Heather Bedard, C.H.E.
Word definitions
Hemoglobin – iron containing protein in red blood cells that carries oxygen from the lungs to the body’s tissues
Anemia – lack of enough healthy red blood cells to carry adequate oxygen to your body’s tissues
Hashimoto’s – an autoimmune disease affecting the thyroid gland
Red blood cell – type of blood cell made in the bone marrow
Hepcidin – an iron-regulating peptide hormone made in the liver. Controls the delivery of iron to blood plasma.
Many people report having an increase in negative health effects following COVID-19 infection. COVID-19 is the name given to a viral infection caused by SARS-CoV-2 which typically affects the respiratory tract. This article will focus on the effects of COVID-19 post infection, as it relates to individuals with a diagnosis of Hashimoto’s disease and the anemia that often results from Hashimoto.
Hashimoto’s is a disease that affects the thyroid gland, which is the gland that produces the hormones that regulate many different bodily functions. This disease is an autoimmune condition, which means that the body begins to attack itself, not being able to tell the difference between its own cells and foreign cells. This causes healthy cells to be destroyed affecting the homeostasis of the body. The hormones produced by the thyroid gland regulate many different bodily functions including how your heart beats…we’ll come back to that later.
One of the effects of the autoimmune attack on the body is low production of a hormone called erythropoietin, which stimulates the production of red blood cells by the bone marrow. Because of this suppressed activity, low levels of red blood cells are produced causing anemia. The symptoms of anemia vary, but are usually characterized by fatigue, weakness, irregular heartbeat, and shortness of breath.
This condition and the resulting anemia relate to COVID-19 in that bacterial and viral infections require the use of iron for the body’s immune response as well as the attack of the invading bacteria or virus. In individuals with an autoimmune condition such as Hashimoto’s, this pull of iron from the body’s already depleted levels can cause serious side effects. Pathogens utilize iron for DNA replication, transcription, and energy transfer, and send out siderophores to scavenge for iron in the body.[1] At the same time, the immune system needs iron for the proliferation if its cells particularly relating to the production of lymphocytes which play a big part in responding to infection.[2] This system is tightly regulated as iron levels that are too high will increase the rate of infection in the body as well as produce oxidative radicals, which are toxic to the body.
If an individual already has low levels of iron, this could put them at risk for severe side effects from COVID-19 infection.
COVID-19, particularly in Hashimoto’s patients, presents with high levels of inflammation as the body responds to the replication of the virus. This inflammation initiates the restriction of iron to inhibit viral replication as mentioned above, on top of the already low iron levels consequent of Hashimoto’s disease.[3] A particularly concerning side effect of this, is the potential for dyspnea (shortness of breath). To understand the importance of this, we first need to understand the role that iron plays in the respiratory system.
Red blood cells carry oxygen from the lungs to the rest of the body by the function of a protein called hemoglobin. When the production of red blood cells is affected by an autoimmune condition such as Hashimoto’s, there aren’t enough red blood cells to carry this oxygen efficiently, resulting in fatigue and shortness of breath. This low level of healthy red blood cells results in anemia. Some people may think this fatigue or weakness is from a problem with the lungs post-COVID, when it may the body’s inability to deliver the oxygen to the physical systems.[4] This experience can be very disheartening for individuals who are struggling with decreased physical stamina.
The lower levels of oxygen in the tissues then requires the heart to overcompensate. This can result in irregular heartbeat or palpitations. The heart is trying to circulate the blood faster to utilize as much of the oxygen as possible. One study showed that patients treated with erythropoietin (the hormone that regulates the production of red blood cells) have been shown to improve their cardiovascular output.[5] It is this function that shows that cardiovascular output and iron levels can be related. While there has been some work done correlating the cardiovascular issues with anemia, more randomized, controlled trials need to be done. [6],[7]
There can be many factors determining the response of the body to COVID-19 inflammation as it relates to anemia. Firstly, as the body already has low stores of iron, the immune response can express itself in severe anemia causing reduction of oxygen and heart palpitations. Individuals that struggle with Hashimoto’s may already present with heart palpitations as it can be a symptom of Hashimoto’s without the introduction of COVID-19. Secondly, the anemic response can also be characterized as anemia of inflammation (also called anemia of chronic disease), which is already at work in the body due to Hashimoto’s.[8] Potential responses to this presentation would be addressing the underlying cause of inflammation, which will then improve this diagnosis. Coupling the inflammation of Hashimoto’s with COVID-19 inflammation can be expressed in the patient with exacerbated symptoms.[9] The effects of these symptoms, post-COVID, can affect their lives for many months. There are a few steps these individuals can take to resolve their anemia and find relief from symptoms such as dyspnea and heart palpitations if this is the true cause of their post-COVID symptoms (also referred to as long-haul COVID).
Firstly, stomach acidity affects the absorption of iron. This can be controlled by bringing down inflammation levels and taking a probiotic to restore the microbiome. Increasing the amounts of fruits and vegetables in the diet and reducing meat intake can also help to reduce inflammation caused by diet. In addition, eliminating oils and all dairy will help immensely because both food groups cause inflammation in the body.
Secondly, once the gut microbiome is recovering, do what you can to increase your iron absorption. Vitamin C helps with absorbing iron, while the elimination of oils and dairy will help you to avoid foods that prevent absorption. Cantaloupe, citrus fruits, bell peppers, and tomatoes have a good amount of vitamin C.
Thirdly, do not take iron supplements. These supplements can raise iron levels which in turn can cause the body to restrict iron. Too much iron is toxic for the body, and it will do what it needs to do to keep it regulated. It is best to ingest iron through diet as differing components of the food, such as phytic acid, will ensure that iron levels do not get too high, and eating whole foods is the best way for the body to extract the nutrients it needs.
The recommended dietary allowance (RDA) of iron for men of all ages is 8mg. The same goes for postmenopausal women. The RDA for premenopausal women is 18mg. Eating fruits and veggies with a high iron content will help you to achieve this easily. You’ll find high iron levels in apples, bananas, spinach, and organic soybeans.
For individuals with Hashimoto’s that are suffering from post-COVID effects like fatigue and heart palpitations, it may be comforting to know that there may not be any lung or heart damage, but instead they may be able to reduce or eliminate their symptoms by addressing anemia through nature’s medicine of fruits and vegetables!
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[1]Cherayil BJ. The role of iron in the immune response to bacterial infection. Immunol Res. 2011;50(1):1-9. doi:10.1007/s12026-010-8199-1
[2]Soyano A, Gómez M. Participación del hierro en la inmunidad y su relación con las infecciones [Role of iron in immunity and its relation with infections]. Arch Latinoam Nutr. 1999;49(3 Suppl 2):40S-46S.
[3]Igor Theurl, Elmar Aigner, Milan Theurl, Manfred Nairz, Markus Seifert, Andrea Schroll, Thomas Sonnweber, Lukas Eberwein, Derrick R. Witcher, Anthony T. Murphy, Victor J. Wroblewski, Eva Wurz, Christian Datz, Guenter Weiss; Regulation of iron homeostasis in anemia of chronic disease and iron deficiency anemia: diagnostic and therapeutic implications. Blood 2009; 113 (21): 5277–5286. doi: https://doi.org/10.1182/blood-2008-12-195651
[4] https://www.ahajournals.org/doi/10.1161/01.CIR.8.1.111
[5]Portolés J, Torralbo A, Martin P, Rodrigo J, Herrero JA, Barrientos A. Cardiovascular effects of recombinant human erythropoietin in predialysis patients. Am J Kidney Dis. 1997;29(4):541-548. doi:10.1016/s0272-6386(97)90335-8
[6]Pereira AA, Sarnak MJ. Anemia as a risk factor for cardiovascular disease. Kidney Int Suppl. 2003;(87):S32-S39. doi:10.1046/j.1523-1755.64.s87.6.x
[7]Hegde N, Rich MW, Gayomali C. The cardiomyopathy of iron deficiency. Tex Heart Inst J. 2006;33(3):340-344.
[8]Nemeth E, Ganz T. Anemia of inflammation. Hematol Oncol Clin North Am. 2014;28(4):671-vi. doi:10.1016/j.hoc.2014.04.005
[9]Sonnweber, T., Boehm, A., Sahanic, S. et al. Persisting alterations of iron homeostasis in COVID-19 are associated with non-resolving lung pathologies and poor patients’ performance: a prospective observational cohort study. Respir Res 21, 276 (2020). https://doi.org/10.1186/s12931-020-01546-2