Anemia: What’s Really Going On and Why We Should Think Twice About Iron Supplements
Let’s talk about anemia, iron, and iron supplements. There’s a lot more to this issue than meets the eye. I know a lot of doctors automatically prescribe iron for anemia, but the situation is much more complex than that, and there are indeed cases where supplemental iron can even make matters worse. Indeed, one of the first places we should look in the presence of anemia is the gut. Let’s see why.
First, the physiology: red blood cells carry oxygen to our cells. They can do this because they contain the substance hemoglobin (that’s what makes them red), to which oxygen binds. Smack dab in the center of each hemoglobin molecule is an atom of iron.
A deficiency of red bloods cells or of hemoglobin, or a low hematocrit, are what define the condition of “anemia.” “Hematocrit” is the percentage of of blood that is solid rather than liquid. This solid portion consists mostly of red blood cells. The ratio of red blood cells to hemoglobin to hematocrit is normally 1:3:9.
Besides the iron that circulates in our bloodstream tucked away inside the hemoglobin in our red blood cells, we also have a storage form of iron. Our storage form of iron is called ferritin.
When we have anemia, we almost always feel fatigued. This makes sense, as we’re not getting enough oxygen to our cells, and we hardly feel like running around.
Now, anemia is not synonymous with iron deficiency. Herein lies the mistaken assumption of many and the reason for the misuse–and complete ineffectiveness–of iron supplements in many cases. Because in fact anemia can arise from a multitude of causes. The genetic anemia thalassemia can actually cause elevated iron levels, in which case iron supplementation is absolutely contraindicated. If we’re eating a diet that contains sufficient iron–or if an iron supplement has not corrected the anemia–iron deficiency in and of itself is almost certainly not the problem.
A major reason we can be anemic is in fact digestive. Vitamin B12 is necessary to make red blood cells, and compromised gut health–including leaky gut and gut dysbiosis (an imbalance in the gut flora population)–are major causes of B12 deficiency and hence anemia. I see this all the time as a GAPS practitioner and paleo doc. When a patient is anemic, one of the first things I look to is the health of their gut. Crohn’s, ulcerative colitis, really all manner of bowel issues can have a hand in stirring the pot. If one takes an iron supplement in the presence of a compromised gut flora population, one will largely feed the dysbiotic microorganisms, who get first dibs, and one will only compound the original problem.
Low stomach acid production is another big culprit. This is especially common on a high-carbohydrate diet. Symptoms of low stomach acid include heartburn, or acid reflux, abdominal gas and bloating, and sometimes constipation or diarrhea or both. This is the condition for which allopathic doctors typically prescribe antacids or proton pump inhibitors–which, diabolically, is just the opposite of what is needed to restore long-term health. This is not only because these substances impede our digestion of our food, but also because, as we’ve just learned, they can cause anemia by predisposing to B12 deficiency.
B12 deficiency can also be autoimmune. This vitamin was actually discovered by researchers studying so-called pernicious anemia. Pernicious anemia is an autoimmune process in which the immune system makes antibodies that go after parietal cells. Parietal cells are cells in the stomach lining that are responsible for secreting a substance called intrinsic factor, which is necessary to absorb B12. A lack of intrinsic factor, because it causes a B12 deficiency, in turn results in anemia. Antibodies against the parietal cells of the stomach are an analyte tested in Cyrex Labs’ Array 5, the Multiple Autoimmune Reactivity Screen (no affiliation). If one cannot absorb dietary B12 due to a lack of intrinsic factor, sublingual B12 supplementation is an option. B12 is not present in plant foods, only in animal foods, which is why vegans must look sharp to supplement this necessary nutrient from some source or risk anemia.
Anemia is also a consequence of infection and chronic disease. When we have a bacterial infection, iron is what the pathogenic bacteria like to eat, so our body wisely sequesters our iron in our mitochondria. If we have anemia of chronic disease and are given an iron supplement, it is the lousy pathogenic bacteria who will get first dibs on it, worsening the situation. This is why, during inflammation, which often accompanies infection, levels of ferritin–our storage form of iron–rise, even when levels of our circulating bloodstream iron may be low. One can see the wisdom of not pouring even more iron into the system in such a case.
One can also see the wisdom of testing for ferritin levels. Too often conventional doctors will test for iron only, thereby potentially missing important clues as to what’s going on in the body as a whole. As we’ve discussed, when high ferritin is accompanied by low iron, we should suspect inflammation, infection, or chronic disease–conditions in which the body deliberately takes circulating iron out of play and stores it.
The flip side, of course, is a normal level of circulating iron but a low ferritin. In this case, for one reason or another, the body has called upon its iron stores to the extent that they are nearly depleted. But because our blood is so important, carrying oxygen to all our cells as it does, the body will bend over backward to keep things running smoothly there. It’ll grab iron from anywhere to keep blood levels up. So, although our iron levels appear normal, yet we can be running on fumes–as our doctor will recognize immediately if she or he has had the forethought to also order ferritin–and has not just assumed all is well because iron is normal.
Just to mention it, in my own practice, when indicated I commonly order not only ferritin, but also an iron panel. An iron panel includes tests for: 1) iron itself, 2) transferrin, the protein that transports iron throughout the body, 3) percent transferrin saturation (about a third of the transferrin is typically “saturated” with iron, leaving two thirds open and available), and 4) total iron-binding capacity (TIBC), a measure of the concentration of transferrin in the blood. The ratios in which we find all of these can give important clues as to the cause of any anemia present.
Although anemia can be a harbinger of many things, it is an important signpost to gluten sensitivity, a widespread phenomenon of which only a small percentage is estimated by the folks who study it to be actually diagnosed. Keep in mind that celiac disease is only one manifestation of gluten sensitivity and that most symptoms of gluten sensitivity occur outside the intestinal tract, in other bodily areas. Gluten sensitivity is primarily neurological. Conventional lab tests for it, which typically consist of assays for antibodies to α-gliadin and tissue transglutaminase-2 (tTG-2), are woefully inadequate and result in a considerable number of false negatives. Cyrex Labs’ Array 3, conversely, is much more comprehensive, testing for some two dozen analytes in its panel Wheat/Gluten Proteome Reactivity & Autoimmunity (again, no affiliation).
Other causes of anemia include simple blood loss–as in metrorrhagia, or heavy menstruation. Hemolytic anemia can result from excessive destruction of red blood cells. And anemia can result from dilution of blood, as happens in the increased blood volume of pregnancy. Here, you can check out Chris Kresser’s article in which he argues that “routine supplementation of iron (without accompanying signs & symptoms of anemia) during pregnancy is not only not beneficial, but potentially harmful” and may not be associated with the best birth outcomes.
Some anemias are genetic and not without purpose, like sickle cell anemia, which is a two-edged sword, as it can confer resistance to malaria. Others, like pernicious anemia, are due to nutrient deficiencies like vitamin B12. Worldwide, infection with tapeworm (Diphyllobothrium latum) is the largest cause of anemia from B12 deficiency, the worm consuming upwards of 80 percent of its host’s B12 intake. There is aplastic anemia, which affects all forms of blood cells; anemia of renal failure, in which insufficient erythropoetin is produced; and a host of other anemias. Back in naturopathic medical school, in Clinical Lab Analysis class, we all spent hours diligently making flow charts categorizing all the numerous anemias.
So, in the end, while prescribing iron may be the instinctive reaction of many doctors, I suggest there’s a much bigger picture. Before rushing to supplement iron, taking thoughtful steps to determine the actual cause of the anemia and then treating at this more fundamental level, I believe, is ultimately the wisest route.
Further reading: Thank you to Jodi Bassett for posting this good article on anemia from Body Ecology called Are You Anemic? Going Beyond Iron Supplements. Its author writes at length and with great insight about the importance of gut health in the treatment of anemia.
Note: Plants use chlorophyll in place of hemoglobin (chlorophyll is what makes them green just as hemoglobin makes our red blood cells red), and instead of an iron atom in the middle, they have a magnesium atom. This is what makes leafy greens a respectable source of magnesium for us.
(Photo credit: Red blood cells/Photos.com/Rice University)
