IRON DEFICIENCY ANEMIA

by Subhuti Dharmananda, Ph.D., Director, Institute for Traditional Medicine, Portland, Oregon

The traditional Chinese medicine view of blood deficiency (xuexu) doesn't correspond completely to the modern medical concept of anemia. This divergence in interpretation often leads to difficulty in discussing the matter with patients. Although there are many types of anemia described in modern medicine (some of them related to rare deficiencies of blood cell production or altered hemoglobin formation), by far the most common type-and the one that might come closest to the usual description of blood deficiency in Chinese medicine-is iron deficiency anemia. The causes, such as excessive menstrual bleeding, are the same in the two systems. Iron deficiency is easily measured by taking a blood sample and evaluating its iron constituents, such as hematocrit (red blood cell proportion), hemoglobin (iron-based blood component), and serum ferritin (iron storage protein). From a symptomatic point of view, there are typical indicators of blood deficiency, which sometimes overlap and sometimes differ in the two medical systems, as shown in Table 1.

TABLE 1: Iron Deficiency Symptoms.
Symptoms that have some overlap or similarity are listed in the same row, those which differ are in separate rows. The modern medicine indications are taken from University of Maryland Medicine (1) and MedLine Plus (2); Chinese indications are from the Advanced Textbook of Traditional Chinese Medicine and Pharmacology (3) and New Practical Syndrome Differentiation of TCM (4).

The primary overlap is in the pale complexion. Easy fatigue is attributed to qi deficiency in the Chinese medicine texts referenced here, and a swollen tongue and shortness of breath may also correspond to qi deficiency. It should be noted that tachycardia is not the same as palpitation, the latter referring to the experience of feeling the heart beat, which seems fast; speeded up heart rate may occur with palpitation. Irritability is sometimes associated in Chinese medicine with a liver qi stagnation syndrome, which, according to doctrine, can arise with liver blood deficiency, but irritability is not considered a typical symptom within the general blood deficiency pattern. Potentially, iron deficiency anemia might correspond to a diagnosis of deficiency of qi and blood in the Chinese system.

While blood deficiency is a commonly treated syndrome in traditional Chinese medicine, few texts devote much space to discussing the basic concept of blood deficiency. In a compilation of information from four Chinese language sources, an article in the Journal of the American College of Traditional Chinese Medicine laid out some of the basic dogma (5). Blood deficiency is described as occurring from excessive blood loss (with insufficient replacement) and by "inadequacy of the blood factors and components required in blood formation due to spleen and stomach dysfunction." It was also pointed out that blood deficiency could arise secondary to blood stasis. This problem is usually attributed to the idea that generation of new blood requires getting rid of old blood, and blood stasis indicates old blood that is retained.

In addition to the signs of systemic blood deficiency as outlined in Table 1, blood deficiency syndromes can be elaborated as belonging to one or more of the major organs, adding certain symptoms, specifically:

• heart blood deficiency, add symptoms of restlessness, agitation, disturbing dreams, and forgetfulness;
• spleen blood deficiency, add anorexia and mental fatigue; and
• liver blood deficiency, add spasms, dry and withering nails.

According to the central doctrine, blood is governed by the heart, stored by the liver, and generated and controlled by the spleen.

Modern medical treatment of iron deficiency anemia is straightforward and easy: the main thrust is to recommend a diet rich in iron. Then, if necessary, iron supplements can be administered (many of these are available over-the-counter). The Chinese treatment of anemia most often revolves around the use of a small number of herbs, with tang-kuei (see Figure 1, last page) as the central one. This herb is an ingredient in the principal blood nourishing formulas of Chinese medicine, such as Siwu Tang, Danggui Buxue Tang, Guipi Tang, and Bazhen Tang. Tang-kuei is not particularly rich in iron, nor are these formulas.

Iron compounds, primarily hematite, pyrite, and magnetite, are used in Chinese medicine, yet these mineral ingredients do not appear in any of the commonly-used blood nourishing prescriptions. However, an important aspect of traditional Chinese medicine in China is combining herbs with food therapies or directly with foods. For example, tang-kuei (or the full formula Siwu Tang) is often administered in a base of chicken soup, providing some iron from the chicken (if the chicken liver is included, that is the source of most of the iron). Siwu Tang, and its expanded form Bazhen Tang (which adds tonics for spleen qi), are usually recommended for recovery from blood loss due to menstruation; for most women, this blood loss is limited. The main formula recommended for treating severe blood loss is Danggui Buxue Tang, comprised of two herbs: a high dose of astragalus (30 g), with a standard dose of tang-kuei (6 g), a formula made without any iron compounds. Another prescription, made with just fresh ginger (15 grams) and a high dose of tang-kuei (9 grams), is cooked with mutton (48 g), a red meat that is high in iron, though not quite as much as in beef. That formula is used for the blood loss associated with childbirth, which can be significant. Evidently, Chinese herbs prescribed for blood loss are not good sources of iron even when treating severe blood loss, though when prepared with chicken or mutton or other meat products, the combination becomes at least a moderate source of iron. It is possible that the herbs promote some aspect of red blood cell production or iron metabolism leading to better retention of iron in the blood; this interpretation remains to be evaluated.

Therefore, within the realm of standard herbal practice, given the ready availability of iron compounds used in making formulas and their absence in blood tonic formulas, one may suspect that iron deficiency anemia is not a significant target of Chinese medicine therapy for blood deficiency. With our modern knowledge of the blood and its constituents and functions, practitioners may wish to find out about the patient's blood test results regarding iron to determine whether iron deficiency is a part of a broader diagnosis of blood deficiency. If it is, dietary recommendations related to adequate iron consumption and consideration of iron supplements might be appropriate, since most patients will not be cooking their herbs with meats in order to get additional iron. The issue of dietary and supplemental iron may be an important one for practitioners who prescribe herbs. It is common for patients who seek herb therapies to pursue vegetarian or near-vegetarian (e.g., no red meat) diets that are low in iron. Further, excessive menstrual bleeding due to fibroids is a frequently presented disorder for treatment by herbs therapies.

GETTING IRON FROM THE DIET

It has been determined that most adults can maintain a healthy level of iron in the blood by consuming a total of about 10 mg of iron each day, with 15 mg per day for menstruating women. According to USDA recommendations, the allowances of dietary iron intake are as follows:

• Young children - male and female: 6 months to 10 years: 10 mg
• Males: 11 to 18 years: 12 mg; 19 and older: 10 mg
• Females: 11 to 50 [menstruating]: 15 mg; 51 and older [non-menstruating]: 10 mg; Pregnant: 30 mg; Lactating: 15 mg

There are three primary dietary sources for iron (see Tables 2 and 3, for specific examples and quantities):

• consumption of meat, usually providing 1-5 mg in a modest serving of about 3 ounces (an amount currently recommended for a single meal portion to minimize consumption of saturated fats);
• dried fruits, fruit juices, vegetables, legumes, and certain nuts usually providing 1-3 mg per serving of about half a cup (these are items that are encouraged to be consumed with higher frequency to assure adequate intake of vitamins, flavonoids, and other beneficial plant components); and
• wheat products, which are usually made with iron-fortified flour, providing, for example, 1-2 mg of iron in two sandwich slices or a cup of pasta.

In a typical diet of three meals per day, one needs about 3-4 mg of iron per meal, which is easily obtained by most people. Some individuals, particularly women, suffer from low iron levels in the blood as a result of: low intake of foods (e.g., low calorie diets); losses of iron from bleeding (e.g., menstrual bleeding; see appendix for further details); and problems with iron uptake or distribution to iron carriers and reservoirs.

TABLE 2: Iron-rich foods arranged from largest to least amount of iron in a typical serving size (1). The quantities of iron may differ slightly from those in the table below based on different samples of the foods (variation is usually not more than 25%).

TABLE 3: Iron content of some common foods rich in iron, divided by heme-iron (more easily absorbed) and non-heme iron (less easily absorbed, by a factor of about 10). These are also grouped according to type of source; note the variation in iron content among different varieties of a food type (6).

IRON SUPPLEMENTS

Iron supplements are readily available, and can provide quantities of iron that range from 10 to 40 mg per daily dose. There are potential problems with some iron supplements, of which the greatest is getting too much iron. Excess intake of iron can cause constipation, impair the uptake of essential trace minerals, and contribute to a higher state of oxidative stress (iron is one of nature's most potent oxidants). Children who accidentally consume large amounts of iron are most susceptible to the adverse effects and the single most commonly reported poisoning from supplements is due to children getting into packages of iron supplements (all supplements providing iron are now required to have child-proof caps). In 2001, the Institute of Medicine set a tolerable upper intake level of 40 mg per day for infants and children through age 13 and 45 mg per day for ages 14 and over. Generally, supplement recommendations, even for severe iron deficiency anemia, are for less than 40 mg/day, because at that level people can experience nausea and other immediate reactions. In an attempt to maximize iron supplementation without evident side effects, many suppliers of supplements for prescription by nutritionists provide 27 mg/day, the highest amount that is associated with a low incidence of complaints. In addition to maximizing iron levels in the supplements, the manufacturers also attempt to maximize its absorption by using iron glycinate and by including vitamins (mainly vitamin C and several B vitamins) that enhance the absorption of iron.

Maximizing iron dosage and promoting efficient absorption together may not be ideal because it involves adding as much iron as possible to the system. An alternative is to provide a more modest amount of iron within a blood nourishing herb formulation that may have other benefits to the blood system.

APPENDIX. THERAPIES FOR EXCESSIVE MENSTRUAL BLEEDING

The base RDA for iron is set at 10 mg, but rises to 15 mg (some suggest 18 mg) for menstruating women to compensate for the monthly blood loss. Dietary sources may prove inadequate to attain this level, especially for those who rely on non-heme sources. A supplement is often indicated, particularly for women who have heavy blood flow during menstruation. By adding about 10 mg of supplemental iron to the daily diet that should already provide 10 mg, a sufficient level (e.g., about 20 mg/day) is attained for most women. There appears to be some correlation between low iron levels and increased blood flow during menstruation, so that a low iron state can end up being maintained easily: the low iron promotes more bleeding, while the bleeding keeps the iron levels low. This situation may be remedied in some cases by the addition of iron supplements to the dietary intake.

Increased menstrual blood flow is a common result of uterine fibroids, a condition that brings many women to seek natural health care alternatives to surgery. Herbs used to reduce uterine bleeding from various causes include tien-chi ginseng (sanqi); lotus (seed, node, and other parts); gelatins (deer antler, tortoise shell, donkey skin); and certain traditional formulas, mainly Guipi Tang (Ginseng and Longan Combination) and Bazhen Tang (Tang-kuei and Ginseng Eight Formula), and patent medicines (mainly Yunnan Bai Yao and Wu Ji Bai Feng Wan).

The low point of blood iron levels occurs as the menstrual period is completed, with maximum cumulative blood loss. Thus, Chinese herbalists emphasize the use of tonic formulas to begin immediately following cessation of menstrual bleeding, and continuing for several days afterward. In some cases, the blood tonics are continued throughout the month, rather than used for just a few days. The decision to purse this routine use of tonics is based on the constitutional analysis, to determine whether tonification is the most appropriate therapy during the rest of the menstrual cycle, as opposed to a possible alternative therapy, such as regulating liver qi.

Similarly, the decision to continue iron supplementation throughout the month, or only during the days following menstruation (and during menstruation, to help control excessive blood flow), would depend primarily on blood tests showing low levels of iron.

REFERENCES

1. University of Maryland Medicine, Iron-deficiency Anemia, 2003 University of Maryland Medical System, http://www.umm.edu/blood/aneiron.htm
2. Medline Plus, Iron in diet, 2003 U.S. National Library of Medicine and National Institutes of Health http://www.nlm.nih.gov/medlineplus/ency/article/002422.htm
3. State Administration of Traditional Chinese Medicine, Advanced Textbook on Traditional Chinese Medicine and Pharmacology, (vol. 1) 1995-6 New World Press, Beijing
4. Wang Qi and Dong Zhi Lin, New Practical Syndrome Differentiation of T.C.M., 1992 China Ocean Press, Beijing.
5. Cheung CS and Belluomini J, Blood, Journal of the American College of Traditional Chinese Medicine 1982 (2): 48-54.
6. McKinley Health Center, Dietary Sources of Iron, 2001 University of Illinois; http://www.mckinley.uiuc.edu/handouts/dietiron.html
7. Dharmananda S, Bag of Pearls, 2002/2003 Institute for Traditional Medicine, Portland, OR.

Figure 1. Tang-kuei (danggui) pressed slices as found in Hong Kong pharmacies. These are made by slicing the roots, putting several root slices next to each other, and then pressing them, to make one large "palm" slice. They are usually soaked in Chinese wine, which makes the active constituents more mobile when cooking as a decoction or when using consuming the ground herb powder.

May 2003