comes on slowly, so many people do not realize that they have it. Is it possible to have symptoms of iron deficiency without being anemic? Slight iron deficiency, too mild to cause anemia, may still cause symptoms, such as fatigue and decreased exercise capacity.

How Much Iron Do You Need?

The following table shows the Office of Dietary Supplements' Recommended Dietary Allowance (RDA) for iron:

Do not take iron just because you feel tired. Make sure to get tested to see whether you are indeed deficient. With iron, more is definitely not better. Excessive iron intake can be harmful.

Iron and Your Diet

If you have been diagnosed with iron-deficiency, your doctor has probably advised you to include more iron in your diet. If anemia is severe, an iron supplement, such as ferrous sulfate, may be prescribed. Knowing which foods are rich in iron is the first step toward boosting your iron stores. Take a look at the list below to put more iron on your menu.

When adding iron to your diet, keep in mind that there are different forms of this mineral:

• Heme iron—efficiently absorbed by the body, found in meats and animal products
• Nonheme iron—may be less well absorbed by the body, found in plant sources
• Additive iron—added in processing to create iron-enriched or fortified baked products and breakfast cereals

Nutritionists have traditionally grouped meat, fish, and poultry together as the best sources of heme iron. But scientists at Utah State University published some results showing that some types of meat may pump more iron into your system than others. The winners? Beef ranked first for heme iron content, followed by lamb, pork, turkey, and chicken. Eggs are also a good source of heme iron.

Eating for Energy

It is not enough to know where iron is lurking. You also have to get it into your system. This is somewhat more difficult for vegetarians since all nonmeat forms of iron are nonheme, and therefore less well absorbed. But, it is certainly not impossible. Here are some tips:

• Choose iron-rich foods.—Lean meats, fish, and poultry are still the best iron sources for meat eaters. For those of you who are not willing to eat a steak once a week, foods like beans and legumes, greens, whole grains, and dried fruits will provide iron, albeit in a less absorbable (nonheme) form.
• Choose more "C".—Vitamin C, which helps trap and dissolve iron, can improve the absorption of nonheme iron. Try broccoli, tomatoes, green and red peppers, orange juice, grapefruit, strawberries, cantaloupe, mangoes, papayas, and baked potatoes.
• Remember that little things add up.—Choose iron-enriched rice, pasta, and breads; switch to an iron-fortified cereal for breakfast; add dark (blackstrap) molasses or raisins when baking. It may sound like an old wives' tale, but cooking in an iron skillet, especially with high-acid foods like tomatoes, can contribute a little extra iron, too.
• Avoid excess coffee, tea, or chocolate with meals.—These contain substances that inhibit the absorption of nonheme iron.
• Supplement with ferrous sulfate or a multivitamin.—For those of us who simply cannot get enough iron from foods, supplementation may be a viable alternative. Talk to your doctor first, though, and find out what supplement is right for you.

Good Dietary Sources of Iron

• Meats—such as lean beef (top or bottom round, pot roast, sirloin, tenderloin), lean pork, lamb, veal, liver, organ meats
• Fish—such as clams, oysters, shellfish (eg, shrimp), tuna
• Poultry—such as chicken and turkey
• Eggs
• Beans and legumes—such as black-eyed plit peas, black beans, kidney beans, lima beans, navy beans, lentils, soybeans
• Vegetables—such as dark, leafy greens (beet greens, kale, spinach, turnip greens); asparagus; bok choy; broccoli
• Dried fruits—such as raisins
• Grains—such as iron-fortified cereal (45% of the daily value or more), whole-grain or iron-enriched foods
• Other types of food—such as blackstrap molasses, Brewer's yeast, tofu