This is a great article (published) from my friend Leona who works in an anemia clinic. Lots of interesting information.
Anemia and the Surgical Bariatric Patient
By: Leona A. Dove RN, BScN
Anemia is a prevalent diagnosis among the surgical weight loss community. The primary cause of this anemia is related to the absorption of components necessary to build healthy red blood cells. Anemia is clinically defined as a HGB < 120 g/L in men and non-menstruating women and a HGB < 115 g/L in menstruating women. As a Blood Conservation Specialist, I tend to treat all patients whose HGB is < 120. Making allowances for the fact that women bleed once a month does not necessarily make that person feel any less symptomatic in terms of fatigue etc.
Hemoglobin (HGB) is an iron derived blood protein that carries oxygen and nutrients to the tissue. It is what makes our red blood cells, and thus our blood red. Low hemoglobin means less than optimal oxygen and nutrients are getting to our tissues. Some of the symptoms of this lack of oxygen and nutrients getting to our tissues are directly related to the tissues not getting enough oxygen and nutrients (e.g. slow healing and infection at the site of surgery, moodiness because the brain is not getting enough oxygen etc). Other symptoms are related to our body’s reaction to not having enough oxygen and nutrients (e.g. Our respiratory rate increases to get more oxygen into our lungs, our heart beats faster to get more blood carrying less oxygen to our vital centres, our blood pressure drops to hold what blood we have in our vital core instead of sending it to our extremities etc).
As I mentioned HGB is an iron derived blood protein. There are three components necessary for the body to convert Iron to hemoglobin.
Iron-The building blocks of hemoglobin
Vitamin B12- The brick mason
Erythropoietin-The General Contractor
Anemia is a result of a lack of, or functional failure of, one of these three components. The type of anemia can be determined from a common blood test (a complete blood count) specifically two values of that count. Once the CBC is evaluated additional blood work may need to be ordered.
Iron Deficient Anemia
Anemia related to low iron is the most commonly diagnosed anemia. If your body does not have enough iron to convert to hemoglobin, you will not have an adequate hemoglobin level. In the bariatric patient, the iron deficiency is often related to the decreased iron absorption surface. Eighty percent of the iron from our food is absorbed at the level of our stomach. Weight loss surgery significantly reduces the size of the stomach thus significantly reducing the absorption surface for iron as a result most Surgical Bariatric Patients need to increase the intake of iron rich foods and rely on iron supplements to ensure they have the “building blocks” necessary for HGB production.
Iron Rich Diet
It is nearly impossible to poison yourself eating foods naturally containing iron; as such this strategy is perhaps one of the easiest if not safest ways to increase the body’s iron reserve. There are two types of Iron we can get from our food:
Heme Iron: Found in animal protein sources, red meat, poultry (specifically the dark meat of the legs and thighs vs. the breast) and fish. Heme Iron is readily absorbed and used by the body, is not affected by what you eat and drink in conjunction with them and helps the body to absorb and use non-heme irons.
Non-Heme Iron: Found in plant protein sources, beans, lentils, whole grains, dried fruits, nuts, green leafy vegetables and some fruits. Non-Heme Iron is not as readily absorbed and used by the body and are affected by what you eat and drink with them. Heme Iron containing foods, and foods rich in Vitamin C (bell peppers, broccoli, strawberries, citrus fruit, Cantaloupes) increase the absorption and use of non-heme iron. Foods containing Oxalates (coffee, tea, cola, and chocolate) and foods rich in calcium (milk, cheese etc) block the absorption and use of non-heme irons.
To Maximize The Absorption of Iron From your Food:
ü Remember iron is in colourful foods red meat, green leafy vegetables and the rich golden browns of whole wheat. If your food is grey because of age or over cooking what iron was in it is likely minimized.
ü Maximize the body’s absorption and use of Non-Heme Iron by consuming them withfoods containing Heme Iron and/or foods rich in Vitamin C.
ü Avoid the consumption of oxalate and calcium containing foods for one hour before and after your Iron Rich Meal
The arbitrary use of an iron supplement without the recommendation of a health care professional can be dangerous. Iron is a “fat stored” mineral, which can reach toxic levels, resulting in liver damage. If an iron supplement is recommended there is some valuable information you need to have.
There are two generations of iron supplements; the difference is related to where the iron is absorbed.
I. Iron Salts (ferrous sulfate, ferrous Gluconate, ferrous Fumarate) are absorbed in the stomach. They must be taken on an empty stomach (1 hour before a meal or 2 hours after a meal) to maximize its absorption. They cannot be taken with calcium containing medications or foods, aluminum salts based antacids (Maalox, gaviscon, Tums) or oxalate containing foods as these things block the absorption of the iron salt. The use of Vitamin C in conjunction with the Iron Salt will increase the absorption of the iron salt. Recent studies have also proven that the use of Proton Pump Inhibitors and H2 inhibitors (medications that reduce the acidity of the stomach “juices”) inhibit the digestion and absorption of iron salts.
Things to know about Iron Salts
ü Can cause black “tarry” or “sticky” constipated stools. Fastidious skin care is necessary after bowel movements to avoid painful skin irritation in this area.
ü Should not be taken with coffee, tea, milk, cola, or chocolate as these will block its absorption
ü Consider taking your iron salt supplement with a juice rich in Vitamin C to maximize its absorption. My personal favorite is a swallow of prune juice for two reasons:
i. Prune juice is a natural laxative ii. Prune juice is rich in iron
ü Can cause gastric irritation and GERD like symptoms, this can be minimized by remaining in an upright position for 30 minutes after taking the iron salt
ü Antacids (Maalox, Gaviscon), or calcium supplements should not be taken within 30-60 minutes of the iron salt because its absorption will be blocked.
ü Absorption of Iron Salts is most effective when taken on an empty stomach (one hour before you eat or two hours after you eat). Personally and professionally I recommend two hours after you eat to decrease the gastric irritation and GERD like symptoms common to iron salts
II. Non-Salt Iron Supplements
A. Proferrin is a bovine sourced HEME iron. It is absorbed in the small intestine
B. Polysaccharide Irons (FeraMAX, Triferritin) are manufactured irons also absorbed lower in the digestive tract. Severely Iron Deficient patients may be prescribed an intravenous form of polysaccharide iron, while beneficial in some cases this alternative will not be discussed today. Things to know about Heme and Polysaccharide Irons ü DO NOT need to be taken on an empty stomach
ü Are Not effected by the use of antacids, calcium supplements Proton Pump Inhibitors, or H2 Inhibitors
ü Are Not effected by Vitamin C consumption
ü DO NOT cause Gastric Irritation or GERD like symptoms
ü DO NOT usually cause black tarry, sticky or constipated stools.
The Great Supplemental Iron Debate
ü ODB most supplemental health plan will cover prescribed Iron Salts.
Some supplemental health plans will cover Proferrin if bought with a prescription.
Polysaccharide Iron Supplements are considered a dietary supplement (they have no DIN) and are not covered by either ODB or Supplemental health plan
ü Decreased absorption surfaces resultant from surgically decreasing the stomach size directly results in the decreased absorption of iron salts
ü Use of Proton Pump Inhibitors, and H2 inhibitors decrease the digestion and absorption of iron salts
ü Although exact location in the intestine where polysaccharide and heme irons are absorbed has not been mapped, it is believed that polysaccharide irons are absorbed still lower than Heme irons and as such are the supplement of choice for Duodenal Switch patients
ü Heme irons are derived from animal sources vegetarians, and certain religious groups may object to using such derivatives
ü Physicians and dieticians are more familiar, and thus more comfortable with the use of Iron Salts as opposed to Heme and Polysaccharide Irons
B12 Deficient Anemias
As mentioned earlier B12 is the brick mason of HGB production. B12 stimulates the conversion of Iron into Hemoglobin. Without sufficient B12 adequate Iron reserves cannot be converted into oxygen and nutrients carrying Hemoglobin. The absorption of B12 requires Intrinsic Factor which is secreted by the stomach. The area where Intrinsic Factor is excreted is severely reduced and/or completely lost during the surgical reduction of the stomach. Without sufficient Intrinsic Factor, B12 from food or oral supplements cannot be absorbed. It is recommended that Surgical Bariatric Patients take a sublingual (under the tongue) B12 supplement or regular B12 injections.
Erythropoietin and Anemias
Erythropoietin is a hormone manufactured and excreted by the kidneys; it is the substance that triggers the bone marrow to use hemoglobin to produce Red Blood Cells. It is very possible to have adequate stores of Iron and B12 and still be anemic related to an insufficiency of erythropoietin. This malady is common in patients with impaired kidney function. The reason why I mention it however is that it is possible to use synthetic erythropoietin (Eprex) in conjunction with oral and sometimes intravenous iron supplements to rapidly boost the hemoglobin of patients with severe iron deficient anemias.
Anemia is a broad spectrum diagnosis, individually honed through the assessment of the patient and their lab work. Just as every patient is unique so is the treatment of their anemia. I urge you all to advocate for yourself, be health care consumers, educate yourselves and in turn educate the health care professional that is caring for you