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Anemia: overlooked & under-treated

Anemia comes from the Greek language meaning “without blood.” It is defined as a condition where the capacity of blood to transport oxygen to tissues is reduced. This is seen as decreased red blood cells, hemoglobin, and/or hematocrit. Anemia itself is not a disease but a manifestation of a disease.

Iron deficiency and anemia are underdiagnosed public health concerns that affect mainly women of reproductive age. Anemia affects 30% of non-pregnant women, 42% of pregnant women, and more than 5% of US reproductive-age women. These percentages do not account for iron deficiency prevalence, the precursor to anemia. These women will become anemic if nothing changes and if they do not receive treatment. Anemia also has racial disparities with 24.4% of black women younger than 50 being affected and 8.7% of Hispanic women. 

Anemic and iron deficient patients experience a wide range of symptoms, but the most common are:

  • Fatigue
  • Loss of stamina
  • Impaired work performance
  • Depression
  • Tachycardia (rapid heart rate)
  • Cold intolerance
  • Hair loss / thinning
  • Restless leg syndrome
  • Pica (mainly for ice)
  • Shortness of breath

Take another look at that list above. How often are these symptoms in women written off  by the medical community and general population? “You’re just tired because you’re close to your cycle.” “Maybe you’re sad because you’re PMSing.” “Hair thinning happens when you age.” “Women tend to have cold feet and hands, that’s normal.” There are real, physiological reasons for these symptoms backed with research. If doctors examine basic labs, they can help you identify if this is a concern, prescribe proper treatment, and help you feel better. 

There are many reasons we can become iron deficient, but they can be categorized into four main factors: 

  • Inadequate intake
    • Low iron diet
    • Vegetarian/vegan diet
    • Poor food pairing 
    • Taste preferences
  • Inadequate absorption
    • Celiac disease
    • Inflammatory bowel diseases
    • Surgical causes such as gastric bypass
    • GI infections such as SIBO
  • Inadequate utilization
    • Diseases that affect storage to use
    • Low enzyme levels
    • Chronic immune activation
    • Chronic infections
    • Malignancy
  •  Increased loss
    • Heavy menstrual bleeding
    • Uterine fibroids
    • Pregnancy and delivery
    • Gastric bleeding
    • Gastritis
    • Ulcers

Bleeding is a leading cause of iron deficiency and anemia which is why this is more common in women. Iron deficiency is the precursor to iron deficiency anemia. As stated before, we know 30% of women are already anemic. Logically, this means there are large amounts of women that are iron deficient and likely don’t know it. When any of the signs and symptoms included in the long list above presents in those who approach their doctors looking for help, it is their doctors’ responsibility to consider iron deficiency as a cause. Plus, as Thomas DeLoughery, MD, MACP, FAWM, points out in his article, Iron Deficiency Anemia, iron deficiency independent of anemia can still have symptoms of anemia that impact quality of life.

Sadly there are many doctors in the United States who have not updated their practices about the diagnosis and treatment of these conditions. There are still doctors that will only consider a blood test called a “CBC,” a complete blood count, when diagnosing these conditions. This test is important but isn’t the whole story. It looks at important factors such as red blood cell levels, hemoglobin levels, and hematocrit. There are other widely available, approved tests such as iron panels (iron saturation levels, serum iron, transferrin, TIBC, UIBC) and ferritin levels that evaluate iron status.  These other tests are crucial when you want to consider the full picture of an individual’s iron health. If your doctor only orders a CBC when looking into iron deficiency and anemia, you should find another doctor. Keep reading more to find out why.

The goal when treating those with iron deficiency is not only to raise hemoglobin and red blood cell levels; it’s to increase iron storage so when stress occurs there is a reserve to use. One way to imagine iron storage is like a savings account: you need savings when funds are low in the checking account, especially in times of stress and increased bills. One method to evaluate iron storage is a lab test called serum ferritin. Dr. DeLoughery states that, “serum ferritin is the most efficient test for iron deficiency.”

There are different ways to treat iron deficiency and anemia, and which to use depends on severity of the condition, if the cause is ongoing, and how long the condition has been present. Oral iron is often the first line therapy, and there is nothing wrong with starting here. As a practitioner with years of experience in treating this condition, the biggest mistake I see my colleagues make is prescribing an oral iron supplement and never giving other options or revisiting this recommendation. Oral iron supplementation is affordable, accessible and non-invasive. But it also causes gastrointestinal upset and constipation in the majority of people who take it. Up to 70% of adults don’t tolerate iron supplements and have gastrointestinal side effects, and 56% of patients report “substantial” adverse effects when taking. This leads to non-compliance: people won’t take the recommendation and will never feel better. 

This oral supplement recommendation as stand-alone treatment also ignores the fact you could be supplementing with nutrition. “Food is medicine” is a saying for a reason. There are important topics to discuss with patients in order to increase the nutrition of iron from food, including food pairing and frequency. To ignore this is to ignore the most accessible and frequent way we give our body nutrition. See my blog about iron nutrition here to learn more.

Oral iron supplementation has come a long way, as has the research. There is evidence that taking an iron supplement every other day has better efficacy than taking it every day. There are also more tolerable forms than others. If you don’t tolerate one, make sure you tell your doctor so she or he can give you another type to try. If they don’t make themselves available to make this change or don’t have another recommendation – find a different doctor.

Oral iron has more problems than causing GI upset and needing specific dosing. When taking in ideal situations, it is still poorly absorbed. The maximum rate of absorption is about 10%. How often in medicine are our first line therapies only ten percent effective? That poor of an efficacy is often used in arguments against therapies. Oral iron is also largely impacted by other foods and drugs, further decreasing the already low absorption rate. Clinical experience has shown me that even with my most compliant patients, oral iron over the course of 6-8 months only raises iron storage minimal amounts. That’s a long time to feel awful, especially when it’s an easily treatable problem.

This is why, after using education and nutritional therapies first, I often recommend a course of IV iron therapy. It can be used to rapidly replenish iron stores in a matter of weeks or days and is well tolerated. It also overcomes the issue of low absorption. When giving an IV dose of iron, the patient absorbs 100% of the medication, which is certainly better than 10% absorption and months of futile effort. 

IV iron had a bad reputation for a long time due to safety concerns, and uninformed medical practitioners may still think these still are common. The earlier formulations of high molecular weight iron that caused allergic reactions in some are no longer available. IV iron comes in many formulations today and is largely well tolerated. Iron sucrose, ferric gluconate, and ferric carboxymaltose are some examples of well tolerated iron products that have rare allergic reaction rates and good efficacy at raising important iron markers. In fact, there is evidence that finds IV iron formulations have less toxicity than oral iron and equivalent safety to placebo. Many IV iron products are even safe to use with other health considerations including heart failure, kidney disease, inflammatory bowel disease, and pregnancy.

Low iron status in pregnant females is a serious health issue that can lead to iron deficiency in the early life of their child, which can have long-term brain and behavior consequences. Iron deficiency doesn’t often present until the 2nd trimester; there’s only a matter of weeks before a decision needs to be made about delivery plans. For example, if a pregnant female has  iron levels that are too low, she is not advised to have a home birth according to best practice guidelines. Anemic, pregnant females treated appropriately with IV iron have better iron levels at delivery than those treated with oral iron alone, which means these mothers will have more iron reserved for potential blood loss in delivery and iron loss in breastfeeding.

People running on treadmill in gym doing cardio workout

For the individuals without anemia who are experiencing the symptoms that can present with iron deficiency, IV iron can also be helpful to treat the deficiency and feel better. If you have low iron levels, talk to your physician to see if he or she offers IV iron, or get a referral to someone who offers this treatment.