Iron deficiency anaemia

If you have anaemia, you may not have any symptoms at all. If you do have symptoms, they’ll differ depending on the type of anaemia that you have. However, there are some common symptoms of all types of anaemia which include feeling:

• tired
• weak
• dizzy
• short of breath
• a thumping or unusual beating of your heart- called palpitations

These symptoms can be caused by other things, but if you do have any of the above, contact your GP surgery for advice.

There are many different types of anaemia, which are all caused by different things. Some of the different types of anaemia are outlined below.

Iron deficiency anaemia
This type of anaemia is the most common and happens if your body doesn’t have enough iron. Your body needs nutrients like iron to make something called haemoglobin. Haemoglobin is a key part of your RBCs and without it, they can’t work properly. The normal amount -concentration- of haemoglobin is at least: 13g/dl for men, 11.5g/dl for women, 11g/dl for pregnant women.

Symptoms of iron deficiency anaemia include:

• Feeling breathless after little exercise
• Feeling tired, looking pale
• A rapid pulse or palpitations (the sensation of feeling the heartbeat thumping in the chest)

You may become deficient in iron if:

• you lose a lot of blood
• you’re not getting enough iron in the foods that you’re eating
• your body is using more iron than usual - for example, if you’re pregnant

Vitamin B12 deficiency anaemia
You need vitamin B12 for many important processes inside your body. It helps to keep your nerves healthy and is used to make RBCs. If your body lacks vitamin B12, it can’t make as many RBCs as normal. The ones it does make are larger and get removed from your bloodstream quicker than usual.

Your body may lack vitamin B12 if:

• the foods you eat don’t contain enough vitamin B12 - a common problem for vegetarians and vegans
• your body can’t absorb the vitamin - an immune condition called pernicious anaemia can cause this

Folate deficiency anaemia
Your body uses folate to make cells (including your RBCs). If you don’t have enough folate (B vitamin), your body can’t make enough RBCs to meet its needs. They will also be abnormally large and won’t last as long as they should.

If you don’t have enough RBCs, your tissues and organs may not get enough oxygen. This leads to the following symptoms:

• a sore tongue
• indigestion
• a reduced sense of taste
• diarrhoea

You may become deficient in folate if:

• Poor diet. Your body can’t store folate, so you would need to eat foods that contain folate every day.
• Medicines. Certain epilepsy medicines and methotrexate, which is used to treat rheumatoid arthritis, can interfere with the way that folate used in your body.
• Alcohol.
• Bowel disease
• Chronic haemolytic anaemias – Including certain inherited conditions such as thalassaemia and sickle cell anaemia.
• Pregnancy – If you’re pregnant, you might require more folate to meet the needs of your developing baby.

Anaemia of chronic diseases (ACD)
Some conditions like HIV and hepatitis C can cause ACD. If your body gets injured, for example, during surgery or after an accident, this can also cause ACD. These can result in anaemia because the inflammation they cause interferes with the iron that’s kept in your body. Fewer RBCs are made and sometimes those that are don’t last as long in your bloodstream as they should.

Anaemia of chronic kidney disease
Some conditions like HIV and hepatitis C can cause ACD. If your body gets injured, for example, during surgery or after an accident, this can also cause ACD. These can result in anaemia because the inflammation they cause interferes with the iron that’s kept in your body. Fewer RBCs are made and sometimes those that are don’t last as long in your bloodstream as they should.

Haemolytic anaemia
If you have kidney damage, this can cause anaemia. This is because your kidneys make something called erythropoietin that’s needed for your body to make RBCs. If you have kidney damage, you won’t produce as much erythropoietin, and therefore RBCs.

Aplastic anaemia
Aplastic anaemia is rare. It’s a condition that affects your bone marrow – the soft, spongy part inside your bones where your blood cells (including your RBCs) are made. If you have aplastic anaemia, you produce fewer RBCs than normal. Your other blood cells (including your white cells and platelets) are usually affected too.

For some people symptoms of aplastic anaemia are quite mild, but for others it can be a life-threatening condition. Lots of different things can cause aplastic anaemia, including some medical conditions and certain types of drugs. But most commonly, the cause of aplastic anaemia isn’t known.

Sickle cell anaemia
Sickle cell anaemia is a condition that is inherited from your parents. If you have this condition, your body makes faulty haemoglobin which causes your RBCs to form an unusual crescent shape. If you have sickle cell anaemia, your RBCs may clot under certain conditions. These blood clots then interfere with the flow of blood around your body. This is called a sickle cell or vaso-occlusive crisis.

Your GP will ask about your symptoms and examine you. He or she may also ask about your medical history. If your GP suspects you have anaemia, they’ll ask you to have a blood test. Your blood will be sent to the laboratory for some of the following tests.

• A full blood count (FBC). This is to check the level of haemoglobin in your blood and how many of each of the different types of blood cell you have.
• A check on iron, vitamin B12, and folate levels.
• A blood film test. This involves looking at your blood under a microscope to check the size and shape of your red blood cells (RBCs). It will also assess the other cells that make up your blood.

You may need to have further tests to help identify the cause of your anaemia. Some of these investigations may need to be done at the hospital. Depending on the type of anaemia you have, your GP may refer you to a specialist.

Anaemia is caused because you don’t have enough red blood cells (RBCs) or haemoglobin – the part of your RBCs that carries oxygen – to meet your body’s needs. This can happen if:

• your body lacks vitamins and minerals that are needed to make haemoglobin
• your body makes RBCs that don’t work properly
• your RBCs are destroyed or lost from your body - for example, when you bleed

To treat anaemia you have to treat the underlying cause. Your treatment will therefore differ depending on the type that you have. Outlined below are some of the different types of anaemia and how they can be treated.

Iron deficiency anaemia
If you’re iron deficient, it’s important to find out why this may be so you can get the right type of treatment. Some people have iron deficiency anaemia because they aren’t getting enough iron from the foods they eat. If this is the case, you can start to make a difference at home by eating foods rich in iron. These include:

• dark green vegetables - for example, spinach or chard
• red meat
• apricots
• prunes
• raisins

Your GP may also recommend that you take iron supplements, such as ferrous sulphate tablets. Iron supplements make up for the shortage of iron and will then build up your body’s stores of iron to the normal level. You will usually need to take tablets two to three times a day for up to seven months.

Side-effects of taking iron supplements may include constipation, heartburn, nausea, tummy (abdominal) pain or diarrhoea. If you have these side-effects, contact your GP surgery for advice. You may need a lower dose or a different type of iron supplement. If this type of iron supplement isn’t working, or you can’t tolerate the effects, you may be offered treatment with iron injections.

If this isn’t the case, you may need further tests to find out what’s causing your iron deficiency so that you can get the best possible treatment.

Vitamin B12 deficiency anaemia
Finding out why you have vitamin B12 deficiency anaemia is important so you can get the right type of treatment. If you’re deficient because you have an underlying condition called pernicious anaemia, you’ll need to have vitamin B12 injections. You’ll need injections because pernicious anaemia stops you from being able to take in (absorb) vitamin B12.

If you have this type of anaemia because you’re not getting enough vitamin B12 from the foods you eat, your GP will recommend eating more vitamin B12-rich foods. Products that come from animals such as meat, fish, milk and eggs are all good sources. Others include some fortified soy products and cereals. These products have vitamin B12 and other nutrients added to them, making them ideal for vegans and vegetarians.

As well as keeping an eye on the foods you’re eating, you may also need supplements to replace the vitamin B12 in your body. If your body’s vitamin B12 levels go back to normal and your diet has improved, this treatment may be stopped. For more information on vitamin B12 deficiency anaemia and supplements, see our FAQ on Vitamin B12 injections and anaemia.

Folate deficiency anaemia
To treat folate deficiency anaemia your GP will advise you to eat foods containing lots of folate, including:

• broccoli
• Brussels sprouts
• asparagus
• peas
• chickpeas
• brown rice

You may also need to take folate (folic acid) supplements to help get your folate levels back to normal. Most people take an oral supplement, meaning the supplement is swallowed or ingested rather than being injected into your body. Folate comes in a synthetic (artificial) form called folic acid. This is a water-soluble vitamin that your body can use instead of folate. You will usually need to take 5 milligrams per day. Treatment usually lasts for around four months.

If you’re taking folic acid to treat anaemia, your GP will monitor your blood count and folate level. You will be asked to have a blood test shortly after you start taking the supplements and again about eight weeks later to confirm that you’re responding to the treatment.

Special considerationsIf you're pregnant and don't get enough folate in your diet, there is an increased risk of your baby developing a neural tube defect. It can result in spina bifida, which is where your baby's spine doesn’t form properly.

If you're planning to have a baby, you should take a supplement of 400 micrograms of folic acid before you become pregnant, and also in the first 12 weeks of pregnancy. This will help to reduce the risk of your baby having a neural tube defect. If you have previously had a child with this problem, ask your GP for advice as you may need to increase your intake of folic acid during your pregnancy. See our common questions for more information.

It's also important to eat folate-rich foods, such as broccoli, Brussels sprouts, asparagus, peas, chickpeas and brown rice. Although liver is a good source of folate, pregnant women shouldn't eat liver or liver pâté because it contains lots of vitamin A. Large intakes of vitamin A during pregnancy are linked to an increased risk of birth defects.

Anaemia of chronic diseases
If your anaemia is being caused by another underlying condition, it’s important that you get treatment for it to help improve your symptoms.

If your anaemia is manageable, it’s possible that you won’t need to have any treatment at all. But if your anaemia is interfering with your day-to-day life, or is a risk to your health, there are treatment options available.

Erythropoietin stimulating agents (ESAs). This type of treatment is used to help your bone marrow make more red blood cells (RBCs).Blood transfusion.

Anaemia of chronic kidney disease
Your kidneys produce something called erythropoietin that’s needed to make RBCs. If you have kidney damage, you won’t have enough erythropoietin, and therefore RBCs, to meet your body’s needs.

To treat anaemia of chronic kidney disease you may have erythropoietic-stimulating agent (ESA) therapy to help your bone marrow make more RBCs. If ESA works for you, you may also be given iron supplements. This is because iron is used up when making RBCs and so you may become deficient in iron during ESA treatment.

You may also be treated for iron deficiency more generally as iron deficiency can contribute to anaemia of chronic kidney disease. For example, some people with chronic kidney disease have trouble using the iron that’s already stored inside their body or absorbing iron in the first place.

Haemolytic anaemia
If you have haemolytic anaemia, the type of treatment you have will depend on what the cause is. You may need to stop taking certain drugs or get treatment for any underlying infections or conditions that could be causing your symptoms. You may also need to take folate supplements. This is because haemolytic anaemia can cause you to become folate deficient. Some people with haemolytic anaemia may also need to have a blood transfusion, but this will only happen if it’s absolutely necessary.

Aplastic anaemia
Most cases of aplastic anaemia are mild and don’t need any treatment. However, if your anaemia is severe you may need any of the following:

• immune suppressive therapy (IST)
• stem cell transplant
• blood transfusion

If you’ve been diagnosed with aplastic anaemia and need treatment, talk to your doctor about your options.

Sickle cell anaemia
If you have sickle cell anaemia, treatment is based around stopping your symptoms from coming on and managing them if they do. Treatments include things like managing your pain with painkillers, taking a drug called hydroxycarbamide, blood or exchange transfusions and taking antibiotics to stop you getting infections. A bone marrow transplant can cure patients with sickle cell anaemia, but because of its complications, very careful thought will be given before you have this treatment.

To stop your symptoms from coming on, you should avoid things that can trigger them. Make sure you:

• keep hydrated
• don’t push yourself too much when doing exercise
• avoid the cold
• avoid high altitudes
• treat infections promptly

Complications can vary depending on the type of anaemia you have. Some general complications of anaemia may include:

• feeling very tired
• feeling short of breath
• heart problems
• increased risk of infections

Making sure you get enough of the right vitamins and minerals from the foods you eat, can help to prevent some types of anaemia. This includes some vitamin B12, iron and folate deficiency anaemias. Some food sources that contain lots of these vitamins and minerals are outlined in the table below.

Sources of vitamins and minerals

Vitamin or mineral	Source
Iron	Red meats including beef and lamb Green vegetables including spinach, watercress and kale Dried fruits such as apricots
Folate	Poultry Pork Shellfish Green vegetables including pees, Brussels sprouts and broccoli
Vitamin B12	Red meats including beef and lamb Eggs Dairy products

Where you can, make sure you get enough of these in your diet. You should also try to get enough vitamin C. Vitamin C is important as it helps your body take in iron from the food and drink you consume. Orange juice is a good source of vitamin C and convenient if you’re on the go.

Some types of anaemia can’t be prevented. One example is sickle cell anaemia. If you have sickle cell anaemia, you may be offered genetic counselling to talk about the risk of your children also having the condition.

1. Will my iron-deficiency anaemia need to be monitored? How often should I go back to see my GP?

Answer
Once you have been diagnosed with iron-deficiency anaemia and started treatment, you will need to go back to your GP for further blood tests to make sure that your blood count and iron levels have returned to normal.

Explanation
The most common treatment for iron-deficiency anaemia is a course of iron tablets, such as ferrous sulphate tablets. You should take the tablets as directed by your GP - usually, you will need to take them two to three times a day. Always read the patient information leaflet that comes with your medicine, and if you have any questions ask your GP for advice.

You will be asked to return to your GP two to four weeks after starting your iron tablets for a blood test, to check that they are working. You will then need to return two to four months later to make sure that your haemoglobin level has returned to normal.

Once your GP is happy that your blood count is normal, you will usually need to continue taking your tablets for a further three months. This is to make sure that your body's iron stores are completely topped up. Once you have stopped taking your tablets, you will need to return to your GP for a blood test after a few months. If your blood count and iron level have fallen again, you will be given another course of iron tablets.

If the iron tablets prescribed by your GP aren't working, you may be referred to a haematologist for further investigation. A haematologist is a doctor who specialises in treating blood disorders. It's very important to understand why you have iron-deficiency anaemia because it's usually caused by blood loss. In women, this is most often through heavy periods, but in men and older women it's possible that there is bleeding from your stomach or bowel, so this must be investigated.

If you have any questions or concerns about iron tablets or iron-deficiency anaemia, talk to your GP.

2. I get an upset stomach when I take iron tablets, what should I do?

Answer
Some people find that they get an upset stomach when taking iron tablets, but it's important to continue taking the tablets as directed by your doctor if at all possible. If you need to, you can take over-the-counter medicines to ease your stomach symptoms until they settle by themselves.

Explanation
When taking iron supplements, some people find that their digestive system is disturbed. This can cause:

• stomach pain
• constipation or diarrhoea, often with black faeces
• heartburn
• nausea

Usually these symptoms settle down quickly, so there is no need to stop taking your tablets. In the meantime, there are medicines you can buy from your pharmacy to relieve your symptoms, for example, antacids for heartburn or medicines for constipation.

You could also try taking your tablets with or after food rather than on an empty stomach, and as one daily dose instead of spreading them out through the day.

It's important to follow your GP's advice and keep taking your iron tablets as directed. If they are causing you a lot of discomfort and your symptoms don't settle, go back to see your GP before you stop taking them. He or she will be able to advise you on alternative brands or formulations to try.

3. I've heard that taking too many iron tablets can be harmful, why is this?

Answer
Taking a large number of iron tablets at one time is extremely dangerous, and can be fatal. It can damage your gut and liver and cause heart failure. Taking iron tablets over a long period of time when you don't need to can also be harmful.

Explanation
Taking too many iron tablets is harmful to your body for two reasons. First, it can damage your gut, and secondly, it can harm organs such as your heart and liver and may cause irreversible damage.

If you have taken too many iron tablets, you must go to hospital as quickly as possible - an iron overdose is a medical emergency. Treatment is best started within one hour of taking the tablets, so it's important to take immediate action.

Iron overdose is the most common type of childhood poisoning, usually happening when children take tablets meant for adults. Iron tablets are often brightly coloured and sugar-coated, so can be mistaken as sweets by children. It's extremely important to make sure that all medicines and tablets are kept out of the reach of children.

If you take a normal dose of iron tablets over a long period of time when you don't need them, this can also be harmful. Iron can build up in various organs, such as your liver, pancreas and heart, and eventually cause damage. It's particularly important to avoid taking unnecessary iron tablets if you have certain inherited conditions such as genetic haemochromatosis or thalassaemia.

Always read the patient information leaflet that comes with your medicine and follow the recommended dose, unless you have been instructed otherwise by your doctor.

If you have any questions or concerns about iron overdose, talk to your GP.

4. What is hookworm infection and how does it cause iron-deficiency anaemia?

Answer
Hookworm infection occurs when a parasitic worm (hookworm) gets into your gut and feeds from the wall of your bowel. This may result in blood loss and is a common cause of iron deficiency in certain parts of the world, such as the tropics.

Explanation
Hookworms are parasitic worms that you can pick up from eating contaminated foods or through your skin, usually the soles of your feet. They are commonly found in developing, tropical countries. It's estimated that over 740 million people in the world have a hookworm infection.

Once inside your body, the hookworms pass into your lungs. They are then coughed up and swallowed down into your gut (gastrointestinal tract). Once there, they attach themselves to the wall of your bowel and feed on your blood.

Most hookworm infections are mild and there are usually no symptoms. However, if the infection is more severe, the blood lost from your gut (sucked by the worms) can lead to iron-deficiency anaemia. Other symptoms can include an allergic reaction in a specific part or all over your body, and stomach pain. These symptoms can be caused by many conditions, not just hookworm. It's important that you see your GP to get the correct diagnosis.

Once your GP has examined you and asked about your symptoms, he or she will ask you for a sample of faeces. This is because, once in your bowel, hookworms pass their eggs out through your faeces. You will also be asked to have a blood test. These will both be sent to a laboratory for testing. Once diagnosed, your GP may refer you to a doctor who specialises in treatment of tropical diseases.

Treatment of a hookworm infection is with a medicine called mebendazole. You will need to take it twice daily for three days. You will also need treatment for your iron-deficiency anaemia. This is usually a course of iron tablets, such as ferrous sulphate tablets. Always ask your doctor for advice and read the patient information leaflet that comes with your medicine.

If you have any questions or concerns about hookworm infection or iron-deficiency anaemia, talk to your GP.

5. Is anaemia a life-threatening condition?

Answer
For the majority of patients anaemia is not life-threatening, but rarely it can be. Your doctor will be able to assess which category you fall into and refer you appropriately.

Explanation
Vitamin deficiency anaemias can often be treated successfully by making small changes to your diet and with other treatments like taking supplements. If treated in the right way, there’s no reason why these types of anaemia should become life-threatening.

However, if your anaemia isn’t managed properly and gets worse, this can lead to potentially life-threatening complications like heart failure. Some types of anaemia can also be caused by other severe and potentially life-threatening conditions. In this way, anaemia can then be seen as a life-threatening condition. Some iron deficiency anaemias for example can happen because you are bleeding as a result of a cancerous tumour.

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Further Information

• British Nutrition Foundation - 020 7404 6504 - www.nutrition.org.uk

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