Clinicians will wish to read the entire guidelines on managing iron deficiency anemia just published GUT (International Journal of Gastroenterology and Hepatology), but a few important points are worth noting here:

• “Any level of anaemia should be investigated in the presence of iron deficiency.”
• “Serum ferritin is the most powerful test for iron deficiency.”
• “Gastrointestinal (GI) blood loss from colonic cancer or gastric cancer, and malabsorption in coeliac disease are the most important causes that need to be sought.”
• “Upper and lower GI investigations should be considered in all postmenopausal female and all male patients where IDA has been confirmed unless there is a history of significant overt non-GI blood loss.”
• “All patients should be screened for coeliac disease.”
• “Colonoscopy has advantages over CT colography for investigation of the lower GI tract in IDA, but either is acceptable. Either is preferable to barium enema, which is useful if they are not available.”
• “In patients with recurrent IDA and normal OGD and colonoscopy results, Helicobacter pylori should be eradicated if present.”
• “Faecal occult blood testing is of no benefit in the investigation of IDA.”
• “Rectal examination is seldom contributory, and, in the absence of symptoms such as rectal bleeding and tenesmus, may be postponed until colonoscopy.”
• “Urine testing for blood is important in the examination of patients with IDA .”

Determining the cause and treating any type of anemia is of the highest importance—with even borderline anemia the ability of every cell in the body to function is impaired due to suboptimal oxygen delivery. There are a number of posts presenting studies on the depredations of mild anemia that can be seen by typing ‘anemia’ in the search box above.

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Even in developed nations iron deficiency is a common problem. An important clinical report just published in the journal Pediatrics examines the serious consequences, with recommendations for screening and supplementation. The authors state:

“Iron deficiency (ID) and iron-deficiency anemia (IDA) continue to be of worldwide concern…In industrialized nations, despite a demonstrable decline in prevalence, IDA remains a common cause of anemia in young children. However, even more important than anemia itself is the indication that the more common ID without anemia may also adversely affect long-term neurodevelopment and behavior and that some of these effects may be irreversible.“

The authors undertake a thorough revision and extension of the previous policy statement on ID and IDA in children last published in 1999, offering up-to-date guidelines for diagnosis and prevention in infants and toddlers aged 1 to 3. Clinicians reading this can peruse the study (the link above opens the paper in its entirety) for the specifics on acceptable hemoglobin levels and iron fortification. I encourage attention to the complications of iron deficiency, iron supplementation, and lead toxicity:

“Results of both animal and human studies have confirmed that IDA increases intestinal lead absorption…In contrast, iron supplementation in a child with IDA who also has lead poisoning without chelation therapy seems to increase blood lead concentrations and decrease basal lead excretion…Thus, in theory, selective rather than universal iron supplementation would be more likely to reduce lead poisoning and its potential harmful effects on these children.”

While lead toxicity is a problem for some, the effects of ID/IDA on neurodevelopment are universal:

“Results of a preponderance of studies have demonstrated an association between IDA in infancy and later cognitive deficits. Lozoff et al have reported detecting cognitive deficits 1 to 2 decades after the iron deficient insult during infancy.”

While the present science on this topic offers mixed evidence, the authors see fit to conclude:

“Given that iron is the world’s most common single-nutrient deficiency and there is some evidence of adverse effects of both ID and IDA on cognitive and behavioral development, it is important to minimize ID and IDA in infants and toddlers without waiting for unequivocal evidence.”

Their recommendations include these guidelines:

1. Breastfed infants should be supplemented with 1mg/kg per day of oral iron beginning at 4 months of age until appropriate iron-containing complementary foods (including iron-fortified cereals) are introduced in the diet.
2. Whole milk should not be used before 12 completed months of age.
3. The iron intake between 6 and 12 months of age should be 11 mg/day.
4. Toddlers 1 through 3 years of age should have an iron intake of 7 mg/day. For toddlers not receiving this iron intake, liquid supplements are suitable for children 12 through 36 months of age, and chewable multivitamins can be used for children 3 years and older.

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Even borderline anemia needs attention because it reduces the functional capability of every cell in the body. Iron deficiency anemia can sometimes respond incompletely to iron supplementation for a variety of reasons. Data from the World Health Organization (WHO) suggest that Helicobacter pylori is the most common infection in the world, with research showing links to cardiovascular disease, stomach cancer and other diseases. This paper recently published in the Post Graduate Medical Journal was inspired by the observation that…

“Recent guidelines on iron deficiency anaemia (IDA) have confirmed the aetiological role of Helicobacter pylori (H pylori), but the relationship still remains controversial.”

The authors documented data from eight studies that showed improvement in IDA with increases in hemoglobin and serum ferritin after H. pylori eradication were superior to those seen when iron was given alone. Thus their conclusion:

“H pylori eradication therapy combined with iron administration is more effective than iron administration alone for the treatment of IDA.”

Note: Helicobacter pylori infection is most accurately diagnosed by either stool antigens or a breath test for exhaled gases (not blood or stool antibodies). I have seen excellent results confirmed by follow-up tests with an evidence-based antimicrobial botanical formula.

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Even borderline anemia due to mild iron deficiency has profound effects. But as this study recently published in the British Journal of Nutrition reveals, care must be taken to avoid creating a functional zinc deficiency even when iron supplementation is necessary. The authors begin by observing…

“Interventions to combat mild Fe deficiency in women of childbearing age may affect Zn nutriture.”

Three groups of subjects with low iron were randomly assigned to one of three groups: dietary advice, a daily iron supplement and placebo. Their data showed that serum zinc increased in the dietary advice group (who ate more meat) and the placebo group. In the iron supplement group zinc decreased, leading to their conclusion:

“Zn status was not improved compared with placebo by an Fe-based dietary intervention. However, a daily moderate-dose Fe supplement with meals appeared to lower Zn status in these young adult women.”

Among its many functions, zinc is involved in neurotransmitter production and the regulation of mood. This important study recently published in the European Journal of Clinical Nutrition begins with the observation…

“The relation of zinc (Zn) nutriture to brain development and function has been elucidated. The purpose of this study is to examine whether Zn supplementation improves mood states in young women.”

The authors used a double-blind, randomized and placebo-controlled procedure to correlate psychological measures, somatic symptoms and serum zinc in two groups who took either a multivitamin or a multivitamin with zinc daily for 10 weeks. What did their data reveal?

“Women who took MV and Zn showed a significant reduction in anger–hostility score and depression–dejection score in the Profile of Moods State (POMS) and a significant increase in serum Zn concentration, whereas women who took only MV did not.”

The authors summarized their findings by concluding:

“Our results suggest that Zn supplementation may be effective in reducing anger and depression.”

It’s easy to see the strong biological momentum to feeling angry and/or depressed around menstruation? Iron is a necessary co-factor for both serotonin and dopamine. Supplementing iron can reduce zinc status, also an important mood-regulating co-factor. Even without adding the hormonal component it’s clear why so many women need help with this.

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Anemia, even low grade, should never be dismissed no matter the primary complaint because it affects the ability of every cell in the body to do its job. Iron deficiency has numerous causes. This fascinating paper recently published in Acta Hæmatologica describes the fairly common phenomenon of iron deficiency anemia (IDA) that does not respond to iron supplementation. The authors state: “Recent studies indicate that 20-27% of patients with unexplained IDA have autoimmune gastritis, about 50% have evidence of active H. pylori infection, and 4-6% have celiac disease. The implications for abnormal iron absorption of celiac disease or autoimmune gastritis are obvious.” [Helicobacter is an extremely common stomach infection and the cause of most gastric ulcers.]

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