Chapter One
Could You Be Anemic?
A SPOT CHECK
For a quick indication of whether you might be anemic, spot-check the following three places on your body: Take a look at the mucous membrane on the inside of your lower lip, gently pull down your lower eyelid and look there, and finally stretch the skin on the palms of your hands so that you can see into the base of your heart line and your life line, the palm's two deepest creases. These three places are always pale in someone who is anemic, even if the person has pink cheeks (pink cheeks can be attributed to a hot room or to the heart pumping the blood fast, for instance after aerobic exercise).
A whole galaxy of possible signs and symptoms of anemia is described in Chapter 3, and if you are anemic you may show one, several, or even possibly none of them. Your hair is a useful give-away in long-established anemia. Is it becoming thinner, both in quantity and texture? Is it losing its color and going gray if you are dark, or a dirty straw color if you are blond? And is this happening sooner than in your friends or in your mother, if she can remember?
VAGUE SYMPTOMS
Chances are, even if you are anemic, you won't suspect it.
Kirsty said she couldn't have anemia; she ate well, rather too well, and was definitely plump. Her weakness was rolls and buns and bread and potatoes-all of them deficient in iron, vitamins, and protein. Her fatigue was not due to overweight, but rather to anemia from undernourishment.
Carol was slim, in fact verging on anorexic, and she, too, was sure she was not anemic. She ate such "healthy" food-all fruit, salads, and vitamin tablets. She was depriving herself of iron and protein-vital raw materials for making blood.
Susie was losing weight and was trying to live on lettuce, black coffee, and an occasional boiled egg.
All these girls were in the peak age range for developing anemia, fifteen to twenty, and none of them was getting enough iron to reequip her red blood cells as they wore out from daily living.
Eloise felt she was at no risk for anemia. She was forty-one, and she had taken iron tablets since the birth of her one child (she intended to have no more). She always washed them down with her favorite beverage, hot, strong tea. But the tannin in the tea precipitated the iron into insoluble, unabsorbable solids, like the deposit staining the inside of her teapot.
Jennifer, too, felt she could not get anemia because she was taking iron supplements. Quite often, however, she forgot them for several days running, so to make up she would swallow two or three at a time. This was counterproductive. The first tablet would temporarily flood her system with iron, to the point where her body failed to absorb any more.
Most illnesses display overt signals of their presence. You wake up one morning feeling "not quite right," or you are nauseated, feverish, or have a sore throat or pain. You have no doubt that something is wrong when it happens. By contrast, anemia creeps up on you slowly, perhaps taking years, so that you fail to notice the changes as they occur. Besides, the symptoms themselves may be so vague-a fall-off in energy, the stairs seeming steeper, your appetite diminishing for meat meals especially, your memory on the blink-that they're nothing you can identify as "abnormal."
Pre-Anemia
The smart move is to pick up on the situation when you are heading for anemia and zap it while you still have time to sidestep the illness and the challenges of curing it. If your iron level is low and/or falling, you are most likely in a pre-anemic state. Depending on how iron stores are measured, as many as 30 percent of American women of childbearing age are iron deficient (in the same study, the ratio of iron-deficient women increased to 48 percent of those who were regular blood donors); yet only about 5 percent have full-blown anemia. Women who are low in iron during pregnancy are more likely to have a baby that is premature or seriously underweight.
To determine whether you're pre-anemic, one clue to look out for is a reduced capacity for physical work or exercise. For example, I had a patient who became aware she might have a problem because her golf handicap was going up. Or you may first become aware of reduced powers of concentration. This shows up most clearly in schoolchildren, because they are constantly being tested and compared with others.
Iron deficiency-before it reaches the level of anemia-is a health problem in its own right; in fact, epidemiologists label it the world's most common nutrition disorder. Without adequate iron, the component of hemoglobin that is responsible for carrying oxygen cannot be manufactured.
WHEN TO TEST FOR IRON DEFICIENCY
The most useful investigation for determining iron stores is a blood test that measures hemoglobin level; this assessment is always included in routine blood testing. A low hemoglobin level spells anemia for sure. Another method is the serum ferritin test, which measures the concentration of iron in the blood. Some researchers consider it more effective than the hemoglobin test for determining pre-anemic iron deficiency, but it is a more difficult test to perform. Usually the hemoglobin test is enough.
Persons should have their blood tested for iron-deficiency anemia if they fall into any of the following "at-risk" groups for anemia:
* Those undergoing rapid growth, such as during childhood and adolescence, when heavy demands are placed on the body
* Babies under twelve months of age. There is a special risk of decreasing iron reserves between the ages of four months and twelve months
* Those entering puberty, especially during the development of the sex organs
* Pregnant women. Demands are increased by the growing breasts and womb, as well as by the fetus, the placenta, and the amniotic fluid
* Nursing mothers. Although the level of iron in breast milk is small, even a small loss adds up if it is sustained regularly for weeks or months
* Those who have sustained a loss of blood, for example due to surgery or injury. The body requires weeks to make up the loss of blood from a serious injury unless action is taken, usually in the form of a blood transfusion. Meanwhile, anemia makes a patient vulnerable to other illnesses
* Women experiencing heavy periods due to the presence of uterine fibroids or for any other reason
* Women who have recently given birth. Blood loss during childbirth was a common cause of death among women until Victorian times (this phenomenon is a rarity today in Western cultures)
* Those suffering from bleeding hemorrhoids (the condition thought to be responsible for the Queen Mother's anemia). Hemorrhoids are easy to ignore if the blood loss is slight, but can have a serious effect if it is continuous
* Persons bleeding from a peptic ulcer or ulcers in the intestines. The blood shows red if the leak is from low down in the digestive tract, but may be black if the blood has traveled far. A black stool shows a substantial loss of blood from the esophagus or stomach
* Persons undergoing long-term use of certain painkillers. Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, especially can cause bleeding from the stomach. These drugs are used frequently to treat arthritis
* Those who've had a stomach operation, for whatever reason. Such patients should have an annual blood test indefinitely
* Those who've experienced a loss of blood through the digestive system due to any other reason. The occult blood test picks up leaks of blood from the digestive tract, and is useful when such leaks cannot otherwise be pinpointed (occult means hidden)
* Persons who suffer from poor absorption of iron and nutrients-caused by damage to the lining of the small intestine -because of IBD (inflammatory bowel disorder), ulcerative colitis, or Crohn's disease
* Those with bad teeth, who cannot eat meat, nuts, fruits, and vegetables. A diet lacking in these foods is deficient for warding off anemia. A diet composed mainly of soft carbohydrate foods is easy to prepare and swallow, and senior citizens, particularly those who live on their own, often slip into such eating habits
* Athletes-amateur or professional-who engage in excessive running and/or jumping. These activities may damage the red blood cells in the feet so that they leak. Some athletes give their hemoglobin a boost with a blood transfusion before a big event, although officially this practice is not allowed
* Frequent blood donors, or those who donate when the body's blood reserves are low
Astrid was twenty-three when she took a year off and traveled around South America. In Colombia her money ran out. When she saw a notice offering dollars for blood she thought it would be a simple matter. She had given blood twice before at home in the UK, and had experienced nothing worse than a light-headed feeling for an hour or two afterwards. Giving blood once would have been harmless enough, but she failed to bounce back after a second donation, especially since she was on an iffy diet. She kept experiencing waves of faintness, her energy seemed to have drained away with the blood, and she felt depressed. When Astrid got home a hemoglobin test showed a level of 8 g/dl (grams per deciliter), well below normal (the minimum normal level is 11.5 g/dl for women and 13.5 g/dl for men).
Key Life Stages
As is probably evident from the list above, people are especially susceptible to developing anemia during the following normal life stages. At these times, people need to pay special attention to their diet, and they should undergo blood tests regularly:
* During the first year of a baby's life
* During the fast-growing teen years
* During and after pregnancy, especially while breastfeeding
* While going through menopause
* In the golden years, over age sixty-five
The special risk factors for anemia in each of these phases in a woman's life are addressed in Chapters 8 through 12.
DANGEROUS DIETS
People who follow faddish or extreme diets are at high risk for anemia-or worse. In particular, the following diets, if strictly followed, provide insufficient nutrition for preventing anemia:
* The Zen macrobiotic diet has ten levels; the "highest" level consists only of grains, with few fluids.
* The Beverly Hills weight-reduction diet consists only of fruit, eaten in a particular order. It cannot sustain the body for long.
* Dr. Atkins' diet, which contains almost no carbohydrate, has been denounced by much of the medical community as a seriously unbalanced diet. I do not recommend it, although a new edition of his book was introduced in late 2001.
* Veganism-a diet that contains no animal products-can lead to pernicious anemia in particular, with madness and paralysis as severe symptoms. Pernicious anemia is caused by a deficiency in vitamin B-12, which comes only from animal products (see Chapters 5 and 6 for more on vitamin B-12 deficiency and pernicious anemia). Breast-fed babies of vegan mothers are at risk of stunted or distorted development.
* Strict vegetarianism is less dangerous than veganism but can still cause anemia.
ISOBEL'S STORY: A NIGHTMARE WITH A HAPPY ENDING
The whole family was plunged into gloom when Isobel, a sprightly grandmother of seventy-three, fell ill. Even her doctors failed to recognize the cause of her symptoms. She developed odd, jerky movements of her head and arms, would eat hardly anything, and lost weight, but worst of all were the mental symptoms. In the daytime she would laugh or cry at the slightest thing, for instance a picture of a puppy in the newspaper, while at night she moaned incessantly and seemed terrified.
This horror went on for six months. The diagnosis at the time was dementia and the outlook grim. Her husband and children were in despair, until a routine general checkup, which included a blood count, showed that Isobel had less than half the normal level of hemoglobin. Severe anemia was depriving her brain and nervous system, as well as her body, of the oxygen and nourishment it needed to function.
The cure was simple. An immediate transfusion of three pints of blood worked a miracle. Her mind cleared, her appetite returned, and a change in her diet, including the addition of iron supplements, has kept her well ever since. Her hemoglobin level is monitored regularly.
Isobel's was a rare case, and was published in the medical press, but it illustrates dramatically the risk of even very severe anemia being overlooked.
Chapter Two
All about Your Blood
Blood: It is a sign of danger or violence if you spill it, yet it is the evidence of health in your child's rosy cheeks. It is the very stuff of life. The ancient Hebrews believed that a person's blood contained his soul; this is why the blood is drained off kosher meat. The Romans thought it carried their most esteemed virtue, courage. If a valiant warrior was slain there was competition to drink his blood-and thereby acquire his bravery. Traits of character, good or bad, are still said to be "in the blood," but nowadays the saying has to do with the legacy we've inherited from our parents, that is, the genes.
WHAT BLOOD IS MADE OF
Blood consists of a straw-colored liquid called plasma, which houses three important elements: red corpuscles (corpuscle is another word for cell), white corpuscles, and myriad minute bodies called platelets.
Red Blood Cells
The red cells-the blood cells that contain life-giving hemoglobin-are the most important ones, but it wasn't until about 1700 that a Dutchman, Jan Swammerdam, first spotted them with his primitive microscope. "Ruddy globules" he called them, but no one was interested. In fact, red blood cells aren't globular but are an unusual shape: like a disc, with the middle part thinner than the edges. This allows them to be squashed into all sorts of shapes without breaking as they are squeezed through the tiniest blood vessels, the capillaries, to carry oxygen to the tissues. If they are the wrong size or shape they cannot function properly, and the person becomes anemic.
A healthy red cell lives for 110 days, give or take three weeks; this means there must be a constant replacement system. (This applies to all the body's other cells, too.)
Francesca's parents came from southern Italy, but they settled in England before she was born because of better job opportunities. Francesca lived a perfectly healthy life until she was twenty-five and got a job as a flight attendant. After a few months she started seeing blood in her urine; this was quite painless, but she became increasingly tired, easily short of breath, and unusually prone to colds and other infections. In spite of a good diet she looked pale and was found to be anemic. Microscopic examination of her blood showed that a number of her red cells were an odd, new-moon shape. These are called sickle cells, and the trait is hereditary. It is most common in Africa, the Arab countries, a few parts of southern Europe, and among African Americans. The sickle-shaped cells tend to get jammed in the blood vessels, and then the white blood cells-the blood's police officers-destroy them. The end result is a shortage of red cells and their hemoglobin: anemia. It was this anemia that made Francesca so tired.
Until she traveled by air regularly her red cells had been, for all practical purposes, normal, and she was not anemic. However, she carried the hereditary sickle-cell trait from her father, which made her red cells vulnerable to the lowering of oxygen levels at high altitudes. They reacted by forming the sickle shape (a similar effect could have occurred if she'd gone under general anesthesia for an operation). Apart from these situations a carrier of the sickle-cell trait usually experiences no problems and may even be unaware of it.
Francesca could not change her heredity, but she could, and did, change her job, and meanwhile underwent short-term treatment for the temporary anemia.
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Excerpted from Anemia IN WOMENby Joan Gomez Copyright © 2002 by Dr. Joan Gomez. Excerpted by permission.
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