5 things you should know about anemia

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Anemia simply means your blood isn’t carrying enough oxygen to your body. The most common form of anemia is when you don’t have enough iron. Iron plays an important role in carrying oxygen on your red blood cells throughout your body. There are many different types of anemia and it can be temporary or permanent; it may also be mild or potentially severe.

The cause of anemia is simply a lack of enough red blood cells in your blood. This deficit may stem from your body not making enough red blood cells, or you may be bleeding, causing you to lose red blood cells more quickly than can be replaced, or your body may be destroying red blood cells.

Red blood cells are one of three types of blood cells your body makes – white blood cells to fight infection, platelets to clot your blood, and red blood cells to carry oxygen around your body. Red blood cells contain hemoglobin, which enables them to carry oxygen from your lungs all over your body and to carry carbon dioxide back to your lungs to be exhaled.


The majority of blood cells (including red blood cells) are made in your bone marrow, a spongy material in the spaces of many of your large bones. Your body needs iron, vitamin B12, folate and other nutrients from your diet to produce hemoglobin and red blood cells.

Common types of anemia, which we will discuss in more detail below, are iron deficiency anemia, vitamin B12 deficiency anemia, anemia during pregnancy, aplastic anemia, and hemolytic anemia.

Iron deficiency anemia

Iron deficiency anemia is common and easily treated. It happens over time when you don’t have enough iron levels in your body to build healthy red blood cells, which ultimately leads to a lower than normal number of red blood cells.

Severe iron deficiency anemia can lead to heart problems, infections, and problems with growth and development in children, among other complications.

Iron deficiency anemia occurs when your iron stores are low due to:

  • Your losing more blood cells and iron than your body can replace;
  • Your body not doing a good job of absorbing iron;
  • You not eating enough iron-containing foods; or
  • Your body needing more iron than normal (i.e. if you’re pregnant or breastfeeding).

Common causes of bleeding that can cause iron loss are

  • Heavy, long, or frequent menstrual periods;
  • Cancer in the esophagus, stomach, small bowel, or colon;
  • Esophageal varices, often from cirrhosis;
  • The use of aspirin, ibuprofen, or arthritis medications for a long time, which can cause gastrointestinal bleeding; and
  • Peptic ulcer disease.

Causes of iron deficiency anemia

Your body may have difficulty absorbing iron if you have:

  • Celiac disease;
  • Crohn’s disease;
  • Gastric bypass surgery; or
  • Take too many antacids containing calcium.

You may not get enough iron in your diet if:

  • You’re a strict vegetarian; or
  • You’re an older adult and don’t eat a balanced diet.

Initial symptoms may be so mild they go unnoticed, but as the anemia worsens the symptoms will intensify. They may include:

  • Extreme fatigue;
  • Weakness;
  • Pale skin;
  • Chest pain, fast heartbeat, or shortness of breath;
  • Headache, dizziness, or lightheadedness;
  • Cold hands and feet;
  • Inflammation or soreness of your tongue;
  • Brittle nails;
  • Unusual cravings for non-nutritive substances (i.e. ice, dirt, or starch); and
  • Poor appetite, especially in infants and children.

Iron deficiency anemia is very common and you are at highest risk if you are a woman who menstruates (especially if your menstrual periods are heavy) or a woman who is pregnant or breastfeeding or has recently given birth.

If you are a person who has undergone major surgery or physical trauma, a person with gastrointestinal disease (i.e. celiac disease, ulcerative colitis, Crohn’s disease), a person with peptic ulcer disease, or a person who has undergone bariatric procedures (especially gastric bypass operations) you are also at high risk.

In addition, vegetarians, vegans, and people who don’t eat iron-rich diets, as well as children who drink more than 16 to 24 ounces a day of cow’s milk are at highest risk.

Reducing your risk

You can, however, reduce your risk of iron deficiency anemia by consuming iron-rich foods. Foods rich in iron are:

  • Red meat, pork, and poultry;
  • Seafood;
  • Beans;
  • Dark green leafy vegetables (i.e. spinach);
  • Dried fruits (i.e. raisins and apricots); and
  • Peas.

Your body absorbs more iron from meat than from other sources, so you must adjust your iron intake of plant-based foods to get the same amount if you choose not to eat meat.

You can also enhance your body’s iron absorption by drinking or consuming vitamin C-containing drinks or foods at the same time you eat high-iron foods. Vitamin C can be found in citrus juice (i.e. orange juice), as well as:

  • Broccoli;
  • Grapefruit;
  • Kiwi;
  • Leafy greens;
  • Melons;
  • Oranges;
  • Peppers;
  • Strawberries;
  • Tangerines; and
  • Tomatoes.

To prevent your infant from developing iron deficiency anemia, feed them breast milk or iron-fortified formula for the first year. Cow’s milk isn’t recommended for infants less than one year and isn’t a good source of iron. After age six months, start feeding them iron-fortified cereals or pureed meats at least twice a day to boost their iron intake. After one year, limit milk intake to less than 20 ounces a day.

Treating iron deficiency anemia

Treatment for iron deficiency anemia includes correcting the deficiency through diet, medicinal iron, intravenous (IV) iron, and/or blood transfusions.

Typically, the amount of medicinal iron needed to treat a patient is higher than the amount provided in an over-the-counter (OTC) multivitamin supplement. Your doctor will prescribe the amount you need in milligrams of elemental iron. Most people will need about 150-200 milligrams per day. Some examples of OTC medicinal iron are

  • Ferretts;
  • Ferate;
  • Poly-Iron 150;
  • EZFE 200; and
  • Slow Iron.

Sometimes, your doctor may recommend IV iron if you don’t absorb iron well in your gastrointestinal tract, if you have a severe iron deficiency or chronic blood loss, if you receive a special medication that stimulates blood production, or if you can’t tolerate oral iron. There are three different types of IV iron:

  • Iron dextran;
  • Iron sucrose; and
  • Ferric gluconate.

If you have a severe deficiency and are actively bleeding or have significant symptoms (i.e. chest pain, shortness of breath, or weakness), you may receive a red blood cell transfusion. The transfusion is given only to replace deficient red blood cells as a temporary improvement, but won’t completely correct the iron deficiency. Your doctor will still need to determine the cause of your anemia and treat it.

Vitamin B12 deficiency anemia

Vitamin B12 deficiency anemia is a condition where you don’t have enough healthy red blood cells due to a lack of vitamin B12. The red blood cells are very large and oval shaped with this type of anemia, which causes the bone marrow to make fewer red blood cells.

A vitamin B12 deficiency may be due to dietary factors, such as:

  • Eating a poorly planned vegetarian diet;
  • Poor diet in infants; and
  • Poor nutrition during pregnancy.

Having certain health conditions may also make it difficult for your body to absorb enough vitamin B12, like:

  • Chronic alcoholism;
  • Crohn’s disease, celiac disease, infection with the fish tapeworm, or other problems that make it difficult for your body to digest foods;
  • Pernicious anemia, which occurs when your body destroys cells that make intrinsic factor (a special protein that helps your body absorb vitamin B12);
  • Surgery that removes certain parts of your stomach or small intestine, i.e. weight-loss surgeries; and
  • Taking antacids and other heartburn medications for a long period of time.

Vitamin B12 deficiency anemia symptoms

You may not have any symptoms or they may be mild:

  • Diarrhea or constipation;
  • Fatigue, lack of energy, or lightheadedness when standing up or with exertion;
  • Loss of appetite;
  • Pale skin;
  • Problems concentrating;
  • Shortness of breath, mostly during exercise; and
  • Swollen, red tongue or bleeding gums.

Low vitamin B12 levels for a long time can cause nerve damage, such as:

  • Confusion or change in mental status (dementia) in severe cases;
  • Depression;
  • Loss of balance; and
  • Numbness and tingling of hands and feet.

You have an increased risk for vitamin B12 deficiency anemia if you have a family history of the disease, have had part of all of your stomach or intestine removed, have an autoimmune disease (including type 1 diabetes), and have Crohn’s disease or HIV. Some medications, strict vegetarian diets, and being an older adult also increase your risk.

Treatment of vitamin B12 deficiency anemia is replacement of the vitamin. Typically, vitamin B12 is given by injection, especially when there’s a severe deficiency or an inability to absorb the vitamin from the digestive tract. It’s given daily or weekly for several weeks until levels normalize, then given every month. Some names of vitamin B12 injection kits include:

  • B-12 Compliance Injection;
  • Physicians EZ Use B-12; and
  • Vitamin Deficiency System-B12.

Anemia during pregnancy

During pregnancy, your body undergoes significant changes, including increasing the amount of blood in your body by about 20 to 30 percent. This increase also raises the supply of iron and vitamins your body needs to make hemoglobin, which is the protein that carries oxygen in red blood cells to the rest of your body.

Most women have an iron deficiency in their second and third trimesters, causing anemia. Mild anemia is normal during pregnancy, but more severe anemia can put your baby at risk for anemia later in infancy. Additionally, if you’re significantly anemic during your first two trimesters, you’re at a higher risk for pre-term delivery or a low birth weight baby. Being an anemic mother increases your risk of blood loss during labor and makes it more difficult for you to fight infections.

There are several different types of anemia during pregnancy and the cause is different depending on the type.

In anemia of pregnancy, the volume of your blood increases meaning more iron and vitamins are needed to make more red blood cells. If you don’t have enough iron it can cause anemia, but it’s not abnormal unless your red blood cell count falls too low.

In iron deficiency anemia, your baby uses your red blood cells to grow and develop (especially in the last trimester). If you don’t have enough iron stores in your bone marrow, you can get this type of anemia (also the most common type in pregnancy).

In vitamin B12 deficiency anemia, women who don’t eat any foods that come from animals (vegans) are most likely to get this type of anemia. Vitamin B12 is vital in making red blood cells and protein, so strict vegans usually will need to get vitamin B12 shots during pregnancy.

In folate deficiency, folic acid (i.e. folate) is a B vitamin that works with iron to help with cell growth. A folate deficiency can lead to an iron deficiency, as well as increase the risk of brain and spinal cord defects in your baby.

Symptoms of anemia during pregnancy may not be clear unless your blood cell counts are very low. They may include:

  • Pale skin, lips, nails, palms of hands, or underside of the eyelids;
  • Feeling tired;
  • Sensation of spinning or dizziness;
  • Labored breathing;
  • Rapid heartbeat; and
  • Trouble concentrating.

Risk factors for anemia during pregnancy include having two pregnancies close together, being pregnant with more than one child, vomiting frequently due to morning sickness, not consuming enough iron, and having a heavy pre-pregnancy menstrual flow.

Preventing anemia during pregnancy consists of good pre-pregnancy nutrition. Eating a healthy, balanced diet before and during pregnancy will help keep up your iron and other nutrient levels. In addition, experts recommend that all women of childbearing age and all pregnant women take at least 400 micrograms of folic acid a day.

Treatment for your anemia during pregnancy will depend on your individual characteristics, such as your pregnancy, overall health, and medical history; extent of the disease; your tolerance for specific medications, procedures, or therapies; your expectations; and your preferences. It will also depend on your type and severity of anemia. For example, treatment for iron deficiency anemia will include iron supplements.

Aplastic anemia

Aplastic anemia is a form of bone marrow failure that’s primarily a disease of children and younger adults, but can occur at any age. Typically, as old blood cells naturally die off they’re replaced by new ones formed in the bone marrow, but in aplastic anemia the bone marrow doesn’t produce new cells.

The cause of aplastic anemia is damage to the bone marrow’s stem cells, but there are two different reasons. In acquired aplastic anemia, you aren’t born with the condition and only later develop it; this type is more common and sometimes can be temporary. In inherited aplastic anemia, which is rare, your parents pass the gene for the condition on to you.

In many people, the cause is unknown, but some research suggests that our body’s own immune system attacks its cells by mistake.

There are many diseases, conditions, and other factors that can cause you to acquire aplastic anemia:

  • Toxins, i.e. pesticides, arsenic, and benzene;
  • Radiation and chemotherapy;
  • Medications, i.e. chloramphenicol;
  • Infectious diseases, i.e. hepatitis, Epstein-Barr virus, cytomegalovirus, parvovirus B19, and HIV;
  • Autoimmune disorders, i.e. lupus and rheumatoid arthritis; and
  • Pregnancy (the anemia usually goes away after delivery).

Sometimes, cancer from another body part can spread to the bone, causing acquired aplastic anemia.

Some inherited conditions can lead to aplastic anemia, including Fanconi anemia, Shwachman-Diamond syndrome, dyskeratosis congenital, and Diamond-Blackfan anemia.

Aplastic anemia symptoms

Symptoms of aplastic anemia stem from much lower than normal quantities of the three blood cell types – unexplained infections (white blood cells), unexpected bleeding (platelets), and fatigue (red blood cells). The most common symptoms include:

  • Significant fatigue or weakness;
  • Bruising or bleeding easily;
  • Shortness of breath;
  • Recurring infections and/or flu-like symptoms;
  • Appearance of small red dots on the skin that indicates bleeding under the skin;
  • Headache; and
  • Fever due to infection.

While men and women are equally likely to have aplastic anemia, it’s most common in adolescents, young adults, and the elderly. The disorder is also two to three times more common in Asian countries. Your risk is higher if you have been exposed to toxins; have taken certain medications or had radiation or chemotherapy; or have certain infectious diseases, autoimmune disorders, or inherited conditions.

Although there’s generally no prevention for the majority of aplastic anemia cases, you can try to decrease your risk by avoiding exposure to insecticides, herbicides, organic solvents, paint removers, and other toxic chemicals.

Treatment for aplastic anemia may range from observation for mild cases to blood transfusions and medications for more serious cases to bone marrow transplantation for severe cases.

Blood transfusions are used to control bleeding and relieve anemia symptoms, but aren’t a cure. They simply provide the blood cells your bone marrow isn’t producing. A transfusion may include red blood cells and/or platelets. Multiple transfusions can sometimes lead to complications, like an overload of iron or antibody development.

Bone marrow transplants are sometimes the only successful treatment option for patients with severe aplastic anemia. If a donor is found, your diseased bone marrow is depleted with radiation or chemotherapy, then the healthy donor stem cells are injected intravenously into your bloodstream. From there, they migrate to the bone marrow cavities and start making new blood cells. The procedure requires a long hospital stay and medications to prevent your body from rejecting the donor bone marrow.

Some patients require the use of different types of medications to treat their aplastic anemia:

  • Immunosuppressants: Gengraf, Neoral, Sandimmune, Atgam;
  • Corticosteroids: Medrol; Solu-Medrol; and
  • Bone marrow stimulants: Leukine, Neupogen, Neulasta, Eopgen, Procrit.

Hemolytic anemia

Hemolytic anemia is a disorder in which your red blood cells are destroyed faster than they can be made; it can be inherited or acquired.

With inherited hemolytic anemia, one or more of the red blood cell production genes are faulty. The resulting abnormal cells may be fragile and break down in the bloodstream, and the spleen then removes the cell debris from the bloodstream.

Some types of inherited hemolytic anemia include:

  • Sickle cell anemia: a serious disease where the body makes abnormal hemoglobin, causing the red blood cells to have a sickle or crescent shape. This type of anemia primarily affects African Americans in the United States.
  • Thalassemias: disorders where the body doesn’t make enough of certain types of hemoglobin. They usually affect people of Southeast Asian, Indian, Chinese, Filipino, Mediterranean, or African origin or descent.
  • Glucose-6-Phosphate Dehydrogenase (G6PD) Deficiency: a condition where the red blood cells are missing the G6PD enzyme. If the red blood cells come into contact with certain substances in the bloodstream, the missing enzyme causes the cells to burst and die. It’s more common among African Americans in the United States.

With acquired hemolytic anemia, your red blood cells may be normal but some disease or other factor causes your body to destroy the red blood cells and remove them from the bloodstream.

Autoimmune hemolytic anemia accounts for half of all hemolytic anemia cases. It may come on very quickly and become serious. With this condition, your immune system makes antibodies that attack your red blood cells for an unknown reason.

The immediate cause of hemolytic anemia is the destruction and removal of red blood cells from the bloodstream before their normal lifespan is over. In inherited hemolytic anemia, ultimately the genes that control how red blood cells are made are faulty. In acquired hemolytic anemia, a disease, condition, or other factor is responsible for destroying the cells, such as:

  • Immune disorders;
  • Infections;
  • Reactions to medicines or blood transfusions; or
  • An enlarged spleen.

If your anemia is mild, you may not have symptoms. The first symptoms you may experience could be:

  • Feeling weak or tired more often than usual, or with exercise;
  • Headaches; and
  • Problems concentrating or thinking.

If your anemia worsens, you could have:

  • Lightheadedness when you stand up;
  • Pale skin;
  • Shortness of breath;
  • Sore tongue; and
  • Enlarged spleen.

Hemolytic anemia treatment

Treatment for your anemia will depend on your individual characteristics, such as your age, overall health, and medical history; how sick you are; the cause of the disease; how well you handle certain medications, treatments, or therapies; if your condition is expected to worsen; and your preferences. It will also depend on the cause and may include:

  • Blood transfusions;
  • Corticosteroid medication: Medrol, Solu-Medrol;
  • Treatment to strengthen your immune system (IV immune globulin); and
  • Rituximab.

In severe cases, you may require

  • Surgery to remove your spleen; and
  • Immunosuppressive medication.

About the Author

Julie Kaplan, Pharm. D.
Julie Kaplan is a licensed pharmacist in Virginia and the District of Columbia. She received a Bachelor’s of Arts in English from The College of William and Mary and a Doctor of Pharmacy from Virginia Commonwealth University. She has experience in patient communication from working as a retail pharmacist.