‘Ferritin face’: what you need to know about low iron

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1:55Inger's phrase, you are not ugly, you just have ferret in face.

2:00Madeleine Finlay: It's a new social media term for a pale, washed outlook with dark circles under the eyes, all caused by a lack of iron. So just another TikTok health fad? Not necessarily. Iron is used in every cell in the body and needed for everything from cognition to physical strength.

2:26Madeleine Finlay: So today, is ferritin face really a thing? And why iron might be the most important nutrient you don't know you're missing? I'm the Guardian Science Editor, Ian Sample, and this is Science Weekly.

2:47Madeleine Finlay: Maddy, today you're going to tell me about iron. Why? Well, everyone, it seems, is talking about this thing called ferritin face. And ferritin face is when you become pale, you have bags under your eyes, maybe your skin is very dry, your hair is brittle, and supposedly that is because you are iron deficient. It looks like this then, what you're saying. Well, maybe you need to go for a blood test. Maybe I need to get a test, yeah. But the reason that this is coming up, I think, is because recently the American Society of Hematology, they brought out their 2026 guidelines and they shifted their guidelines.

3:31So more people were iron deficient than maybe the previous tests would have indicated. I have to admit, I am chronically iron deficient, really struggle with getting enough iron. I'm vegetarian. And so my algorithm somehow picked up on that. And I was seeing so many videos of iron rich recipes and all kinds of things. And it's just been supercharged. Now, iron deficiency, it's actually one of, if not the most common nutrient deficiency in the world. So there are estimates that maybe 25%, so a quarter of the world's population is iron deficient. It does affect women predominantly and that's because women are menstruating, might be pregnant.

4:18Those are things that will really deplete your iron stores. There's a racial and ethnic disparity as well. So for example, iron deficiency is much more common in black women than in say white women. Another one of the ways that you might become iron deficient is actually through strenuous exercise. So you do a lot of exercise, your muscles are using their iron stores. And so that can actually bring down your iron. So it really is a big, big thing.

4:49Madeleine Finlay: Why do we need iron then? What does it do in the body? So iron is used by the mitochondria. So that's the powerhouses of the cell to produce energy. if your mitochondria don't have enough energy your cell isn't going to be able to function as it should so if this is every cell in the body you can imagine that without enough iron it's going to affect your whole body so hey let's start with the brain if you don't have enough iron you might experience things like brain fog poor concentration insomnia perhaps you're not producing enough of those neurochemicals like serotonin so maybe you know you struggle with low mood anxiety then we can move to the muscles now it's so so important in your muscles and this is also because your muscles have stores of iron in something called myglobin so if you don't have enough iron for your muscles you might feel particularly weak but the most single important use of iron in the body.

5:55It's where you're going to find 70 % of your iron is in your red blood cells in haemoglobin, this protein haemoglobin. And what iron does is it helps bind oxygen in the haemoglobin so that it can be transported all around your body to wherever the oxygen is needed. Now, to understand all of this better, while I was doing my research, I got in touch with two brilliant scientists. So I spoke to Dr. Sue Pavord. She is Professor of Practice in Medical Haematology at Oxford University Hospitals. And I also spoke to Hal Drake-Smith. He is Professor of Iron Biology at the Wetherill Institute of Molecular Medicine at the University of Oxford.

6:43So two iron experts. And this is how Hal explained the transport of iron and oxygen around our bodies. There's a dedicated protein that we have in our blood plasma called transferrin, which as the name suggests transports iron to anywhere in the body that really needs iron and delivers it to the cells which are needing iron to grow and to develop. And most of that In you and I, a steady state is in the bone marrow to make new red blood cells. It's why your blood is red, is because it's the iron in the red blood cells binding oxygen. So, going back to ferritin face very quickly, Ian, there is a sort of nugget of truth in this, right?

7:32Because actually, when you think about the fact that all our cells need iron and iron is what makes our blood red, you can understand that actually, if you are iron deficient, you might be pearler. You might look grey. You might have bags under your eyes. It's going to affect your nails and your skin and things like that. And actually, those other things are probably more important to look for if you have black or brown skin, because you might not see that you're more pale than usual. So there are kind of physical signs, but certainly nobody should diagnose themselves just by how they look, because there are plenty of reasons why you might be pale or look a bit tired.

8:22Madeleine Finlay: okay so iron is an essential nutrient how do we get it well we eat it we eat it um there's lots of iron in meat especially red meat um as well as fish for the non-meat eaters uh for the non-pescatarians It's also in beans and nuts and lentils and dried fruits like prunes and leafy vegetables and chickpeas. And then things like cereals and breads might be fortified with iron as well. Now, as we vegetarians and vegans well know, it's much harder to get iron from non-meat sources. And that's because it's different kinds of iron. So meat sources have a type of iron called heme, and we're much, much better at absorbing heme iron than non-heme iron.

9:17But what helps with iron absorption is vitamin C. It just makes it easier for our bodies to absorb.

9:23Madeleine Finlay: I mean, this takes us on to the difference between iron deficiency and anemia. And, you know, you often hear these things used sort of interchangeably, but what's the difference between those? What are they? So as I said, iron deficiency is when your body just does not have enough iron to perform the functions that it should. But the body tries to preserve its iron as much as it possibly can for the production of red blood cells. So for as long as possible, it keeps making red blood cells so that it can transport oxygen around the body. Now, at some point, your iron might become so low that even this becomes difficult for your body.

10:10And that's when you're anemic. So anemia is when either you don't have enough red blood cells or you don't have enough hemoglobin to transport oxygen around your body.

10:23Madeleine Finlay: I've also heard that iron is important for the immune system, but it's not the usual nutrient you hear when people talk about, you know, your immune defences. So what is going on there? Does it have a role? It does have a really, really important role. Now, you can imagine that when you mount an immune response, your body is doing things like producing loads of antibodies. It's producing immune cells. It has to grow them really rapidly. this takes a lot of energy it takes a lot of iron and what I found super super super interesting that when I was asking Hal about this he said oh can I take you back 3.2 billion years and he was saying that you know at that point there wasn't any oxygen around the earth was a very different place.

11:15But what very early life realised was iron was this amazing chemical that could be used to catalyse reactions. And so iron is kind of built into these basic fundamental processes in all of life. And because of this, it's not just important for us, but important for other things as well, including what our immune systems are fighting.

11:45Madeleine Finlay: Okay, so you have to tell me more about that. How does that bit work? Exactly. So because iron is this fundamental ancient nutrient, pathogens need it as well. And the role of iron in the immune system is more complicated than it just being used for making and producing this immune response. and this is this is one of hal's areas of research and expertise so i asked him to explain to me exactly what is happening here it turns out there's this thing that we call the battle for iron where there's a tug of war um and the bugs that are that are invading us are trying to steal our iron because we're a great source of iron for them so you can think of infection as the theft of nutrition, nutritional resources.

12:34They're trying to eat us essentially and mammals have mutated back to try to combat that in particular specific ways. So this battle for iron also tells you how important iron is for biology because it doesn't really happen for any other nutrient, certainly not to the same extent. So this battle for our iron between us and the bugs that are invading us this kind of gives us a theoretical concept for some work that is very very very early days Hal was telling me that you can kind of take this concept and turn this whole thing into a therapeutic there are many many diseases where cells are working against us so I'm thinking like autoimmunity or maybe even when you receive a transplant and your own immune system then tries to attack the transplanted graft, or in cancer when our own cells go wrong and start multiplying uncontrollably, all of those cells, which are, if you like, pathological cells, they all need iron.

13:36So if there was a way to really stop those cells getting hold of their iron, that would stop them. That would be a really neat way of shutting down their function, and they wouldn't be able to get out of that because you can't evolve out of needing iron. It's too fundamental. So there are many groups who are thinking about targeting iron in a way to control disease. And I think that's a very exciting part of the field.

14:07Madeleine Finlay: Coming up, if you are low in iron, how can you build your stores back up?

14:18I've really underestimated the profound racism there exists towards Muslims and Arabs in this country. Political conversation is dominated by one topic above all, race. You're saying that the entire media system is actually riddled with Islamophobia? I think so, yeah. Nezri Malik has been way ahead of the pack in diagnosing how immigrants, their kids and grandkids are reshaping not just politics, but Western societies. All politics is identity politics. It's just when people do it on the lines of race that it gets naff. So where have never-ending culture wars and real wars in the Middle East left people of colour?

15:00My opus will not be called The Audacity of Hope. It'll be called The Terrifying Prospect of Hope. This is Radical Thinking, a new series from The Guardian with me, Adit Chakraborty. Out Saturday in your Politics Weekly feeds.

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16:18Madeleine Finlay: Maddy, iron is this fundamental, ancient nutrient. So why are so many of us iron deficient? It's actually a bit of a mystery because it is kind of weird how many of us are iron deficient. Why? Why is it so common? And I did ask both Hal and Sue about this and there were lots and lots of different theories. but ultimately there is this big question mark around it because you would expect us to be a bit better adapted. You know, menstruating women, women who are pregnant, you would think that the body would be able to kind of bring the levels back. And so there are lots of different potential explanations but as I said, Hal's interest is in iron and the immune system and the way those interact.

17:06He had a really interesting thought on this. It certainly seems to be the case that iron deficiency itself is protective against some very important infections, for example, malaria. There's pretty good data that says that iron deficiency protects against malaria in pregnant women and in children as well. So assuming that that really is the case and the data is pretty good to support that, then perhaps there's been a selection pressure on humanity to be iron deficient because it can protect against very severe infections. So that's still a little speculative, but it may be part of the reason why iron deficiency is so common.

17:46Madeleine Finlay: So how do you treat iron deficiency or iron deficiency anemia? Is it just a case of taking a bunch of supplements? Yes, you can take supplements. There are a few different types of iron that you can take. So some people might find that particular forms of iron agree with them better than others because iron supplements, they can give people sort of an upset stomach. They might make you constipated. They tend to give you dark stools. Now, interestingly, Sue said to me that what you don't want to do is take iron in a multivitamin. You want to take it as a separate tablet. And that's because there are things in the multivitamin that actually impair the absorption of iron.

18:28Now, if you've gone to your doctor and they have done a blood test and you're iron deficient or you're anemic, what they'll probably recommend is a course of tablets. Now, if you're pregnant, you'll want to be taking at least a tablet a day, although your doctor will advise you on this because you have a limited amount of time to get that iron level back up. For a lot of people now, actually, the advice has changed. So it used to be if you were iron deficient or anemic, they would say maybe one to three tablets a day of something like ferrous fumarate. But now what they say is that because there are these issues with taking it with your stomach, they recommend that you take it every other day.

19:07And what that does is that sort of balances getting the most amount of iron from that tablet and balancing that with trying to avoid some of those side effects. Now, it is slow. It takes a long time to get your iron back up. So you might be on this course for something like three months. You go back to your doctor. You might get another test to see what your ferritin levels are like. It might take a year. It might take two years. You might go to your doctor and your iron levels are so low, they're so on the floor, you're really anemic, that actually even the cells that are absorbing the iron are affected and are impaired.

19:48And at that point, you might be recommended or you might want to consider an IV infusion of iron.

19:56Madeleine Finlay: So Maddy, to wrap up, after all this research, what's your take home on iron? I think my biggest take home is, you know, after seeing all those videos online of people worrying about ferritin face and worrying about iron deficiency, it was one thing that Sue said to me. And she basically said, you know, particularly if you are a woman who menstruates, there is just no harm in taking an iron supplement, say, every other day or Monday, Wednesday, Sundays or even one a week. That is a really good thing to do and a good thing to consider. And, you know, I don't think we're necessarily one for promoting supplements on this podcast, Ian.

20:44Of course, you can look at your diet and think about how do I up my iron. But for people who don't eat meat or fish, a supplement is a really good thing to consider. I can't believe I'm saying that on the podcast to you.

20:59Madeleine Finlay: I can't believe you're saying it either. What have you done with Maddy?

21:05Madeleine Finlay: Thanks again to Maddy. Before you go, if you're a regular listener, you'll know that here on Science Weekly, we love to dissect the latest health trends and explore which ones actually work. So for a future episode we want to hear your questions about the wellness hacks you've been tempted to try. NAD Plus for ageing? Beetroot juice for athletic performance? Send us a video message with your name and question and we'll sort fact from wellness fiction. Just email scienceweekly at theguardian.com. That's it from us today. This episode was produced by Josh and Chana, Jacob Liebenberg and Nonny Okonkwo.

21:48Madeleine Finlay: The sound design was by Job Cox and the executive producer was Ellie Bury. We'll be back on Tuesday. See you then.

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