Iron Deficiency Anemia

It is not uncommon for morbidly obese patients to have anemia and/or nutritional deficiencies prior to surgery. Studies have shown that up to 22% of bariatric surgery patients had anemia prior to surgery. (, 2009).

Iron is very important in maintaining many body functions. It is necessary to maintain healthy cells, skin, hair and nails. Iron is absorbed into the body from the foods that we eat by the cells that line the gastrointestinal tract. The iron is then released into the blood stream. Transferrin (a protein) then attaches to it and delivers iron to the liver. Iron is stored as ferritin and released as the body needs to make new red blood cells in the bone marrow. Red blood cells have a life span of approximately 120 days and are then re-absorbed by the spleen. Iron from old cells can also be recycled by the body. (American Society of Hematology, 2014)

Red blood cells contain hemoglobin which carry oxygen to body tissues. Red blood cells are produced in the bone marrow, erythropoietin (hormone that regulates red blood cell production) secretion from the kidneys red blood cell production. Anemia is a decrease in the number of red blood cells or alteration in the function of red blood cells. This results in adequate oxygen delivery to the tissues. The body responds in many ways. The heart will try to increase more blood to the tissues by increasing heart rate. In addition, the brain will consume oxygen that it needs by shunting blood away from the skin leading to pallor (pale skin). When the body needs rapid delivery of oxygen to tissues ie during exertion or exercise, one will experience shortness of breath.

Other symptoms of iron deficiency include fatigue, generalized weakness, pounding in the ears, headache, cravings for ice or clay, sore or smooth tongue, as well as brittle nails or hair loss. (Berkowitz, 2007)

Who is at Risk?

    • Menstruating women, especially if menstrual periods are heavy
    • Pregnant women, those breastfeeding or recently given birth.
    • People who have undergone major surgery or physical trauma.
    • Those with gastrointestinal diseases such as celiac disease, inflammatory bowel diseases such as ulcerative colitis or Crohns Disease, peptic ulcer disease.
    • Those who have undergone bariatric procedures.
    • Vegetarians, vegans and any diet that does not contain iron rich foods.
    • Excessive intake of cows milk. (can decrease iron absorption and irritate the intestinal lining causing chronic blood loss).

Less common causes include:

    • Blood loss from the gastrointestinal tract due to inflammation of the stomach, esophagus, ulcers in stomach or bowel, hemorrhoids, leaky blood vessels in the gastrointestinal tract, infections such as diverticulitis, tumors in the esophagus, stomach, small bowel or colon.
    • Frequent blood donations
    • Blood loss from kidneys or bladder
    • Intravascular hemolysis – a condition where red blood cells break down in the blood stream, releasing iron that is lost in the urine. This can also be seen with damaged heart valves or rare disorders such as thrombotic thrombocytopenia purpura (TTP).

Iron deficiency is diagnosed by blood tests, particularly, a complete blood count (CBC). An individual with iron deficiency would show the following:

    • decreased hemoglobin and hematocrit
    • decreased MCV (mean cellular volume)
    • decreased ferritin
    • decreased serum iron
    • Increased transferrin or total iron binding capacity (TIBC)
    • Decreased iron saturation

Severe iron deficiency may show decreased white blood cell count as well as decrease/increase in platelet count.

Treatment of anemia depends on the underlying cause and severity. If anemia is the result of an underlying disease such as an autoimmune disorder, the primary disease must be treated.

There are several ways to increase iron intake: Diet, supplemental iron intake, intravenous iron, and blood transfusions (for severe iron deficiency).Preventing nutritional deficiencies:

Foods high in iron include: beef, pork, lamb, liver, chicken, turkey, duck, fish (shellfish, sardines and anchovies); leavy green members of the cabbage family (broccoli, kale, turnips, collard greens), legumes, including lima beans, peas, pinto beans and black-eyed peas, iron enriched foods such as rice, grains and cereals.

Iron Supplements:

Preferably, ferrous gluconate, ferrous sulfate. Iron is absorbed in the small intestine so be sure not to use enteric coated iron tablets as it may not be absorbed well. Taking Vitamin C with iron has been shown to increase absorption. Do not take iron with Calcium or antacids. Side effects of oral iron intake include abdominal discomfort, nausea, vomiting, diarrhea, constipation and dark stools.

Intravenous Iron:

This may be necessary in those patients who cannot absorb iron in the gastrointestional tract, severe iron deficiency or in chronic blood loss or in those that cannot tolerate oral iron. Side effects are rare, but can include hives, itching, muscle and joint pain.

Blood transfusions:

Packed red blood cells may be given to patients with severe anemia who are actively bleeding with symptoms such as chest pain, shortness of breath, and/or weakness.

Eating healthy with a balanced diet is an important step to decreasing your chance of acquiring deficiencies. Avoid tea, cola, milk, coffee can decrease iron absorption. Maintain regular follow ups with health care provider to ensure that you are not developing nutritional deficiencies. It is also important that you report to your provider any unusual symptoms that you may be experiencing such as irregular heartbeat, fatigue, weakness, dizziness, shortness of breath, cold hands and feet, tingling in hands or feet. Without treatment, the above symptoms can become severe. Close communication with your healthcare provider is key to maintaining a healthy lifestyle.

See images below showing symptoms of anemia as well as how iron is stored in the body.

Image of body parts affected by anemia .

Image of human body and iron distribution .


American Society of Hematology. (2014, February 23). Iron Deficiency Anemia. American society of Hematology, 1-4. (2009). Avoiding Anemia and Nutritional Deficiencies Following Bariatric Surgery.

Berkowitz, A. (2007). The Hematologic System. In Clinical Pathophysiology (pp. 118-125). Miami, Florida: MedMaster, Inc.

Mary Anne

Mary Anne