Dear Mark: Iron Followup

Last week’s post on iron levels got a big response and garnered a ton of questions from you guys. Today, I’m going to clarify a few things and answer as many questions as I can. First, do iron and ferritin levels mean different things for men and women? If so, how do those differences manifest? What about premenopausal women vs postmenopausal women? Second, what do we make of the fact that ferritin is also increased in times of inflammation? Is there a way to distinguish between elevated ferritin caused by inflammation and elevated ferritin caused by high iron? Third, is desiccated liver a good option for liver haters? And finally, I share some exciting plague news.

Let’s go:

Emma wrote:

I’d love to see more info on iron levels as they relate to men and women differently. I recently had an iron infusion for low ferretin, not thinking much would change I actually experienced so many positive effects I didn’t even know were coming my way. I’m less cold, no more afternoon fatigue, less hair falling out, no more random palpitations, improved restless leg syndrome and the number one big change is it improved anxiety levels – in fact my anxiety is now gone. The last two are due to a connection between iron and dopamine. I learnt that children with mental health issues are often treated for low ferretin where possible, elevating levels to around 100 showing positive results (would love to see literature on this), for me my ferretin went from 20 to 130 and its changed my life, at 31 I haven’t felt this good in years. Yay iron!

That’s awesome to hear. Yes, it’s important to stress the very basic essentiality of iron. Without it, we truly cannot produce energy. And since energy is the currency for everything that happens in the body, an iron deficiency makes everything start to fall apart.

As for gender and iron, there’s a lot to discuss.

A good portion of women with hemochromatosis never actually express it phenotypically, meaning their lab tests don’t show evidence of dysregulated iron metabolism or storage. According to one study of hemochromatosis homozygotes (people who inherited the mutation from both of their parents), being a woman makes it 16x more likely that your hereditary hemochromatosis won’t actually present as iron overload.

Another study found that among mostly-age-matched men (42 years) and women (39 years) with hemochromatosis, 78% of the men had iron overload while just 36% of the women had it. Iron overload was defined as transferrin saturation over 52% combined with ferritin levels of 300 ng/mL for men and 200 ng/mL for women.

High iron levels are more of an issue for postmenopausal women than premenopausal women. The latter group regularly sheds blood through menstruation, and if anything, they’re at a higher risk of low iron. Plus, estrogen is a key regulator of iron metabolism. As menopause sets in and estrogen diminishes, that regulation suffers.

For instance:

In postmenopausal Korean women, high ferritin levels predict metabolic syndrome and subclinical atherosclerosis.

High ferritin predicts metabolic syndrome in postmenopausal but not premenopausal women.

In premenopausal Korean women, higher ferritin levels predict better bone mineral density; menopause nullifies this relationship.

Remember that ferritin is actually a measurable protein bound to iron, so testing a ferritin level is technically an indirect way to measure iron. Why is this important? Another characteristic of ferritin (the protein) is that it is an ACUTE PHASE REACTANT. This means that ferritin levels can fluctuate with illnesses and other inflammatory states in the body that drive up a ferritin value that is not related to an actual iron level fluctuation. Don’t get ferritin checked when you are sick with a cold or other illness.

This is a great point.

Ferritin is marker of long term iron storage, but it’s also an acute phase reactant that up regulates in response to inflammation or oxidative stress.

If you want to be really careful, you should get a HS-CRP test—that measures your overall inflammatory status. If CRP is elevated, ferritin can be elevated without saying anything about your iron status.

Come to think of it, if elevated ferritin can be a marker of inflammation and oxidative stress, the inflammation could be responsible for some of the negative health effects linked to high ferritin. Or, if having too much iron in the body can increase oxidative damage, it may be that high iron levels are increasing inflammation which in turn increases ferritin even further. Biology gets messy. Lots of feedback loops. However, the fact that many studies cited in the previous iron post that use blood donation to treat high ferritin have positive results indicates that for most people, ferritin can be, in most situations, an accurate estimation of your iron status.

To make sure it’s an iron problem, get a transferrin saturation test as well. That indicates the amount of iron you’re absorbing, with below 20% being low and over 45% being high. People with high ferritin and high transferrin saturation do have high iron levels. People whose ferritin is artificially enhanced by inflammation will have normal transferrin saturation levels.

I have one last question on this. You say “Don’t stop eating liver every week.” If you can’t stand the taste of liver, what do you think about taking liver capsules made from grass-fed New Zealand beef every day instead?

That’s a great option. Go for it.

People should generally aim for 4-8 ounces of fresh liver a week. Note the amount of desiccated liver in your capsules and multiply by 3 to get the fresh liver equivalent, then take enough each day (or all at once) to hit 4-8 ounces over the week. I hear good things about this one.

Thank you for your article on HH. I carry the gene but have been managing my iron levels through phlebotomies. I am full Keto, meat and all and have found my iron levels have not been effected by going Keto. Early detection is the key and ongoing monitoring. Bring on the plague!!!

You joke about that now, but there’s a startup that’s breeding heritage rat fleas that produce a mild strain of the plague that evades the attention of the immune system and proliferates throughout the body to keep iron levels in check without killing you. I’m an early investor, have a couple swarms installed in my condo, and (knock on wood) so far have avoided anything worse than a sore throat and maybe a mild open sore or two. There’s actually a big rift forming between the techs who want to keep the fleas heritage and those who want to go ahead with CRISPR and engineer them. One variant has had a deer tick gene inserted that adds an anesthetic compound to the flea’s saliva. That way you can have a personal swarm on you and never feel any bites or itches.

I’m not sure about CRISPR just yet, but I gotta say it’s pretty nice to be covered in fleas and not feel the bites. Time will tell.

Ok, I’m joking.

That’s it for today, folks. I hope I’ve answered some of your concerns, and if not, let me know down below. Thanks for reading!


Lainé F, Jouannolle AM, Morcet J, et al. Phenotypic expression in detected C282Y homozygous women depends on body mass index. J Hepatol. 2005;43(6):1055-9.

Qian Y, Yin C, Chen Y, et al. Estrogen contributes to regulating iron metabolism through governing ferroportin signaling via an estrogen response element. Cell Signal. 2015;27(5):934-42.

Seo SK, Yun BH, Chon SJ, et al. Association of serum ferritin levels with metabolic syndrome and subclinical coronary atherosclerosis in postmenopausal Korean women. Clin Chim Acta. 2015;438:62-6.

Cho GJ, Shin JH, Yi KW, et al. Serum ferritin levels are associated with metabolic syndrome in postmenopausal women but not in premenopausal women. Menopause. 2011;18(10):1120-4.

Chon SJ, Choi YR, Roh YH, et al. Association between levels of serum ferritin and bone mineral density in Korean premenopausal and postmenopausal women: KNHANES 2008-2010. PLoS ONE. 2014;9(12):e114972.

About the Author

Mark Sisson is the founder of Mark’s Daily Apple, godfather to the Primal food and lifestyle movement, and the New York Times bestselling author of The Keto Reset Diet. His latest book is Keto for Life, where he discusses how he combines the keto diet with a Primal lifestyle for optimal health and longevity. Mark is the author of numerous other books as well, including The Primal Blueprint, which was credited with turbocharging the growth of the primal/paleo movement back in 2009. After spending three decades researching and educating folks on why food is the key component to achieving and maintaining optimal wellness, Mark launched Primal Kitchen, a real-food company that creates Primal/paleo, keto, and Whole30-friendly kitchen staples.

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29 thoughts on “Dear Mark: Iron Followup”

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  1. Regarding the increased risk of low iron for women, I must say as a woman, the idea that this increased risk is caused by menstruation never made sense to me. It’s really a very small amount of blood being lost (warning, some vivid imagery following). A soaked pad or tampon makes it seem more than it really is, and besides, not all of what we call “menstrual blood” is actual blood, there’s a lot of liquified endometrial lining, dead antibodies and some other stuff. I’m sure that many men used to lose more blood every month back when there was still a lot of warfare and violence around. Besides, how come anemia is common in children of both sexes, but not in adult men? Do boys somehow outgrow it when they hit puberty, while girls don’t? Turns out, yes, that’s pretty much exactly what happens. Contrary to popular belief, girls’ iron stores don’t decrease as they hit puberty, as one would expect if menstruation really had any significant effect of iron loss. Their iron levels remain the same after puberty, it’s boys’ iron levels that increase, due to testosterone surge.

    It seems like men have evolved to maintain higher iron levels as adults becuase they were more at risk of iron loss than women, which makes sense considering that prehistoric hunter-gatherer women used to not menstruate nearly as frequently as today, only had on average 4-6 children every 3-4 years, and due to better general health and muscular functioning, they probably had less postpartum bleeding than modern women, since the amount of blood lost depends on how quickly and effectively the uterus contracts to close the open blood vessels after placenta detaches, and how quickly wound clots and heals. I found that mine heal significantly faster on Paleo, and have seen many people say the same. So it seems to me that prehistorically, men were actually at bigger risk of iron deficiency and that’s why they evolved to have naturally higher iron stores, while women were less at risk and did not need to evolve such measures, but now that modern diet results in much less iron consumption, and with other contributing chronic health issues, this has reversed. Either way, it was found that 86% of anemic women had a gastrointestinal disease, and yet they often remain undiagnosed because doctors keep assuming it’s periods that make women anemic. Just another one of many ways that modern healthcare screws over women.


    1. Thank you Agne, for a wonderful overview! Yes, the assumption that women “bleed” during menstruation is incorrect. However, all our cells carry some iron, and clearing the uterine lining once a month does shed some iron. That said, I agree with you; I don’t think that is the reason so many women have low iron. I found that greater physical activity forced my iron levels to rise. Running worked particularly well.
      And as to why men evolved with higher iron stores, rather than warfare, I think men were more prone to injuries during their day-to-day work endeavors. We forget how very physical life was only a century or so ago…

  2. I’m going to check my iron levels, and also, for some strange reason I’m starting to itch all over …

  3. Thanks for all the iron and ferritin information, Mark.

    Regarding Ancestral Supplements Dessicated Beef Liver, Fakespot gives the Amazon reviews an F for honesty – according to their algorithms, only 27% of the reviews are valid.

    1. Well, that’s interesting. I was reading reviews of AS Beef Liver on Amazon, and I thought it must be an exceptional product to have over 1,000 mostly 5-star reviews.

      Thanks for sharing that.

    2. Susan B., I’m not an affiliate for Ancestral Supplements and have no business connection with them, so what I’m going to say has no benefit to me. Fakespot has been increasingly under fire by those questioning the legitimacy of its algorithms (and more). While it’s smart to do your research, I’d approach Fakespot reviews with skepticism. I eat liver and so have no need for a liver supplement, but I know many people who have good experiences with Ancestral Supplements.

    3. I believe Brian Johnson to be one of the most passionate and ethical people out there in the supplement world, I use his products and my positive reviews ARE authentic. Check out his web site, I think you will get a better feel for his philosophy and quality control protocols.

    4. We receive the occasional email about concerned customers questioning a certain website as it relates to the review authenticity of our products on Amazon. On a positive note, if one were to assume everything that this website says is 100% accurate, then I’d say that I’m a pretty proud papa considering that our nose-to-tail product line has “adjusted” scores of 4.7, 4.8, 4.9 and 5.0… we’ll take it; thank you very much!

      I really couldn’t be more proud that the reviews appear to be created in an “unnatural pattern” with unnatural characteristics. We are a small Texas-based business doing business the old fashioned way… no shortcuts… higher quality… higher standards… where customers come first. In a world where companies continue to put profits before people, I’m proud to stand out with unnatural patterns.

      If you’d like to know more, go here: If you don’t love your Ancestral Supplements, we’ll refund your money and buy you another product (on the house) that may be a better match for your unique needs. For those that have experience with our products, thank you for the love and support.

    5. Hey Susan. I’ve been an avid fan I’ve been supplements for about a year now. In fact I’m one of their reviewers. maybe I’m one of the 27% and maybe I’m not but I know what my experience has been with them. I’ve interacted with Brian on a regular basis and he has been nothing but genuine. I think the product is actually the real deal. I’m a chiropractor and I’ve been practicing for about 20 years now. I have found that their products have been just as good as advertised. I know that they have made a huge difference with my patients, as well as with my family. me, my wife, and my three kids all take the supplements I think they’re amazing.

    6. I can assure you that those reviews are legit. Ive been taking Ancestral Supplements for almost a year now and have seem immense health improvements. Not only have their products helped me with numerous ailments but their customer service is the beyond anything I’ve experienced from any company. It’s obvious they care a lot about their customers. I’d encourage you to try their products and see for yourself.

    7. I am a certified Primal Blueprint Health Coach. I have been referring my customers and personal training clients to Ancestral Supplements for the past year. I love their products. Many of my customers, as well as myself, have left reviews regarding their products and exceptional customer service. I can assure you that my review is not fake… and neither are those of my clients. If you are looking for a reputable desiccated organ meat company, Ancestral Supplements is top notch in my book.

    8. Hey Susan,
      I’ll give the short version of my love for Ancestral.
      A yr and a half ago I was not into my health. I ate what I thought was a “healthy” diet, and later found out was not even close. Almost 3 years ago I got rhabdomyolysis and was in so much reoccurring pain for the year to follow, that I had strayed away from my passion for working out. One day my BF tossed me a bottle of Ancestral Supplements Beef Spleen… and within 2 weeks the pain was gone. I couldn’t believe it… literally… so I became addicted to understanding why… and I found a new meaning for health and wellness.
      I reached out to Brian, just to say thank you. And he responded. A real person. I couldn’t believe it. He didnt care about my money… he was genuinely happy for me.

      All that to say… my review is on there… I’m a real person… and I mean 100% of what I say. My story is not one of a kind… there are beyond thousands of people like me (as you can read)… but their product is. And I thank God everyday for it.

    9. I can assure you that those reviews are 100% authentic. I’ve been taking their products for close to a year and not only have I seen immense health improvements but I couldn’t be more impressed with their customer service. They go above and beyond to take care of their customers and the reviews are clear proof of that. I’d definitely encourage you to try out their products and experience the level of quality and care they provide. They definitely aren’t faking it.

  4. I receive a newsletter from WebMD. Yesterday, it came with an article titled:

    “Plague: What to Know in 2019”

    Gosh, I hope all I needed to know about the plague in 2019 is that it still isn’t an issue! And… good news… it’s not a problem unless you are a cat in Wyoming. Here’s the article:

    Anyway, I thought it was funny that your post today is the second reference to plague I’ve seen within a 24 hour time period after not having heard anything about it since high school World History class.

  5. Because my insurance company didn’t want to pay for the hemochromotosis test, my doc suggested I simply start monthly phlebotomies for 3 months and then check the ferritin again. Fine by me. I really don’t care if I have the marker or not (no kids to pass it down to). So, he diagnosed me with “iron overload.”

    My phlebotomist told me I couldn’t donate blood anymore with that diagnosis, so I called the Red Cross and they confirmed it. Something to do with them not being able to prove you can’t pass along the tendency for iron overload in a blood donation.

    So now I’ll probably have to do regular phlebotomies and have all that blood just thrown away. Seems like such a waste.

    Also, what you said about ferritin being an acute phase reactant makes total sense to me. Back in October I had a bad flare-up of diverticulitis caused by listening to my vegan doctor (long story) recommending I do a vegan variation of keto. Within a week I was suffering from diverticulitis. Blood tests at that time had me at 520 ng/mL for ferritin (had been fairly steady in the 330s for several years before) and my C-Reactive Protein was 120!!! One month later they repeated the tests, and my ferritin was back down to the 330s, and the C-Reactive Protein was less than 1.

  6. Remember kids, you can make your own liver pills. I used take beef liver and cut it partially frozen into oblongs then fully freeze. Swallow whole like a big pill, blend into a smoothie or bone broth and as you get accustomed to the flavor you may be able to eat it on its own.

    The USDA says that beef that’s been frozen for two weeks is safe to eat raw so I never worried about this from a food safety perspective.

    Also chicken liver pate that is half chicken liver and half bacon is a useful liver gateway.

    1. For working liver painlessly into someone’s diet, try chopping a small amount very finely, and adding it into a good meatloaf. It is generally undetectable.

  7. I used to think that bleeding was pretty much always bad except for flushing out a wound.
    I think I’ve been eating a lot of iron lately so I’m off to see my trepanning therapist.

  8. I suffer with Crohns and have issues keeping my iron and ferritin at optimal levels. I used to get iron infusions since iron supplements did nothing except make my Crohns symptoms worse.

    The beef liver and spleen from Ancestral Supplements have been a godsend in getting my iron levels up and maintaining those levels. Their products are the real deal. I’d definitely check out the liver and spleen if you have issues with iron deficiency or just want to get more organs in your diet.

    1. Thanks PrettayyyGood, and thanks for the article, Mark. My ferritin has run below 15 for years. Maybe that’s why I’ve had trouble with energy levels on Primal/Keto eating. I love liver but haven’t been eating it lately. Didn’t know about the spleen connection………

      1. Hey Kari –

        Yeah my experience was that the liver wasn’t enough to get my ferritin levels where they needed to be. Once I added the spleen, I noticed a big difference in my energy levels and increased workout capacity at the gym. From what I understand, there are different mechanisms in the body that support iron health. Adding the spleen triggered those mechanisms in me to get my levels back to optimal. I still take the liver and beef organs every day and add the spleen back if I notice iron deficiency symptoms creeping back. I’d highly recommend both if you are having trouble getting your ferritin/iron to optimal levels.

  9. A number of years ago I asked my doctor for an iron panel. Ferritin was over 300 and transferrin saturation was really out of whack. I forgot about it for a couple years until until my 23 and me results indicated I have one c282y and one h63d. I asked my doc about it and she decided to refer me to a hematologist. The hematologist suggested I give blood. I am not allowed to because I lived in Europe during the mad cow disease era. To my surprise the hematologist suggest phlebotomies to bring and keep my ferritin under 100. It took 3 or 4 draws to get it down. That lasted almost a year. I recently had another draw and my ferritin is again under 100. Seems like a reasonable precaution to me.

    1. That’s good to know! I was wondering how long it would take for my ferritin to get back down to better levels. In the first blog on iron, several of the commenters said they felt so much more energetic after getting the ferritin down. Did you feel that, too?

  10. Thanks for your responses, everyone. I should have been more skeptical, especially since I’ve read many positive comments about Ancestral Supplements on this and other (trustworthy) sites. Also, I tried their desiccated liver and liked it – but being unduly influenced by fakespot, I ordered another brand this time, which I do not like as well.

    1. Well, in that case, I hope that you’ll allow us to extend our “Welcome Back” for tribe members. Please get in touch and reference this MDA article for a welcome back kit that includes some of my favorite ancestral things. I hope to hear from you soon.

  11. How about an extra-strength version of plague fleas? You could market it as a sort of panacea.
    In laboratory tests, after only three days of application, two thirds of our subjects never got sick again! Side effects may include feeling warmer than usual. Some patients report that they are “boiling”, especially in the groin and armpit regions.