Iron Overload: A New Perspective

Mar 15, 2024 | Evidence Based, Inflammation, Nutrients, Nutrition, Science-Based, Wellness

Iron overload is a condition traditionally linked to a host of health issues ranging from liver damage and diabetes to heart problems and distinct changes in skin coloration in severe cases. Symptoms of moderate iron overload include fatigue, joint pain, mood swings, hair loss, and more. The repercussions extend to an elevated risk of neurodegenerative diseases, higher cholesterol levels, and an overall acceleration of the aging process. This understanding is widespread within both medical and health wellness communities.

However, a deeper insight reveals that our grasp on iron’s health implications begins to unravel when considering manganese’s significant role. Manganese overload itself can lead to a myriad of neurological symptoms, including headaches, irritability, and more severe conditions such as impaired balance and Parkinson’s-like symptoms.

Interestingly, genetic factors play a crucial role in iron regulation. Approximately 9% of the global population carries at least one genetic variation affecting iron metabolism, often related to the HFE gene. These variations, particularly the C282Y and H63D variants, predispose individuals to iron overload, with men being more susceptible and women experiencing a delayed onset due to menstrual iron loss.

While conventional medicine typically addresses only those with full-blown hemochromatosis—found in 1 out of every 200 to 500 individuals—functional medicine takes a broader view. It focuses on optimizing iron levels among the 9% who are genetically predisposed to iron handling impairments. This approach acknowledges that even moderate levels of iron overload can contribute to fatigue, elevated cholesterol, diabetes, and an overall faster pace of aging, highlighting the importance of a nuanced understanding of iron and manganese in our health.

Iron and Manganese Overload: Unraveling the Connection

The common strategies to combat iron overload might not be as straightforward as previously thought. The genetic impairments linked to iron overload are also associated with manganese overload. This dual impact significantly complicates traditional approaches like blood donation or dietary restrictions.

Blood donation, a commonly recommended remedy for reducing iron levels, does not address manganese, which is predominantly stored in the liver, not the bloodstream.

Consequently, while donating blood may lower iron levels, it inadvertently heightens the risk of manganese toxicity.

Similarly, dietary strategies aimed at reducing iron intake, such as limiting meat consumption in favor of vegetables, inadvertently increase manganese exposure. This is because reducing dietary iron enhances manganese absorption and retention, due to decreased competition for transport mechanisms.

Moreover, chelation therapy, often touted for its potential to remove heavy metals from the body, poses risks of inducing deficiencies in a wide range of essential minerals, further complicating the situation.

The intertwined nature of iron and manganese metabolism suggests that the well-intentioned measures aimed at mitigating iron overload could inadvertently elevate the risk of manganese toxicity. This revelation underscores the complexity of navigating these nutritional challenges and highlights the need for a nuanced understanding and approach to managing both iron and manganese levels.

So, facing this intricate interplay between iron and manganese, what strategies can be adopted to ensure balance and prevent toxicity? The solution lies in a more sophisticated approach to managing mineral balance, one that considers the unique interactions between iron and manganese in the body.

Navigating Iron and Manganese Overload with Precision Diet

For those genetically predisposed to iron overload, a meticulous dietary strategy focusing on manganese restriction is essential. Limiting manganese intake to no more than two milligrams daily, and even lowering it to one milligram in the four weeks following a blood donation, can significantly mitigate the risk of manganese toxicity. Achieving this balance requires a careful selection of dietary sources, emphasizing a proportion where iron intake consistently surpasses manganese consumption by at least a fourfold margin.

Reducing dietary manganese effectively involves favoring certain foods over others. Opt for carbohydrates from sources with minimal manganese content, such as milk, potatoes, and a variety of fruits including apples, pears, oranges, and bananas, to name a few. These choices help maintain the delicate balance between iron and manganese levels in the body.

The necessity of such dietary adjustments correlates directly with the extent to which genetic predispositions impact your health. Whole genome sequencing emerges as a pivotal resource in this context, offering a comprehensive overview of potential hemochromatosis-related genetic variants. This insight, combined with a thorough nutritional screening and the use of strategic algorithms, lays the groundwork for a tailored approach to managing iron and manganese levels, preempting overload and safeguarding health.

The Complex Interplay Between Manganese and Iron in Liver Health

In 1967, researchers at the Walter Reed Army Institute of Research embarked on a study that would illuminate the intricate relationship between manganese and iron in the context of liver health. Their investigation into the manganese content in liver tissues from individuals who succumbed to hemochromatosis compared to those who died from myocardial infarction revealed a significant discovery: livers affected by hemochromatosis contained double the manganese of those in the control group.

This finding was driven by a critical understanding that bleeding and iron deficiency enhance manganese absorption in rats, hinting at shared transport pathways between the two minerals. This shared pathway led researchers to speculate that the iron overload characteristic of hemochromatosis might also predispose individuals to manganese overload. Given that iron overloading alone does not typically result in liver cirrhosis in rats—nor do iron infusions in humans—yet manganese injections in rats do cause liver cirrhosis, a new perspective began to emerge.

Humans with hemochromatosis often develop liver cirrhosis, a condition marked by irreversible liver scarring that severely disrupts liver function. The hypothesis that manganese overload, concomitant with iron overload, could be a driving factor behind this cirrhosis gained traction through these findings.

Further research into liver diseases deepened this complexity. While rats exhibit fibrosis—a precursor to cirrhosis—from iron overload, it’s the specific mutations in the SLC30A10 gene, responsible for manganese efflux from cells, that underscored the link between manganese accumulation and cirrhosis. Humans with mutations in SLC30A10 exhibit normal or low iron levels but experience toxic manganese build-up in various tissues, including the liver and brain, often leading to cirrhosis.

While iron overload may independently suffice for cirrhosis development in humans, it invariably coexists with manganese overload, underscoring manganese’s significant, if not central, role in the cirrhosis associated with hemochromatosis. This intertwining of manganese and iron in liver disease highlights the need for a comprehensive approach to understanding and managing these mineral imbalances.

Iron, Manganese, and Their Intricate Transport Dynamics

The research journey, unfolding over decades, brings to light the complex interplay between iron and manganese within the human body, particularly highlighting shared transport mechanisms that significantly impact absorption and distribution. Various experiments with rats suggested a shared transport system that becomes upregulated in states of iron deficiency, pointing to a competitive interaction between these minerals that, except at high doses, seemed of limited relevance.

Through mouse models, the study illustrated how the loss of the HFE gene, a key player in hereditary hemochromatosis, leads to increased manganese absorption both from the gastrointestinal tract and, notably, via nasal routes. When manganese was introduced directly into their stomachs, its presence in the bloodstream saw a significant uptick, by 56%. Intriguingly, while iron administration influenced its deposition predominantly in the liver and heart, manganese behaved differently once in the bloodstream, hinting at distinct transport and deposition pathways for these minerals beyond their entry point into the body.

However, a closer inspection of the data hints at a potential for increased manganese deposition in the brain and heart, although these observations did not reach statistical significance within the study’s scope. The researchers did not explore manganese accumulation in the liver following oral intake—an essential consideration, given that nutrients ingested orally first pass through the liver via the portal vein before entering general circulation. This route suggests that the liver might experience a higher manganese load than what is reflected by blood levels alone, implying an underestimation of liver manganese accumulation.

The absence of the HFE gene seemed to reroute manganese preferentially towards the brain, diminishing its presence in the bloodstream. This finding raises crucial questions about the role of genetic factors in mediating the transport and deposition of manganese, particularly concerning brain health and the potential implications for individuals with hereditary hemochromatosis.

Collectively, these findings underscore the need for further research into the shared transport mechanisms of iron and manganese, the genetic influences on mineral absorption and distribution, and the implications for health, particularly in conditions like hemochromatosis where these dynamics are altered. Understanding these complex interrelations is vital for developing more nuanced and effective strategies for managing iron and manganese levels in affected individuals.

Research into the dynamics between iron and manganese absorption, as well as their genetic implications, brings forth intriguing insights, albeit with conflicting findings across studies. An older study from 2001 indicated that the absence of the gene for beta-2-microglobulin, interacting with HFE, doesn’t affect manganese balance, contrasting with later findings that suggest a significant role for HFE mutations in manganese management. Notably, dietary conditions, particularly the levels of iron and manganese intake, might influence these outcomes, hinting at the necessity of a stressed regulatory system to unveil the effects on manganese.

Further exploration reveals the nuanced effects of HFE mutations on manganese distribution within the brain. For example, in mice, the absence of HFE alters the behavioral and neurological impacts of manganese exposure, with variations observed between inhalation and dietary intake modes. These distinctions underscore the complexity of manganese’s role in neurological health, influenced by genetic factors like HFE mutations.

Moreover, the role of ferroportin, a transporter traditionally linked to iron export from intestinal cells and storage cells into the bloodstream, extends to manganese regulation. Mutations in the ferroportin gene, associated with a form of hemochromatosis, impair cellular manganese export, heightening susceptibility to oxidative stress. This connection suggests a delicate balance between iron and manganese within the body, influenced by genetic mutations and dietary intake.

These findings underscore a complex interplay between genetics, dietary intake, and mineral balance within the body. The impact of HFE and ferroportin mutations on manganese distribution and toxicity highlights the need for further research to understand the implications for health, particularly in conditions like hemochromatosis where mineral regulation is disrupted.

Also, there is a process known as the fenton reaction and ferroptosis that should also be taken into consideration. I talk about that in more detail in this blog.  This is a big driver of lipid peroxidation and can actually contribute to endogenous oxalate production.

Patients with hemochromatosis, a condition characterized by iron overload, exhibit significantly higher blood manganese levels compared to healthy individuals. These observations suggest that while the former group may experience a broader dysregulation affecting blood manganese, the latter’s manganese might be preferentially distributed to the liver and brain, reflecting insights gained from animal models.

Additionally, research in communities exposed to ferromanganese emissions, such as those living near a refinery in Marietta, Ohio, reveals genetic associations with manganese accumulation. Individuals carrying the C282Y allele of the HFE gene, one of the genetic variants linked to hemochromatosis, showed a 45% increase in hair manganese, indicating a potential genetic predisposition to higher tissue manganese accumulation. Although findings related to the H63D allele, a less severe variant, showed an increase in hair manganese, they did not reach statistical significance, suggesting the need for larger studies to clarify these associations.

These human studies reinforce the notion that genetic factors related to iron metabolism significantly influence manganese levels in the body. The divergence in manganese distribution based on genetic variations underscores the importance of considering individual genetic backgrounds when assessing risk for manganese overload and its health implications. This evidence further supports the need for tailored approaches to managing mineral imbalances in individuals with genetic predispositions, highlighting the intricacy of mineral homeostasis and its implications for health.

Understanding the complex mechanisms behind manganese transport and its implications for health reveals the intertwined nature of mineral absorption and metabolism in the body. The transport proteins DMT1 and ferroportin play key roles in absorbing manganese and non-heme iron from food, illustrating the shared pathways for these minerals. Hepcidin, a hormone regulated primarily by iron status, influences both iron and manganese transport, highlighting the impact of genetic and environmental factors on mineral balance.

The connection between iron overload conditions, such as hemochromatosis, and increased risk of manganese overload emphasizes the need for cautious management of dietary manganese intake. This is particularly crucial for individuals with genetic predispositions to iron overload, as interventions aimed at reducing iron levels, like blood donation, can inadvertently enhance manganese absorption and exacerbate risks associated with manganese overload.

Neurotoxicity, stemming from excessive manganese accumulation, particularly in the liver and brain, presents a significant health concern. Given this, limiting manganese intake to around 2 milligrams per day, maintaining a minimum iron-to-manganese intake ratio of 4:1, and focusing on dietary adjustments rather than solely on iron reduction strategies become essential steps for those at risk.

The nuanced relationship between iron and manganese in the body underscores the importance of a holistic approach to managing mineral imbalances, particularly in individuals with hemochromatosis-related mutations. As research continues to unravel the complexities of manganese transport and its health impacts, these insights serve as a guide for minimizing the risks associated with manganese overload through informed dietary and lifestyle choices.


 Navigating the intricacies of iron and manganese management in the context of genetic predispositions requires a multi-faceted approach:

  1. Whole Genome Sequencing: Begin by identifying any relevant mutations in genes such as HFE, HFE2, HAMP, TFR2, and SLC40A1 that could indicate a predisposition to iron overload.  Mutations in SLC30A10 can also predispose to improper manganese chaperoning. This step is foundational in tailoring your approach to managing mineral imbalances.
  2. Comprehensive Nutritional Screening: Utilize comprehensive screenings to assess iron status thoroughly. I like to use a combination of Nutreval/metabolomix, HTMA and blood chem testing to determine the presence and extent of iron overload.
  3. Assessing Manganese Overload: Given genetic predispositions and blood marker data collected before any blood donation, it’s prudent to assume that manganese overload mirrors the degree of iron overload. This proactive stance helps in managing potential risks associated with manganese toxicity.
  4. Dietary Management: For those identified as having a predisposition to iron overload, it’s crucial to limit dietary manganese intake to no more than 2 milligrams per day, ensuring that iron intake is at least four times the manganese intake. This strategy helps mitigate the risks associated with manganese overload while addressing iron imbalances.
  5. Post-Blood Donation Caution: In the weeks following a blood donation, additional caution is advised. Consider reducing manganese intake further to one milligram per day during this recovery period to prevent exacerbating manganese overload.
  6. Dietary Adjustments for Manganese Restriction: Achieving manganese restriction involves a dietary preference for animal foods over plant foods and avoiding high-manganese foods like mussels. Focus on sources of carbohydrates that maintain a favorable carbohydrate-to-manganese ratio, such as milk, potatoes, and various fruits.

This comprehensive strategy underscores the importance of genetic insights, precise nutritional assessment, and informed dietary choices in managing iron and manganese levels for those at risk of overload due to genetic factors. By adhering to these recommendations, individuals can navigate the complex dynamics of mineral balance and minimize the health risks associated with these imbalances.

Introduction to Genetic Predispositions

  • Key Genes: The genes essential to iron and manganese homeostasis include HFE, HFE2, HAMP, TFR2, TF, FTL,  SLC30A10 and SLC40A1. These genes play a crucial role in the body’s iron handling and can significantly influence the risk of overload conditions.

Diagnosing Overload through Transferrin Saturation

  • Transferrin Saturation Indicators: A transferrin saturation level above 40% is a strong indicator of predisposition to iron and manganese overload. This measurement serves as an early warning sign, prompting further investigation and intervention.

Genetic Variants and Their Implications

  • Variant Strengths: The genetic landscape of iron and manganese overload is diverse. Having two copies of the C282Y variant is considered the strongest risk factor, while one copy of C282Y or two copies of H63D is of intermediate risk, and one copy of H63D represents the weakest risk.
  • Interpreting Variant Magnitude: The strength of these variants directly correlates with the likelihood and severity of overload conditions. Higher iron saturation levels further confirm the extent of the issue.

Ferritin as an Oxidative Stress Marker

  • Interpreting Ferritin Levels: While ferritin levels provide insights into the body’s iron storage, they should not be solely relied upon to diagnose iron overload. Instead, they offer clues about the duration and potential damage caused by excessive iron, including oxidative stress and inflammation.

Protocol Considerations Based on Genetic and Blood Test Data

  • Agreement Between Genetics and Blood Tests: When genetic predispositions and iron saturation levels align, it presents a clear indication to follow a specific management protocol.
  • Navigating Discrepancies: In cases where genetic and blood test results do not match, the situation requires a nuanced approach. It’s important to monitor your body’s responses and assess the utility of the protocol on an individual basis.

Monitoring for Overload Symptoms

  • Iron Overload Symptoms: Symptoms such as fatigue, joint pain, and increased cholesterol levels signal iron overload. These conditions not only diminish quality of life but also elevate the risk for serious diseases like Alzheimer’s and Parkinson’s.
  • Manganese Overload Symptoms: Early signs include headaches and irritability, progressing to more severe neurological issues such as loss of balance and Parkinson’s-like symptoms.

To effectively manage iron and manganese overload, a strategic approach focusing on diet modification and blood donation can be beneficial. Here’s a concise guide on how to navigate this process:

Modulate Vitamin and Mineral Intake:

    • Aim to limit your manganese intake to no more than 2 milligrams per day. This can be achieved by:
      1. Increasing consumption of animal foods, except mussels, prioritizing meats and dairy products from land animals over plant-based sources.
      2. Adopting a high-fat, low-carb diet, as fats and oils typically contain minimal manganese.
      3. Choosing low-manganese plant foods, with corn, white potatoes, and white rice being excellent staples. Other acceptable choices include apples, pears, oranges, bananas, and grapes. Always aim to maintain an iron-to-manganese intake ratio of at least 4:1.

Blood Donation Strategy:

Consider donating blood, undergoing medical phlebotomy, or completing laboratory tests that in total draw approximately 550 milliliters of blood. Immediately following blood removal, reduce your manganese intake to 1 milligram per day for the first week, then gradually increase to 2 milligrams over the following seven weeks.

Monitor and Adjust Based on Iron Markers:

      • Eight weeks post-blood removal, reassess your iron markers. The target is to maintain transferrin saturation within the 30-40% range and reduce ferritin to at least 150 micrograms per liter. Depending on your health metrics, consider further lowering ferritin to below 60 or even 20 micrograms per liter. Default to donating blood bi-annually, adjusting frequency as needed based on transferrin saturation and ferritin levels.

Continuous Management:

Repeat the blood removal cycle as necessary to keep iron markers within the desired range and to optimize health metrics. Persist with a diet low in manganese to manage overload effectively.

This regimen emphasizes a balanced approach to managing iron and manganese levels through dietary choices and blood donation, tailored to individual health needs and genetic predispositions.

When managing iron overload, it’s crucial to approach dietary and treatment options with caution. Here are some strategies to avoid and the reasons why:

Low-Iron Diets:

    • While reducing iron intake might seem intuitive for managing iron overload, it’s important not to overly restrict iron without considering the broader nutritional impact. Iron is essential for numerous bodily functions, and indiscriminate reduction can lead to other health issues.

High-Phytate Diets:

    • Diets rich in phytates can decrease iron absorption but may also impede the absorption of other crucial minerals like zinc. Balancing mineral intake is key to maintaining overall health, so high-phytate diets should be approached with caution.

Chelation Strategies:

    • Chelation therapy can be effective for removing excess iron from the body. However, the non-specific nature of some chelators can also lead to deficiencies in other important minerals like zinc. Always undertake chelation under medical supervision and consider the potential side effects.

Considerations for Specific Foods and Nutrients:

  • Liver: Although liver is a rich source of iron, it also contains valuable nutrients such as copper, vitamin A, and vitamin B12. Limiting liver intake to 4-8 ounces weekly can balance iron intake while still providing essential nutrients.
  • Phytates: Use phytate-containing foods judiciously. They may help lower iron absorption but could also cause deficiencies in zinc and other minerals. It’s a balancing act that requires careful dietary planning.

When assessing for iron and potentially associated manganese overload through bloodwork, it’s imperative to approach the testing in a baseline state for the most accurate and revealing results. This approach ensures that any predisposition to manganese overload, which might be masked in standard blood manganese levels, is indirectly identified through iron status indicators. Here’s a step-by-step guide on how to proceed:

  1. Baseline Testing:
    • Aim to conduct your lab work before any blood donation or iron-lowering intervention. If you’ve already initiated such activities, refer back to your earliest lab results before these interventions for the clearest insight into your natural predisposition.
  2. Transferrin Saturation Calculation:
    • This crucial marker can be calculated using two formulas based on the units of serum iron and transferrin (TF) in your lab results:
      • For μg/dl of serum iron: Serum iron (μg/dl) / TF (mg/dl) × 70.9
      • For μmol/l of serum iron: Serum iron (μmol/l) / TF (mg/dl) × 398
  1. Iron Panel and Transferrin Saturation:
    • The iron panel provides serum iron and iron saturation levels. By measuring transferrin in the same blood sample, you can compare these values to assess their consistency. Discrepancies might arise due to abnormal albumin levels, but if they generally track well together, future tests might forego the transferrin measurement for the less costly iron saturation.
  2. Ideal Transferrin Saturation Range:
    • The transferrin saturation should ideally fall between 30% and 40%. Levels significantly above 40% indicate a predisposition to both iron and manganese overload, with measurements consistently above 40%—particularly if trending upward—offering stronger evidence of this condition. A single reading above 45% strongly suggests overload, and one above 50% confirms it.

By carefully following this process, individuals can accurately assess their risk for iron and manganese overload, allowing for more informed and effective management strategies.

Understanding the genetic underpinnings of iron overload is crucial for effectively managing and treating the condition. The genes most commonly associated with iron overload include a variety of mutations that can significantly influence iron absorption and storage in the body. Here’s a detailed breakdown:

  1. Prevalence and Key Mutations:
    • Approximately 9% of the global population carries at least one genetic variant associated with iron overload. This high prevalence is largely attributed to two specific alleles in the HFE gene: the more severe C282Y allele and the less severe H63D allele.
  2. Beyond Common Variants:
    • For individuals who exhibit signs of iron overload without carrying the C282Y or H63D alleles, there exists a broader spectrum of genetic mutations that might be involved. With over 215 variants linked to iron handling issues, exploring these less common mutations becomes essential for a comprehensive assessment.
  3. Identifying Rare Mutations:
    • Not all mutations are easily identifiable with standard rs numbers, a common reference system for genetic variants. In such cases, analyzing the raw data file of your genome for specific nucleotide positions within the relevant genes is necessary. A useful PDF from a reputable source can guide this process, highlighting both pathogenic and possibly pathogenic mutations, with a classification number of “2” indicating a pathogenic status.
  4. Interpreting Genetic Ambiguities:
    • Genetic data can sometimes be ambiguous due to the complex nature of hereditary traits and the influence of environmental factors. When genetic findings align with clinical bloodwork indicating iron overload, this convergence of evidence strengthens the case for targeted intervention.
  5. Actionable Insights:
    • For individuals with confirmed genetic predispositions and clinical evidence of iron overload, adopting strategies to manage iron intake and absorption becomes crucial. This includes dietary adjustments, regular monitoring of iron and manganese levels, and possibly blood donation or medical phlebotomy under the guidance of a healthcare professional.

Understanding your genetic predisposition to iron overload empowers you to take proactive steps towards managing your health, preventing potential complications associated with excessive iron accumulation.

When the anticipated changes in ferritin and transferrin saturation levels aren’t observed after implementing interventions aimed at managing iron overload, it suggests that the situation might be more complex than initially thought. Here’s a step-by-step guide on what to do in such scenarios:

  1. Broaden the Diagnostic Lens:
    • If ferritin levels remain high despite a reduction in transferrin saturation, or if transferrin saturation levels don’t stabilize within the expected range, it’s time to consider other potential factors beyond iron overload. This includes examining for deficiencies, toxicities, and other imbalances that might be influencing the body’s oxidative stress levels or inflammatory response.
  1. Conduct Comprehensive Nutritional Screening:
    • Utilize comprehensive nutritional screening to detect any deficiencies or excesses that might be contributing to the observed blood marker behaviors. Pay particular attention to oxidative stress indicators and the balance of antioxidant nutrients.
  1. Investigate Inflammation and Oxidative Stress:
    • If the C-reactive protein (CRP) level is elevated, it’s crucial to consult with a healthcare provider to identify any underlying medical conditions causing inflammation. If CRP levels are normal, focus on addressing oxidative stress and ensuring a balanced intake of antioxidants.
  1. Assess Copper Status and Metabolic Function:
    • Difficulty in maintaining stable transferrin saturation levels may also be linked to copper status or issues related to copper metabolism and energy metabolism. These aspects can be evaluated through comprehensive screening for energy metabolism. I like to combine blood chemistry testing with HTMA for a copper assessment.
  1. Monitor for Iron and Manganese Deficiency:
    • Vigilance for symptoms of iron deficiency (e.g., fatigue, pale skin, cold extremities, hair loss) is necessary to prevent excessive depletion from blood removal strategies. Similarly, watch for signs of manganese deficiency, such as lower bone mineral density and mood disturbances, especially if dietary manganese has been significantly restricted.
  1. Balance Intervention and Health Monitoring:
    • The goal is to find a balance that manages iron and manganese levels without tipping into deficiency. Regular monitoring and adjustments based on health metrics and blood markers are key to this process.

By adopting a comprehensive and nuanced approach, it’s possible to address the complexities of managing iron overload and its associated factors effectively. Collaboration with healthcare professionals, detailed monitoring, and personal vigilance are essential components of successful management strategies.

In the Root Cause Investigation Program, we can run the necessary testing to identify if you have at risk for iron disorders.


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