Iron Deficiency Anemia: All you need to know

Anemia is a condition that occurs when your blood lacks enough red blood cells or enough hemoglobin. Anemia is the most common blood disorder that can be of several types. Iron deficiency anemia is the most prevalent type of anemia the world. Iron deficiency anemia, as the name shows, occurs when there is not enough iron in the body, which can be usually caused either inadequate dietary absorption or insufficient dietary intake of iron. Loss of iron can also be a reason, which can occur due to bleeding.

Bleeding leads to loss of red blood cells more rapidly than they can be reformed. Iron is the most important mineral which is necessary for our body. Iron from your diet is absorbed by the cells lining the gastrointestinal tract. Then the iron is released into the blood where it binds with the protein transferrin.

Transferrin carries iron from the blood to the liver, which acts as a store house for iron. Liver stores iron in the form of ferritin. Liver releases iron into the blood stream according to the needs of the body. Finally, this iron is utilized by the bone marrow for the formation of your red blood cells. New red blood cells are formed after every 120 days.

A vital function of iron in your body is hemoglobin formation, which is a compound formed by the combination of iron and protein. This hemoglobin is a necessary part of your red blood cells. Hemoglobin combines with oxygen in the blood to form a compound known as oxy-hemoglobin that works as an oxygen carrier. As a part of your blood, it delivers oxygen to cells, removes carbon dioxide and carries nutrients. Iron carries oxygen from your lungs throughout your body and also acts as a part and parcel of many enzymes. Iron is also necessary to maintain your cells, nails, hair and skin healthy. Moreover, it also plays a role in many cellular functions.

Why is iron deficiency a concern?

When your body does not have sufficient iron, many parts of your body are affected. Iron deficiency leads to inadequate supply of oxygen to various parts of the body. Iron deficiency can especially occur at the times of pregnancy that can result in underweight babies, premature births, delayed fetal movements and other physical and mental abnormalities in infants. As iron deficiency causes fatigue it can impair the ability of a person to do physical and mental. It can result in poor cognitive skills, poor memory and poor performance. Lower IQs are also linked to iron deficiency.

What are the possible causes of iron deficiency anemia?

There can be numerous causes of iron deficiency. Such as:

Increased need for iron

Iron deficiency can occur when the body demands more iron than it is already getting. It can occur when growth rate is at its peak. Many conditions can cause a person to need additional amount of iron like pregnancy, frequent blood donations, gastrointestinal diseases, infections, heavy menstrual bleeding, surgeries, fibroids, peptic ulcer disease, colon cancer, uterine cancer, accidents and malignancies.

Pregnancy and iron deficiency anemia

A pregnant woman needs iron not only for herself, but also for her baby (fetus). A developing fetus takes iron for his need from his mother. So, there is an obvious need for the pregnant females to increase their iron intake. Without iron supplementation, pregnant women may develop iron deficiency anemia.

Heavy menstrual periods and iron deficiency anemia

Anemia is common among women as compared to men. Women of reproductive age are likely to suffer from iron deficiency as they lose blood during menstruation. Women who have heavy periods are at the risk of iron deficiency. Heavy periods can take away a lot of your iron along with blood. About 1 in 10 women can become anemic due to menorrhagia (heavy menstrual periods). If you are suffering from heavy period you need to increase your dietary iron intake, to compensate your iron loss. If not adequately compensated, menorrhagia can result in iron deficiency anemia.

Infants and iron deficiency anemia

As infants are in a rapid phase of their growth, they require much higher amounts of iron as compared to adults. In order to fulfill this increasing demand their food or milk is often fortified with iron. Nature has blessed human milk with a rich supply of iron as compared to cow’s milk. That is why doctors recommend human milk for infants.

Lack of iron in the diet

Your body gets iron from the diet you take daily. Some iron-rich foods include meat, poultry, eggs, tofu, cereals, beans, dried fruits, spinach, beetroot, leafy green vegetables, fish and iron-fortified foods (foods that have additional iron). If you do not consume these foods regularly, or you eat foods having too little iron, you are likely to become iron deficient. Infants and children for their proper growth and development are dependent on iron too. Poverty is also one of the contributing factors of iron deficiency.

People who are strictly vegetarian may not get enough iron in the body as vegetable contains less quantity of iron as compared to meats. Older people who do not eat a full diet can also suffer from iron deficiency.

Decreased iron absorption

Normally, the iron from food is absorbed into the bloodstream through the small intestine, especially the in the initial segments of small intestine. If there is any disease in the gastrointestinal tract, such as Crohn’s disease, gastritis and celiac disease, there will be insufficient absorption of iron by the body.

Deficiency of intrinsic factor (a chemical necessary for vitamin B12 absorption), autoimmune diseases and hormonal imbalances can also limit iron absorption. Gastric bypass surgery is another factor that can result in inadequate iron absorption. Post surgical resection or inflammatory bowel disease, can limit the absorption of iron in the body by reducing the surface of the gut. All these conditions can lead to iron deficiency anemia. Even if you have sufficient iron in your diet, you may not be able to absorb it. This can happen if there is insufficiency of stomach acid (hypochlorhydria or achlorhydria) due to H.pylori infections or long term use of proton pump therapy. Conditions that can result in precipitation of ferrous and ferric iron salts may also lead to malabsorption of iron.

Factors affecting iron absorption

The absorption of iron from the diet depends on many factors. Source of iron is the main factor. Iron obtained from the meat sources, like chicken, beef, mutton and fish, is known as heme iron. While iron obtained from the vegetables, beans and cereals is known as non-heme iron. Heme iron is absorbed by the body approximately two to three times more efficiently than non-heme iron. The amount of iron absorbed from the food also relates to other types of foods eaten at the same meal. Vitamin C rich foods enhance absorption of non-heme iron when eaten at the same meal. Certain substances e.g. polyphenols, calcium and phytates, that are present in tea, coffee, milk, dairy products, legumes, chocolates and fibers, can decrease the absorption of non-heme iron.

Calcium can decrease the absorption of heme iron as well. Other nutrients such as vitamin B12, zinc or folate, can facilitate sufficient absorption of non-heme iron.

Medicines used to treat peptic ulcer disease and gastrointestinal acid reflux disease, such as antacids, proton pump inhibitors, can reduce the absorption of iron.

ZANTAC

Zantac is a histamine receptor blocker; H2 antagonist. It prevents the secretion of acid into the stomach and is used to treat gastroesophageal reflux disease (GERD), erosive esophagitis, stomach and duodenal ulcers, heartburn and Zollinger-Ellison syndrome. Gastric acid secretions facilitate the absorption of iron. Inhibition of gastric secretion by the H2-receptor antagonists can result in malabsorption of dietary iron. Long term use of zantac could contribute to the occurrence of iron-deficiency anemia. If a person is taking antacids with Zantac, chances of anemia are amplified.

ZOLOFT

Zoloft is the brand name of antidepressants, which belongs to a class of drugs called as selective serotonin reuptake inhibitors (SSRI). Zoloft is used to treat panic disorder, depression, premenstrual disorder, anxiety disorder, obsessive compulsive disorder and post-traumatic stress disorder. An adverse side effect of SSRI, is iron deficiency anemia. Long-term use of Zoloft can affect the absorption of iron from the diet, leading to iron deficiency anemia. In addition to iron deficiency anemia ZOLOFT also interacts with caffeine, as you can read in this article.

Blood loss

As blood contains iron, loss of blood leads to the loss of iron too. Bleeding produces a need for the extra amount of iron to replace the lost iron. Most causes of bleeding are obvious. Repeated blood donations, surgery, trauma or severe injuries, heavy menstrual bleeding, long periods, bleeding fibroids, multiple pregnancies etc. are the obvious causes of bleeding.

All these conditions may lead to iron deficiency anemia. Internal bleeding (bleeding inside the body) may also lead to loss of iron. Internal bleeding occurs from the digestive tract occurs slowly. It is not always obvious and can go undetected. Some common causes of chronic internal bleeding are: gastrointestinal ulcers, hiatal hernia, colon cancer, colon polyp, rectal cancer, hemorrhoids, gastritis, peptic ulcer, ulcerative colitis, stomach or duodenal ulcer, inflammation of the esophagus and intestines, esophageal varices and other rarer bowel disorders. The iron that you may lose with the internal bleeding may be more than you eat. This imbalance can result in iron deficiency anemia.

Other bleeding conditions that may contribute to iron deficiency anemia include:

• Use of over the counter pills such as NSAIDs (for example, ibuprofen and naproxen), aspirin, anticoagulants (warfarin and clopidogrel). NSAIDs and other anti-inflammatory drugs irritate the lining of the stomach, which may then lead to bleeding.
• Medicines for arthritis may also cause bleeding.
• Urinary tract bleeding. This may result from various diseases of the kidney or bladder.
• Alcohol abuse.
• Poisoning from lead and other toxic chemicals.

Parasitosis

Infestation of intestine with parasitic worm is the leading cause of iron deficiency worldwide. Tapeworms, flukes, and roundworms are the examples of parasitic worms. According to the World Health Organization estimate, approximately two billion people are infected with intestinal worms worldwide. Parasitic worms cause inflammation as well as chronic blood loss.

Faulty red blood cell production

Healthy and adequate red blood cells production is necessary to prevent iron deficiency anemia. The blood cells that are not working properly can cause anemia. Conditions associated with faulty, decreased or abnormal red blood cells production include the following:

• Sickle cell anemia.
• Thalassaemia.
• Iron deficiency anemia.
• Vitamin deficiency.
• Mineral deficiency.
• Bone marrow problems.
• Other health conditions.

What are the signs and symptoms of iron deficiency anemia?

If you’ve iron deficiency, you’re more likely to develop following symptoms:

• Irritability
• Weakness
• Shortness of breath
• Low blood pressure (especially on standing or changing posture)
• Sore and inflamed tongue known as glossitis
• Brittle and dry nails
• Unusual food cravings called pica
• Decreased appetite markedly in children
• Headache
• Tiredness, fatigue, lethargy and lack of energy
• Shortness of breath while walking short distances, climbing stairs and doing work.
• Pallor (Pale yellow skin)
• Poor performance in school and work
• Slow cognitive (mental) development
• Slow social development
• Sensitivity to cold and difficulty in maintaining body temperature
• Decreased immune functions and increased susceptibility to infections
• Difficulty in exercising
• Rapid heartbeat
• Dizziness
• Depression
• Poor appetite
• Restless legs syndrome
• Loss of interest in relationships, recreation and intimacy
• Having trouble in concentrating
• Grumpiness (a fussy and eccentric disposition)
• Anxiety
• Constipation
• Tinnitus (ringing in the ears)
• Sleepiness/ hypersomnia
• Hair loss
• Palpitations
• Depression
• Vertigo
• Twitching of muscles
• Numbness
• Tingling or burning sensations
• Amenorrhea (missing of menstrual periods)
• Pruritus (itching)
• Koilonychias (spoon shaped nails)
• Angular cheilitis (inflammatory lesions at the corners of mouth)
• Infants who are anemic may be fussy, slowly growing. They develop skills, such as talking and walking, later than normal.

Who is at risk of developing iron deficiency anemia?

Infants and children

Premature and low birth weight infants who do not get enough iron from milk are at risk of iron deficiency anemia. Infants exclusively dependant on cow’s milk are also at risk. Growing children demand high amounts of iron to fulfill their requirements and they may also be at risk. Among children, iron deficiency is most often seen among between the age group 6 months to 3 years.

Children who eat lead containing paints or soil are at risk because lead interferes with the body’s ability to make hemoglobin. Children with chronic infections or restricted diets are also at risk.

Women

Because women lose blood during periods, adolescent girls and women of childbearing age are at risk of iron deficiency anemia. Underweight teenagers can also be at risk. As pregnancy demands much greater amounts of iron as compared to non-pregnant women, pregnant ladies are at risk.

Vegetarians

People who are completely dependent upon vegetables and do not consume meat are at risk.

Frequent blood donors

Frequent blood donation can deplete iron stores. People who frequently donate blood are at risk.

Adults who have internal bleeding

Those diseases that can lead to internal bleeding increase the risk of iron deficiency anemia.

People who get kidney dialysis

Because blood is lost during dialysis, these people are at risk. They may develop iron deficiency anemia. Kidney secretes a hormone that the body needs to produce red blood cells. Inability of the kidney to secrete this hormone also contributes to iron deficiency.

Poor socioeconomic status

These people eat poorly and are at risk. People who follow a high fiber diet are also at risk because high fiber slows down the absorption of iron.

How iron deficiency anemia can be diagnosed?

To diagnose iron deficiency anemia following steps are necessary:

Detailed medical history

In history your doctor will ask about your symptoms, diet, socioeconomic status and medicines you take.

Physical examination

During the physical examination, your doctor will look at your nails, pulse, gums and skin. He will also examine your heart, lungs abdomen and rectum to find out the signs of iron deficiency anemia.

Diagnostic tests

CBC

Complete blood count is the first and foremost test to detect anemia. In this report following entities are noted:

1. RED BLOOD CELL COUNT: Normal red blood cell count is 4.3-5.9 million/uL for males and 3.5-5 million/uL for females. Red blood cell is decreased in iron deficiency anemia.
2. HEMOGLOBIN: Normal Hb values for males are 13.6-17.2gm/dl and for females are 12-15gm/dl. Its value gets decreased in iron deficiency anemia.
3. MCH: Normal mean hemoglobin is 27-33pg. It decreases in iron deficiency anemia.
4. MCV: Normal mean corpuscular volume is 82-96fL. It also decreases in iron deficiency anemia.

Reticulocyte count (RC)

Reticulocytes are young, immature red blood cells. Normal RC is 0.5-1.5%. RC decreases in iron deficiency anemia.

Serum iron

Serum iron measures the amount of iron circulating in the blood.

TIBC

Total iron binding capacity measures the amount of a transferrin, which is capable of transporting iron, in the blood.

Serum ferritin

Ferritin measures the amount of iron stored in the liver and spleen. It is the most accurate test for iron deficiency anemia.

Peripheral smear

In this test a sample of blood containing red blood cells is examined under a microscope. Red blood cells in iron deficiency become smaller and paler than normal.

Other tests

Other tests are colonoscopy, fecal occult blood test, bone marrow biopsy and upper endoscopy. These tests are usually not preferred but in extreme cases one can go for these tests too.

What is the possible treatment of iron deficiency anemia?

To treat iron deficiency anemia you have to boost the low levels of iron in your body. You can increase iron levels in your body by following ways:

Diet

Iron rich sources are:

• Meat: Mutton, beef, pork, or lamb. The liver is especially rich in iron.
• Poultry: Chicken especially liver.
• Shellfish, anchovies and sardines.
• Dark green leafy vegetables including broccoli, kale, turnip greens, and collard greens.
• Legumes, beans and peas, such as baked beans; soybeans; and chickpeas.
• Pastas, grains, rice, and cereals are iron enriched foods.
• Iron-fortified bread or cereals.
• Brown rice
• Pulses
• Nuts and seeds
• Tofu
• Eggs
• Dried fruit, such as raisins, dried apricots and prunes.
• Spinach
• Prune juice
• Peanut
• Butter
• Oatmeal
• Kale

Iron pills

Your doctor may recommend you iron tablets to replenish your body’s iron stores. Your doctor will tell you the exact doses of iron that you should take. The usual recommended dosage of iron is 150-200 mg per day. Iron supplements can be taken on an empty stomach. You can also take pills with meals. Do not take iron with calcium or antacids as these can interfere with the absorption of iron in the body.

Intravenous iron

Your doctor may recommend you intravenous iron. Intravenous iron is usually recommended for those persons who cannot tolerate oral iron. Patients with gastrointestinal tract diseases, severe iron deficiency, non-compliant patients or patients with chronic blood loss can be advised intravenous.

There are different preparations of IV iron:

• Iron dextran
• Iron sucrose
• Ferric gluconate

When large doses of iron are needed iron dextran can be used. Iron sucrose and ferric gluconate require frequent doses. Some patients are allergic to IV iron.

So, a test dose should be administered before the infusion. Allergic reactions are more common with iron dextran.

This necessitates switching to a different preparation. Side effects include fatigue, vomiting, headaches, diarrhea, irritability, urticaria, pruritus, and muscle and joint pain.

Vitamin C

As vitamin C increase iron absorption it should be included in the diet of an iron deficient person.

Blood transfusions

Severe iron deficient people should be given blood transfusions.

Treat the underlying cause

To treat iron deficiency anemia you must treat the underlying cause.

How iron deficiency can be prevented?

You can prevent iron deficiency anemia by following ways:

• Take iron rich foods.
• Add some vitamin C to your diet.
• Between the ages of 4-6 months feed your baby with iron fortified cereals to boost iron intake.
• Take some iron supplements
• If you are strict vegetarian, make a habit of taking some multivitamins or iron supplements.