In Which Part Of The Intestine Are Iron Folate

Overview

Your body needs iron and folate (a B vitamin) to make healthy red blood cells. Both come from food, but they are not taken in evenly along your gut. Iron is mostly absorbed in the duodenum — the very first and shortest part of your small intestine, just below the stomach — and in the upper jejunum, the section that follows. Folate is absorbed mainly in the jejunum. The small intestine is a long, folded tube where most nutrients pass into your bloodstream. The stomach, the large intestine (colon) and the rectum play only a small part in this. This matters because if the upper small intestine is damaged, inflamed, or has been shortened by surgery, your body may not get enough iron or folate — even if you eat a good diet. The result can be anaemia (a low level of healthy red blood cells), which causes tiredness and breathlessness.

Yes. Low iron is one of the most common nutritional problems worldwide, and low folate is also seen often. Problems absorbing these nutrients are common too, especially in people with gut conditions or who have had stomach or bowel surgery.

Anyone can be affected. It is more likely in people with coeliac disease, Crohn's disease or ulcerative colitis, people who have had surgery on the stomach or bowel (including weight-loss surgery), people who take long-term acid-reducing medicines, people with heavy periods, people who are pregnant or breastfeeding, and people who drink a lot of alcohol. Children going through growth spurts and older adults with a small appetite are also at higher risk.

Symptoms

Common symptoms

• Feeling tired or lacking energy, even after rest
• Pale skin, lips, gums or inside of the eyelids
• Breathlessness or dizziness when active
• Headaches or trouble concentrating
• Cold hands and feet
• Brittle nails, or hair that sheds more than usual
• A sore, smooth or red tongue, or mouth ulcers that keep coming back
• Restless legs, or unusual cravings such as for ice or soil (more typical of low iron)
• Pins and needles or numbness in the hands and feet (can happen with low folate)

Symptoms in children

• Tiredness and poor concentration at school
• Growing or gaining weight more slowly than expected
• Poor appetite, irritability or low mood
• More infections than usual
• Reaching movement or learning milestones later than expected (with severe, long-standing deficiency)

Symptoms in older adults

• Breathlessness doing everyday tasks such as dressing or walking to the shops
• Palpitations, or chest pain that gets worse with activity
• Memory problems, confusion or low mood
• Unsteadiness or falls linked to dizziness
• Symptoms put down to 'just getting older' — a simple blood test can check this

Causes

Main causes

• Not getting enough iron or folate from food over time
• Poor absorption because part of the small intestine is damaged or inflamed — for example in coeliac disease or Crohn's disease
• Surgery that removes or bypasses part of the stomach or small intestine, including weight-loss surgery
• Blood loss — heavy periods, bleeding ulcers or growths in the bowel, or frequent nosebleeds
• Extra demand — pregnancy, breastfeeding, rapid growth in children, or recovery from illness
• Some medicines reduce absorption, such as long-term acid-reducing tablets; ask your pharmacist about yours
• Heavy alcohol use, which affects how well folate is absorbed and stored

Risk factors

• A diagnosis of coeliac disease, Crohn's disease or ulcerative colitis
• Previous stomach or bowel surgery, or weight-loss surgery
• Heavy menstrual periods
• Pregnancy or breastfeeding
• A limited diet — very restrictive eating, or a vegan diet without iron-rich foods
• Long-term use of acid-reducing medicines or certain other medicines
• Regular heavy alcohol use
• A family history of coeliac disease or anaemia
• Older age, frailty or a small appetite

When to see a doctor

See a doctor urgently if:

• You are breathless at rest, or breathless after very little effort
• You notice blood in your stool or black, tarry stools
• You have chest pain, fainting or a racing heartbeat
• You have lost weight without trying
• You feel confused or unusually drowsy

Book a routine appointment if:

• You feel tired all the time and it is not improving
• You look pale, or others have commented on it
• Your periods are heavy or you have other ongoing blood loss
• You have a sore tongue, mouth ulcers or pins and needles
• You have a gut condition, or have had stomach or bowel surgery, and want your levels checked
• You are planning a pregnancy or are in early pregnancy

Diagnosis

Your doctor will ask about your diet, your medicines, your periods, your bowel habits and your family history, and will examine you. A simple blood test is usually the first step. If your levels are low, the next question is why — so your doctor may arrange further tests to look at absorption and to rule out bleeding or a gut condition.

Tests that may be done

• Full blood count — shows whether your red blood cells are small and pale (a sign of low iron) or large (a sign of low folate)
• Iron studies, including a ferritin level, which shows how much iron is stored in your body
• Folate and vitamin B12 levels — these are usually checked together
• A coeliac blood test — you need to keep eating gluten until this test is done, so ask first
• Stool tests to look for blood or inflammation
• Endoscopy or colonoscopy if bleeding or gut disease is suspected
• Sometimes a scan or a tiny camera pill to look at the small intestine

What to expect at your appointment

For most people this is a short process: a conversation, an examination and a blood test, with results usually back within days. If further tests are needed, your doctor will explain why and what it involves. You can ask for the results in plain language, and it is fine to bring someone with you or to write your questions down beforehand.

Treatment

Treatment usually does two things at once: it replaces what your body is missing, and it finds and treats the reason you became low in the first place. Your healthcare team may suggest changes to your diet and, if needed, prescribe supplements. Do not start high-dose supplements on your own — too much iron can be harmful, and supplements can interact with other medicines.

Self-care at home

• Take any supplement exactly as advised, and ask your pharmacist how and when to take it — timing, and what you take it with, affects how well it works
• Pair iron-rich foods with a source of vitamin C, such as citrus fruit, peppers or tomatoes, to help absorption
• Keep tea, coffee, milk and calcium supplements away from iron-rich meals — they block uptake
• Eat folate-rich foods most days: green leafy vegetables, beans, peas, lentils, citrus fruit and fortified cereals
• Keep a short note of your symptoms so you can tell whether things are improving
• Tell your doctor about any bleeding, however minor it seems
• Go for your follow-up blood tests — they show whether your body's stores are rebuilding

Medical treatments

Your clinician may prescribe iron or folate supplements, usually as tablets and sometimes as a drip into a vein if levels are very low, absorption is poor, or tablets upset your stomach. They will also treat the underlying cause — for example a strict gluten-free diet for coeliac disease, anti-inflammatory treatment for Crohn's disease, or a review of medicines that may be blocking absorption (never stop a medicine without asking your doctor first). Follow-up blood tests check that levels are rising. Treatment often continues for several months after levels look normal, so your body can refill its stores.

When is surgery considered?

Surgery is not used to treat low iron or folate itself. Occasionally an operation is needed for the cause — for example to stop bleeding from an ulcer or a growth in the bowel, or to treat a damaged section of bowel. People who have had weight-loss surgery usually need lifelong vitamin and mineral checks.

Living with this condition

Most people find that once the cause is found and treated, energy slowly comes back over weeks to a few months. In the meantime, pace yourself, plan rest into busy days, and tell family, friends or colleagues if you need a bit more help than usual. Keep taking any prescribed supplements even when you feel better — stopping early is the most common reason levels drop again.

Lifestyle tips

• Eat regular meals that include an iron source and a vitamin C source
• Limit tea and coffee around mealtimes
• Keep alcohol within recommended limits, or ask for support to cut down
• Get regular sleep and gentle activity, building up slowly as your energy returns
• If you follow a vegan or very restricted diet, ask for advice from a dietitian
• Attend follow-up appointments and blood tests, even if you feel well

Diet and exercise

Good sources of iron include lean meat, liver (avoid in pregnancy), beans, lentils, chickpeas, tofu, dark green vegetables, nuts, seeds and fortified cereals. Folate is found in green leafy vegetables, broccoli, beans, peas, lentils, oranges and fortified cereals. Vitamin C — from fruit, peppers or tomatoes — helps your body take up iron from plant foods. Gentle exercise such as walking can help you feel better, but build up gradually while your levels are low, and stop if you feel dizzy or breathless.

Mental health and emotional wellbeing

Low iron and low folate can both affect mood, concentration and sleep, and long-term tiredness can wear anyone down. It is common to feel frustrated, anxious or low. Tell your doctor how you are feeling — it is part of your health, not a separate issue. If low mood or anxiety ever becomes overwhelming, or you have thoughts of harming yourself, please contact your local emergency number or a crisis support line in your country straight away. You deserve help right away, and help is available.

Prevention

Often, yes — or at least made much less likely. Eating a varied diet with regular iron and folate sources helps, as does treating gut conditions early and having your levels checked if you are in a higher-risk group. If you have heavy periods, a restricted diet, or have had stomach or bowel surgery, regular blood tests can catch low levels before anaemia develops.

Screening programmes

Blood counts are commonly checked in pregnancy, in people with coeliac disease or inflammatory bowel disease, and after weight-loss surgery. Folate supplements are routinely recommended before conception and in early pregnancy, because they lower the risk of problems with the baby's developing spine and brain. Ask your doctor whether screening is right for you.

Complications

If left untreated

• Anaemia that gets worse over time, causing severe tiredness and breathlessness
• Strain on the heart and lungs from long-standing anaemia
• More infections and slower recovery from illness
• In pregnancy, low folate raises the risk of problems with the baby's developing spine and brain
• Restless legs, poor sleep and difficulty concentrating at work or school
• In children, slower growth and development
• Missing the underlying cause, such as a bleeding ulcer or gut disease

Long-term outlook

The outlook is good. Low iron and low folate are among the most treatable health problems there are, and most people feel noticeably better within weeks of starting the right treatment. The key is finding out why your levels dropped, so the problem does not keep coming back. With the right support and follow-up, most people get back to their normal energy.

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