Eugene Weinberg, PhD. Professor Emeritus Microbiology, Indiana University
For—my son David, my daughter-in-law Nan Thein Shwe, my granddaughter Jennifer, and my husband Clyde.
Greatly appreciated—recipe testers, page editing contributors, estimators of recipes heme and non-heme content, beta readers, and recipe “samplers”. These include: Rachel Meyer, Clyde Garrett, David Garrison, Nan Garrison, Jennifer Garrison, Rebecca Lantz, Kim Wiles, and Members of the Brookwood Church Monday & Tuesday Morning Women’s Bible Study Groups. Also, I wish to point out that in the review process, I used Grok, Elon Musk’s AI (artificial intelligence) tool to double check the iron content in these recipes. I was delighted to find how close our painstaking manual calculations agreed with Grok. With that said, the iron content in recipes contained in this cookbook are approximates. If one wishes to calculate the amount of iron in a recipe that they have created, one invaluable resource is the US Department of Agriculture (USDA), FoodData Central. This is a comprehensive source of food composition data with multiple distinct data types. This database is free to the public.
Table of Contents
Section One—The Basics
One: The difference between iron deficiency and anemia?..........
Two: When we eat iron, where does it go? ..................................
Three: How do I know I’m iron deficient? .....................................
Four: What type of doctor do I need? ..........................................
Five: Therapies to replenish iron ..................................................
Six: Boost Your Iron Savings Account .........................................
The Healthy Iron Replenishment Approach
Section Two—Tools to Help You Organize
Worksheet to Calculate Iron (blank) ..............................................
Menu Planner (blank) ...................................................................
Shopping List (To be created) ......................................................
Story One: Ronnetta Griffin former Miss South Carolina; former Mrs. South Carolina ........................................................
Story Two: One Family, Three Different Iron Challenges: The Garrison family David, Nan, and Jennifer ................................
Dietary Iron Pioneers
Ray Glahn (absorption artificial gut; yellow bean) .....................
John Beard (iron deficiency in children) ...................................
Mary Frances Picciano (dietary supplements) ...........................
Disclaimer: The Anemia Cookbook is for educational and informational purposes only and is not intended to replace the advice given by a patient’s physician. Reviewers, contributors, and advisors who contributed text, images, or remarks for portions of this book are not responsible for errors, omissions, or overall content.
Preface
In 1994, I knew very little about the dangers of iron. I owned and operated a restaurant that was open seven days a week and employed as many as 28 people. I was fortunate to have good help, which included my teenaged son David. In the restaurant we cooked in cast iron skillets and in my medicine cabinet I had a bottle of liquid iron, recommended to me by a health food store operator as a cure for my fatigue.
In late 1995 David got ill, but the reason for his illness was a mystery until late 1997. A family doctor, who happened to be a regular customer in my restaurant had noticed my son’s dramatic weight loss and offered to run some tests. At that time physicians could order a “bundled” set of tests, which in this case, included serum iron, total iron binding capacity, and serum ferritin. Results of these tests provided important clues and in my son’s case it was the notation of “elevated iron”. In fact, the laboratory technician noted on the report that David’s iron was “wildly high”. Also notable was David’s blood sugar; it too was elevated. I was concerned about this because I knew that juvenile diabetes was a serious matter but I was intrigued by the “wildly high” iron and asked the doctor about the sugar and the iron. He told me that elevated iron is often seen in diabetic patients.
The Internet was in its infancy and foolishly, desperate for answers, I listened to someone who urged me to get genetic tests. This I regret… because the genetic test although helpful, tells you nothing about iron levels and the damage excess iron can do to vital organs. Needing trustworthy sources for information I purchased the Merck Manual. In this book, I read that iron poisoning could be fatal. Reading those words were
sobering—because David’s iron was “wildly high”, I believed that he was going to die. Feeling helpless and scared, I knew that worry would get me nowhere. I lacked the credentials necessary to get into a university-based medical library, but thanks to Howell Clyborne I was given access to a hospital-based medical library.
Here I found the writings of Thomas Bothwell and Eugene Weinberg. What I discovered helped me structure a treatment strategy for David, which initially was met with mild reluctance by his doctor who was concerned about my son’s elevated blood sugar. I knew a little bit about diabetes because of restaurant customers who needed special meals. David had some symptoms common to diabetes like rapid weight loss and fatigue, but not the excessive thirst or frequent urination. From what I read about excess iron, I believed that with phlebotomies, the sugar would come down along with the iron. After discussing this with David’s doctor, it was agreed that if the phlebotomies did not bring down the sugar, David would have a glucose tolerance test and we would have a diagnosis of juvenile diabetes.
During my pursuit for answers, I contacted Dr. Eugene Weinberg, a microbiologist at Indiana University. He talked with me for long hours and eventually directed me to an epidemiologist at the US Centers for Disease Control and Prevention (CDC). Dr. Sharon McDonnell told me that I was in “uncharted waters”; but she listened to my crude protocol and agreed that it had merit.
My son benefited from this protocol, which is described in his story. Today he is careful about his diet and periodically checks his iron levels. What he has learned through this experience has helped him take care of his wife and daughter. Their story is told in a later chapter entitled One Family, Three Different Iron Issues: The Garrison family.
Compiling the Anemia Cookbook has been a fifteen-year journey of creating, testing and analyzing recipes. All that appear in this publication are my own creations, although you might find similar ones on the Internet. I have gained knowledge about the iron we consume from nutrition experts Dr. Ray Glahn, Dr. Patrick MacPhail, and from my
Preface
earlier writings, which were inspired and supported by my mentors, microbiologist Eugene Weinberg, cancer specialist hematologist Leo Zacharski, nutrition experts Dr. John Beard and Dr. Thomas Bothwell, hematologists Dr. Gordon McLaren, Dr. Barry Skikne, Dr. Robert Means, Jr., and Dr. Prad Phatak, and metabolic experts Dr. Herbert Bonkovsky and Dr. Bruce Bacon.
The Hemochromatosis Cookbook which was formerly entitled “Cooking with Less Iron” published in 2001 still garners comments that I deeply appreciate. If I were to change anything in the HH Cookbook, I would emphasize the importance of polyphenols, particularly catechins like epigallocatechin gallate (EGCG), which are abundant in green tea. Excessive consumption of EGCG especially in supplemental capsule form can harm the liver.
To quote my dear friend and colleague Gerald (Gerry) Koenig, “It’s not the bad stuff that’s going to kill us; it’s not eating the good stuff [that will do us harm].” Gerry was referring to the importance of the daily consumption of whole fruits and vegetables.
It is my hope that this book and others that I have written will become useful tools in the homes and kitchens of many.
Take care,
Cheryl Garrison Garrett
Co-Founder, Iron Disorders Institute
Certified Lay Iron Educator
Bachelor of Science degree Indiana University, Bloomington
Author, The Hemochromatosis Cookbook
Contributor Guide to Hemochromatosis
Contributor Guide to Anemia
Contributor Exposing the Hidden Dangers of Iron
Section One—The Basics
This cookbook is meant for an adult who is iron deficient. The book provides practical, medically accepted ways to eat and supplement to replenish low iron reserves. The recipes and suggestions are not a cure, nor are they meant to replace medical advice.
There are many types of anemia; in this book we will focus on two: anemia caused by not enough iron (iron deficiency) and anemia caused by inflammation.
Chapter One The Difference Between Iron Deficiency & Anemia
Some use the word “iron deficiency” and “anemia” interchangeably, but these conditions are not the same. Iron deficiency is not enough iron. Anemia is below normal hemoglobin.
How can a person can be iron deficient but not anemic? When the hemoglobin is normal but serum ferritin is low. Iron is stored mainly in the body in a container called ferritin. As new red blood cells are formed and iron is needed, the body pulls iron from ferritin and places the iron in hemoglobin. For adults, an average normal range for ferritin is 50-100ng/ mL; for hemoglobin the average range is around 12.0-15.0g/dL. As long as hemoglobin remains within a normal range, the person is not anemic. However, when the ferritin level dips below normal range, the person is iron deficient. Rare exceptions where serum ferritin is low can occur in hypothyroidism. When the hemoglobin is normal, but the ferritin is low, this person is iron deficient but not anemic.
Laboratory ranges differ by age, gender, ethnicity, government health agency, institutes, and clinical labs. Most agree that a serum ferritin below 15ng/mL is sufficiently low enough to diagnose iron deficiency in an adult.
How can a person be anemic but not iron deficient? When the hemoglobin is low, but the ferritin is elevated. If the body senses a harmful invader such as a bacterium or virus, this will trigger inflammation
and the body will withhold iron and slow the production of hemoglobin. In this state, a person has ample iron in reserve (in ferritin) so they are not iron deficient, but the body is slowing down hemoglobin production until the harmful invader (pathogen) is eliminated. The body does this to protect the person because harmful pathogens need iron just as much as humans do. This iron disorder is called “anemia of inflammatory response,” and is sometimes called “anemia of chronic disease.” The system responsible for this protection is called the Iron-WithholdingDefense System. When the harmful invader is eliminated, this system stands down until needed and hemoglobin will return to normal.
How prevalent is iron deficiency? According to some reports, nearly two billion people worldwide lack enough iron for the body to function properly. Iron deficiency is more prominent in impoverished countries where poor diets and increased disease exist. In the United States of America (USA) fewer people are at risk for iron deficiency, but those who are at risk can suffer greatly with the symptoms. Sometimes these symptoms are debilitating to the point that work, rest or sleep is affected. In a 1998 Centers for Disease Control (CDC) report on women’s health, about 9-16% of childbearing age women are iron deficient without anemia; they have low ferritin but normal hemoglobin and 2-5% of childbearing age women are iron deficient with anemia; they have low ferritin and below normal hemoglobin. In India where the diet is high in certain spices or seasonings that impede iron absorption, such as turmeric, it is speculated that this may be the underlying reason for such a high number of Indian males and females who are iron deficient.
Who is most at risk for iron deficiency?
Factors that influence the risk of iron deficiency include an individual’s age, health status, gender, what they eat or drink, frequency of extreme physical activity, supplements being consumed, and genetic makeup. In the adult population, the elderly or women who are old enough to have babies are most at risk.
Before taking an iron supplement, find out if you are iron deficient.
Chapter One: The Difference Between Iron Deficiency & Anemia
Knowing key iron levels is important because these levels, when considered together, provide important information about stored iron, iron in use and how much iron is being absorbed and carried (transported) to bone marrow where it is needed to make hemoglobin or to the liver and spleen to be contained in ferritin.
Typical iron tests for adults include (but are not limited to) hemoglobin, serum ferritin, fasting serum iron and unbound iron binding capacity (UIBC) or total iron binding capacity (TIBC.) Serum iron divided by TIBC and multiplied by 100% provides a person’s transferrin-iron saturation percentage (TS%.) Normally this range is 25-35%. When this level is low, iron deficiency is suspect but anemia of inflammatory response also could be the cause. When TS% is elevated above 40%, the possibility of iron disorders can include iron overload/hemochromatosis, thalassemia, or sideroblastic anemia.
A routine complete iron panel requires taking blood from a vein. These tests can be ordered by a primary healthcare provider, physician assistant or in some states direct to consumer labs where the patient can arrange to have the tests performed.
An iron panel includes:
• fasting serum iron (SI)
• total iron binding capacity (TIBC)
• serum ferritin (SF)
• hemoglobin (Hgb)
Some healthcare providers will order a complete blood count (CBC,) which includes hemoglobin. A CBC is recommended because it provides helpful information about blood cells.
When the results of any one of the iron tests is too high or too low, the underlying cause must be investigated and determined. Reasons vary.
Among the underlying causes that can lead to iron deficiency are: Heavy menstrual periods, pregnancy, ulcers, colon polyps, hemorrhoids, inherited disorders, a diet that does not include enough iron, and blood
disorders such as myeloproliferative disorders, sickle cell disease, thalassemia, sideroblastic anemia, aplastic anemia, which is a condition that can be inherited or acquired, Glucose-6-phosphate dehydrogenase (G6PD) deficiency, which is a metabolic disorder. Other causes can include: zinc or copper imbalance, folic acid or B12 deficiency, Celiac disease, Crohn’s/colitis, abnormal thyroid function, infection, erythropoietin (EPO) deficiency, bone marrow problems or esophageal variances which are varicose veins of the esophagus due to build up of blood pressure in the liver. Imbalances in hepcidin and ferroportin are emerging as an important contributor to iron disorders as these two proteins generated by the liver serve as ushers of iron into and out of the cells.
What we eat plays an important role. In the USA, iron deficiency is not as prevalent as it is in other parts of the world. This is because as a rule Americans, are big meat eaters. Iron deficiency is more common in cultures where very little meat is consumed and where diets are high in spices and herbs, such as turmeric and oregano, known inhibitors of iron absorption.
Just as anemia (below normal hemoglobin) is a symptom of some underlying health issue, iron deficiency (low ferritin) is a sign of something wrong in the process of absorbing, transporting, containing, using, and losing iron. Discovering what’s wrong can be accomplished with tests (blood, urine), imaging, or procedures (biopsy, bone marrow aspiration) that allow a medical expert to rule out causes and pursue a diagnosis.
How serious is iron deficiency? Severe iron deficiency with anemia can result in heart failure, but this may be a rare happening. Usually, signs or symptoms such as pica which is a behavior of habitually eating nonfood items, shortness of breath, or fainting will be noticed and prompt a person to seek medical help.
Being iron deficient can affect all aspects of life.
Insert Pages for Chapter 2
Amaranth Porridge
Ingredients
1 cup organic whole grain amaranth
12 ounces filtered water
8 ounces filtered water
½ cup pear juice
½ teaspoon salt
1 Tablespoon date syrup
1 Tablespoon butter
Instructions
Soaking: in a medium sized pot, combine 12 ounces of filtered water, ½ teaspoon salt; and 1 cup of amaranth. Cover and let soak overnight or at least for 5-6 hours. After soaking, rinse amaranth thoroughly. (Cheesecloth is suggested because the seeds are tiny and will fall through a wire mesh strainer.)
In a clean pot, add pear juice and amaranth; on medium heat, bring mixture to a boil; cover and simmer for 10-15 minutes.
Sweeten with date syrup, honey, or table sugar; add butter or coconut milk.
Approximate
Iron Content (porridge only)
Total Iron
Heme: 0.0mgs
Non-heme: Approx. 5.6mgs
(7.5 mgs total if adding 8 oz. of coconut milk)
Barbecued Chicken Thighs
Ingredients - Serves 4
2 Tablespoons olive oil
½ cup finely chopped sweet onion
1 6oz can tomato paste
½ cup water
2 Tablespoons apple cider vinegar
1 ¼ cup dark brown sugar
1 Tablespoon spicy mustard
⅛ teaspoon red pepper
4 organic chicken thighs with bone (about 4-5 ounces each)
Instructions
Sauce:
In an iron skillet, on medium heat, sauté onion in oil until tender and golden, about 20 minutes. Add remaining ingredients. Stir well, cover, lower heat, and simmer 1 hour.
Preheat oven to 375 degrees.
Rinse chicken, pat dry and place skin side down in a 10-inch iron skillet. Cover with aluminum foil and bake for 40 minutes. Uncover, drain off fat, and pour sauce over chicken. Lower oven temperature to 350 degrees. Bake uncovered for 20 minutes. Turn off oven and let cooked chicken remain in the warm oven for 40-45 minutes.
