The Analyst™

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  Anemia (Iron deficiency)  
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Signs, symptoms and indicators | Conditions that suggest it | Contributing risk factors | Other conditions that may be present | Recommendations


Iron deficiency anemia is the most common form of anemia. Iron is an essential component of the hemoglobin molecule: without iron the bone marrow is unable to produce hemoglobin. The red cell count falls and those which do enter circulation are smaller than normal (microcytic) and lacking in hemoglobin, hence they are pale (hypochromic). The deficiency of iron may be absolute (there is no iron available for the production of hemoglobin - this is true iron deficiency anemia) or relative (the iron is present in storage in the marrow but other reasons prevent its incorporation into red blood cells). Iron deficiency anemia is usually easy to resolve.

If iron deficiency is low, a doctor my simply recommend an increase in iron rich foods - such as red meats and dark, leafy greens. For more severe iron deficiency or for individuals with increased iron needs (like vegetarians, pregnant women and endurance athletes) iron supplements may be recommended. An anemia that does not respond as expected may require the help of a hematologist and additional testing.
Development of anemia
It must be remembered that anemia in iron deficiency develops slowly. The type and severity of the anemia varies with time. The development stages are:
   1. Depletion of iron stores, decreased ferritin levels, no anemia
   2. Increased transferrin levels, no anemia
   3. Fall in serum iron, no anemia
   4. Development of normocytic, normochromic anemia
   5. Development of microcytic, hypochromic anemia.

Iron requirements
The average amount of iron in the average adult male is 4gm and in the average adult female 2.5gm. The normal North American diet contains approximately 15-20mg of iron per day. Most is present in meat and green vegetables; approximately 1.0mg is absorbed each day and just about an equal amount is lost in feces and sweat. As a result, the average adult's iron intake is in delicate balance, but is of little consequence as there is slightly more iron absorbed than lost and a store of iron is gradually accumulated. If for some reason the rate of iron loss increases, these stores can be depleted and an absolute iron deficiency develops. Such a deficiency requires large doses of supplemental iron to resupply the body stores and sufficient monitoring to prevent iron overload.

Iron absorption is increased by the presence of sufficient stomach acid, glucose, fructose, some amino acids and ascorbic acid (vitamin C). These substances aid in the absorption process by either reducing ferric iron to the ferrous state or by helping bind the iron to the mucosal cell receptor sites. The established benefit of vitamin C has resulted in many iron supplements being manufactured with this vitamin present. Heme iron (iron from meat myoglobin) is 10 times more easily absorbed than elemental iron, or iron from non-meat sources. Iron absorption is decreased by the presence of phosphate, bicarbonate or bile acids. Thyroid medication and iron supplements should be taken at different times of the day.

The adult male requires approximately 1.0mg per day, just enough to cover normal iron loss. The adult female requires approximately 2.0mg per day, enough for daily loss and menstruation. Pregnant females require approximately 3.0mg, enough for normal, ongoing loss and fetal requirements. Children require approximately 2.0mg, enough for normal loss and extra to produce some residual iron stores and allow for increasing red cell mass.

Causes of iron deficiency
   - Diet - uncommon except in children
   - Failure to absorb
   - Increased utilization (for example pregnancy, adolescent growth)
   - Atransferrinemia
   - Failure to utilize (for example lead poisoning, chronic diseases)
   - Blood loss.
Chronic blood loss is the most common cause of iron deficiency anemia.


Signs, symptoms & indicators of Anemia (Iron deficiency):
Lab Values - Cells   Low red blood cell count
  In iron deficiency anemia the RBC count may be normal or elevated, though it is typically low.

  Microcytic red cells
  (Very) low hemoglobin levels
  (Very) low hematocrit
  (Very) low MCH
  Decreased MCH is associated with microcytic anemia and increased MCH is associated with macrocytic anemia.

  Elevated ESR or High ESR

  Macrocytic red cells
  Normal/high hematocrit
  High/normal hematocrit
  High/normal hemoglobin levels
  Normal/elevated hemoglobin levels

Lab Values - Common

  Rapid pulse rate

Symptoms - Bowel Movements

  Significant/frequent blood in stools
  Black or tarry stools
  Gradual blood loss from the GI tract may result in an iron deficiency anemia.

Symptoms - General

  Constant fatigue
  Major fatigue for over 12/major fatigue for over 3/minor fatigue for over 3 months

  Not having constant fatigue

Symptoms - Metabolic

  Low stamina
  Low/definitely normal body temperature

Symptoms - Mind - General

  Short-term memory failure
  See the link between Iron Deficiency and Poor Memory.

Symptoms - Nails

  Backward-curving fingernails
  Nails that are mostly white or nails turning white towards the ends

Symptoms - Respiratory

  Easily being short of/always being short of breath

Symptoms - Skin - General

  Lighter/paler skin color
  When the level of oxygen-carrying red blood cells drops, the body must adapt to lower levels of oxygen. By drawing blood away from organs that can function with less oxygen, the body can supply the two most important organs, the brain and the heart, with enough oxygen to survive. Because skin is one of the first major organs to sacrifice blood supply, anemic patients are characteristically pale.

Conditions that suggest Anemia (Iron deficiency):
Metabolic   Headaches, Migraine/Tension


  Restless Leg Syndrome (RLS) / Periodic Limb Moveme
  Iron may also represent a primary factor in the development of RLS, as suggested by pathologic and brain imaging studies. However, the method by which dopamine and iron - and probably other compounds - interact to generate the circadian pattern in the occurrence of RLS symptoms remains unknown. Secondary causes of RLS are associated with dopamine receptor blockers, end-stage renal disease, fibromyalgia, iron deficiency, discontinuation of opiates, pregnancy, use of spinal anesthesia, and uremia.


  Cold Hands and Feet

Symptoms - Cardiovascular

  History/absence of iron deficiency anemia

Risk factors for Anemia (Iron deficiency):
Autoimmune   Ulcerative Colitis
  Gluten Sensitivity / Celiac Disease
  Anemia is a frequent presentation of celiac disease. In one study, 200 consecutive patients of a hematology clinic were screened for antigliadin and antiendomysial antibodies. Patients with both positive titers underwent intestinal biopsy, and in 10 patients (5%), results were positive for celiac disease. The prevalence increased to 8.5% if the patients with macrocytic anemia and the patients with bleeding who responded to iron therapy were excluded.

  Crohn's Disease


  Parasite Infection
  Different types of parasites can cause a deficiency of vitamin A, vitamin B12, and iron.

Lab Values - Chemistries

  (Very) low serum iron
  Elevated TIBC
  While TIBC is commonly elevated in iron deficiency anemia, it is also increased with the use of oral contraceptives and in pregnancy, blood loss and acute liver damage.

  (Very) low ferritin levels

  Elevated/normal ferritin levels
  High serum iron


  Iron Requirement
  Copper Deficiency
  Copper deficiency, due to its effects on ceruloplasmin, may cause an iron-deficiency anemia which can only be corrected with copper supplementation as it impairs iron absorption, reduces heme synthesis and increases iron accumulation in storage tissues. [J Orthomol Med 4( 2): pp.99-108, 1989]

Organ Health

  Kidney Failure
  Patients with CRF often suffer from complications such as anemia, which occurs when failing kidneys no longer produce sufficient erythropoietin, a hormone that stimulates the production of oxygen-carrying red blood cells (RBCs). In addition to decreased levels of RBCs, patients often begin to accumulate toxic metabolites, which shorten the lifespan of existing RBCs.

Symptoms - Gas-Int - General

  Had typical/had severe gastric bypass

Symptoms - Reproductive - General

  (Much) recent breastfeeding
  Breast-feeding a baby can deplete iron stores.

  Being in late/being in mid-/being in early pregnancy
  Pregnancy can deplete iron stores.

Tumors, Benign

  Submucous fibroids are the type that most commonly cause significant problems; even small tumors located in or bulging into the uterine cavity may cause heavy bleeding, anemia, pain, infertility or miscarriage.


  Menorrhagia (Heavy Periods)

Anemia (Iron deficiency) suggests the following may be present:
Autoimmune   Ulcerative Colitis

Cell Salts

  Cell Salt, Ferrum Phos Need
  Cell Salt, Calc Phos Need




  Chronic Fatigue / Fibromyalgia Syndrome

Organ Health

  Kidney Failure
  Patients with CRF often suffer from complications such as anemia, which occurs when failing kidneys no longer produce sufficient erythropoietin, a hormone that stimulates the production of oxygen-carrying red blood cells (RBCs). In addition to decreased levels of RBCs, patients often begin to accumulate toxic metabolites, which shorten the lifespan of existing RBCs.

Recommendations for Anemia (Iron deficiency):
Botanical   Chlorella / Algae Products

Not recommended:
  Green / Oolong / BlackTea (Camellia sinensis)
  Tea "chelates" iron, removing it from the body which may cause iron deficiency anemia in young people.


  Artificial Sweetener Avoidance
  Splenda (sucralose) use has been linked to a reduced red blood cell count.

  Caffeine/Coffee Avoidance
  Research has shown that drinking coffee causes a significant loss of several vitamins and minerals, including vitamins B and C, calcium, iron, and zinc.

Not recommended:
  Therapeutic Fasting
  Fasting should be avoided in severe cases of iron deficiency anemia.


  Nutritional Yeast
  EpiCor is a revolutionary dietary ingredient that is creating an entirely new category of immune health products. It is an all-natural, high-metabolite immunogen that nourishes the body�s immune system. EpiCor is an all natural yeast-based product derived from Baker's yeast (Saccharomyces cerevisiae) through a multi-stage fermentation and drying process.

The ingredient is manufactured by Embria Health Sciences, a unit of Iowa-based animal feed supplier Diamond V Mills. It can be ordered by anyone from Internet suppliers.

Researchers recruited 25 healthy participants (average age 27.6, average BMI 26.2 kg per sq. m, 13 women) and randomly assigned them to receive daily EpiCor supplements (500 mg) or placebo (brown rice flour mixed with 1 per cent molasses and 1 per cent tamari) for five weeks.

The red blood cell portion of the blood (hematocrit) increased amongst people in the EpiCor group, said the researchers. The number of red blood cells did not increase, but the volume of red blood cells (RBC) increased by about seven%. No significant change in the hematocrit was observed in the placebo group.

�We conclude that the consumption of EpiCor resulted in production of healthier RBC, since their numbers did not change, but their volume (as measured by the hematocrit) and content of haemoglobin increased compared to baseline,� stated the researchers.

Lab Tests/Rule-Outs

  Test CBC (Complete Blood Count)
  A complete blood count will give you a good idea if iron deficiency anemia is present. This test is routinely ordered by doctors along with a blood chemistry profile as screening tests.

  Test Iron Stores (Ferritin)
  Test Copper Levels
  If you're slugging down iron pills but remain weak and anemic, the culprit may not be iron at all, but another metal: copper. A new genetic find explaining why is described by a University of California, Berkeley, scientist and his colleagues in the February, 1999 issue of the journal Nature Genetics.

The researchers discovered a protein, hephaestin, that appears critical for moving iron to the bloodstream. This protein contains copper and cannot be produced in the absence of copper. Thus in some cases, having too little copper present even with an ample iron supply might cause anemia, said the lead author on the paper, Assistant Professor Christopher Vulpe of UC Berkeley's Division of Nutrition and Toxicology in the College of Natural Resources.


  Iron supplementation, with as much as 200mg of elemental iron per day, is the obvious therapy for treating and preventing the recurrence of iron deficiency anemia.


Not recommended:
  Supplemental zinc (zinc gluconate, 22mg per day) improved zinc levels but reduced iron levels in a study of 11 young women with low iron stores (plasma ferritin< 20 �g/L), but who were not yet anemic. [ J Nutr 2002;132(7): pp.1860-1864]


  Vitamin C (Ascorbic Acid)
  It has been well established that better iron absorption occurs from both plant and animal sources when vitamin C is taken at the same time, whether from foods or as a supplement. 75mg of vitamin C in a meal will cause about a six-fold increase in the absorption of heme iron. It appears that vitamin C enhances non-heme iron absorption in individuals with low iron status, but does not increase iron status unnecessarily in iron-replete individuals. [Effect of ascorbic acid on iron absorption from different types of meals. Hum Nutr: Appl Nutr,1986 40A: pp.97-113]

  Vitamin A
  Vitamin A and iron supplementation had the following effect on anemic pregnant women: 35% became non-anemic with only Vitamin A. 68% became non-anemic with just iron supplementation. 97% became non-anemic after supplementation with both Vitamin A and iron. [Lancet, 342 (8883), November 27, 1993, pp.1325-1328]

Weak or unproven link
Strong or generally accepted link
Proven definite or direct link
Strongly counter-indicative
Very strongly or absolutely counter-indicative
May do some good
Likely to help
Highly recommended
May have adverse consequences


Acute:  An illness or symptom of sudden onset, which generally has a short duration.

Anemia:  A condition resulting from an unusually low number of red blood cells or too little hemoglobin in the red blood cells. The most common type is iron-deficiency anemia in which the red blood cells are reduced in size and number, and hemoglobin levels are low. Clinical symptoms include shortness of breath, lethargy and heart palpitations.

Anesthesia:  Loss of sensation caused by neurological dysfunction or a pharmacological depression of nerve function.

Antibody:  A type of serum protein (globulin) synthesized by white blood cells of the lymphoid type in response to an antigenic (foreign substance) stimulus. Antibodies are complex substances formed to neutralize or destroy these antigens in the blood. Antibody activity normally fights infection but can be damaging in allergies and a group of diseases that are called autoimmune diseases.

Bile:  A bitter, yellow-green secretion of the liver. Bile is stored in the gallbladder and is released when fat enters the first part of the small intestine (duodenum) in order to aid digestion.

Biopsy:  Excision of tissue from a living being for diagnosis.

Celiac Disease:  (Gluten sensitivity) A digestive disease that damages the small intestine and interferes with absorption of nutrients from food. People who have celiac disease cannot tolerate a protein called gluten. Common symptoms include diarrhea, increased appetite, bloating, weight loss, irritability and fatigue. Gluten is found in wheat (including spelt, triticale, and kamut), rye, barley and sometimes oats.

Chronic:  Usually Chronic illness: Illness extending over a long period of time.

Cobalamin:  Vitamin B-12. Essential for normal growth and functioning of all body cells, especially those of bone marrow (red blood cell formation), gastrointestinal tract and nervous system, it prevents pernicious anemia and plays a crucial part in the reproduction of every cell of the body i.e. synthesis of genetic material (DNA).

Copper:  An essential mineral that is a component of several important enzymes in the body and is essential to good health. Copper is found in all body tissues. Copper deficiency leads to a variety of abnormalities, including anemia, skeletal defects, degeneration of the nervous system, reproductive failure, pronounced cardiovascular lesions, elevated blood cholesterol, impaired immunity and defects in the pigmentation and structure of hair. Copper is involved in iron incorporation into hemoglobin. It is also involved with vitamin C in the formation of collagen and the proper functioning in central nervous system. More than a dozen enzymes have been found to contain copper. The best studied are superoxide dismutase (SOD), cytochrome C oxidase, catalase, dopamine hydroxylase, uricase, tryptophan dioxygenase, lecithinase and other monoamine and diamine oxidases.

Dopamine:  A neurohormone; precursor to norepinephrine which acts as a stimulant to the nervous system.

Fibromyalgia:  (FMS): Originally named fibrositis, it is a mysteriously debilitating syndrome that attacks women more often than men. It is not physically damaging to the body in any way, but is characterized by the constant presence of widespread pain that often moves about the body. Fibromyalgia can be so severe that it is often incapacitating.

Fructose:  Fructose is a monosaccharide (simple sugar), which the body can use for energy. It is found mostly in fruits, honey and HFCS (high fructose corn syrup). HFCS is added to many prepared foods and drinks. It is addictive. A high intake of fructose results in craving for sweets and calories.

Gastrointestinal:  Pertaining to the stomach, small and large intestines, colon, rectum, liver, pancreas, and gallbladder.

Glucose:  A sugar that is the simplest form of carbohydrate. It is commonly referred to as blood sugar. The body breaks down carbohydrates in foods into glucose, which serves as the primary fuel for the muscles and the brain.

Gram:  (gm): A metric unit of weight, there being approximately 28 grams in one ounce.

Heme:  The deep red iron-containing hemoglobin found in foods of animal origin.

Hemoglobin:  The oxygen-carrying protein of the blood found in red blood cells.

Hormones:  Chemical substances secreted by a variety of body organs that are carried by the bloodstream and usually influence cells some distance from the source of production. Hormones signal certain enzymes to perform their functions and, in this way, regulate such body functions as blood sugar levels, insulin levels, the menstrual cycle, and growth. These can be prescription, over-the-counter, synthetic or natural agents. Examples include adrenal hormones such as corticosteroids and aldosterone; glucagon, growth hormone, insulin, testosterone, estrogens, progestins, progesterone, DHEA, melatonin, and thyroid hormones such as thyroxine and calcitonin.

Iron:  An essential mineral. Prevents anemia: as a constituent of hemoglobin, transports oxygen throughout the body. Virtually all of the oxygen used by cells in the life process are brought to the cells by the hemoglobin of red blood cells. Iron is a small but most vital, component of the hemoglobin in 20,000 billion red blood cells, of which 115 million are formed every minute. Heme iron (from meat) is absorbed 10 times more readily than the ferrous or ferric form.

Metabolite:  Any product (foodstuff, intermediate, waste product) of metabolism.

Milligram:  (mg): 1/1,000 of a gram by weight.

Myoglobin:  An oxygen-carrying muscle protein that makes oxygen available to the muscles for contraction.

Parasite:  An organism living in or on another organism.

Red Blood Cell:  Any of the hemoglobin-containing cells that carry oxygen to the tissues and are responsible for the red color of blood.

Serum:  The cell-free fluid of the bloodstream. It appears in a test tube after the blood clots and is often used in expressions relating to the levels of certain compounds in the blood stream.

Stomach:  A hollow, muscular, J-shaped pouch located in the upper part of the abdomen to the left of the midline. The upper end (fundus) is large and dome-shaped; the area just below the fundus is called the body of the stomach. The fundus and the body are often referred to as the cardiac portion of the stomach. The lower (pyloric) portion curves downward and to the right and includes the antrum and the pylorus. The function of the stomach is to begin digestion by physically breaking down food received from the esophagus. The tissues of the stomach wall are composed of three types of muscle fibers: circular, longitudinal and oblique. These fibers create structural elasticity and contractibility, both of which are needed for digestion. The stomach mucosa contains cells which secrete hydrochloric acid and this in turn activates the other gastric enzymes pepsin and rennin. To protect itself from being destroyed by its own enzymes, the stomach�s mucous lining must constantly regenerate itself.

Thyroid:  Thyroid Gland: An organ with many veins. It is at the front of the neck. It is essential to normal body growth in infancy and childhood. It releases thyroid hormones - iodine-containing compounds that increase the rate of metabolism, affect body temperature, regulate protein, fat, and carbohydrate catabolism in all cells. They keep up growth hormone release, skeletal maturation, and heart rate, force, and output. They promote central nervous system growth, stimulate the making of many enzymes, and are necessary for muscle tone and vigor.

Uremia:  Condition characterized by excessive urea and other nitrogen compounds in the blood due to renal insufficiency.

Vitamin A:  A fat-soluble vitamin essential to one's health. Plays an important part in the growth and repair of body tissue, protects epithelial tissue, helps maintain the skin and is necessary for night vision. It is also necessary for normal growth and formation of bones and teeth. For Vitamin A only, 1mg translates to 833 IU.

Vitamin C:  Also known as ascorbic acid, Vitamin C is a water-soluble antioxidant vitamin essential to the body's health. When bound to other nutrients, for example calcium, it would be referred to as "calcium ascorbate". As an antioxidant, it inhibits the formation of nitrosamines (a suspected carcinogen). Vitamin C is important for maintenance of bones, teeth, collagen and blood vessels (capillaries), enhances iron absorption and red blood cell formation, helps in the utilization of carbohydrates and synthesis of fats and proteins, aids in fighting bacterial infections, and interacts with other nutrients. It is present in citrus fruits, tomatoes, berries, potatoes and fresh, green leafy vegetables.