Tuesday, June 9, 2009

Anemia in a Teen...what's up?

Here's a recent letter I received.

Dear Nurse Deb,
Can you recommend iron rich foods for an anemic teenage boy? Would simply not eating enough greens make him anemic?Thank you,

Sacramento Gal

Let's start with some definitions of terms here. Anemia is a general term that is used to describe a blood condition where there are less healthy red blood cells than is expected, available to carry oxygen around to the body's muscles, organs and tissue. This number varies by age and gender and is impacted by living at high elevations or being dehydrated, being pregnant, or menopausal. Generally, a healthy teen male would be expected to have a Hemaglobin (Hgb) level of 14.5, (a range of 14-18 is considered normal) and for females 14 with a range 12-16. People who are anemic often describe symptoms including: feeling easily fatigued, short of breath when exerting oneself, pale skin, and may have 'pica' which means obsessively eating non-food items (dirt, clay, ice, paint, hair, etc).

Anemia can be caused by loss of blood (injury, heavy menstrual flow, bleeding gastric ulcers, etc) or can be triggered by deficiencies in the building blocks our bodies use to form new blood cells in the bone marrow in our 'long bones' of our legs. What are these building blocks? Iron is an important one and a leading cause of anemia in children who have inadequate dietary intake of iron-rich foods. Folic acid or folate is another, ferritin, and Vitamin B12, and protein are the primary components. It makes sense that if you don't provide building materials, the bone marrow will be unable to form enough red blood cells to work for the body. There are other more obscure types of anemia that are related to blood cancers, hypothyroidism, or organ system problems that destroy healthy red cells (heart valve disease or kidney disease) so that they are ineffective workers to carry oxygen around the body, but these types are far less likely to occur in otherwise healthy kids.


Your doctor will want to take a thorough history talking to both the teen and parents about diet, food preferences, and daily food log. S/he will ask about the teen's activity level, any injuries (rule out bleeding), stress level (is this teen at risk for bleeding gastric ulcerations?), medications (are there any that cause cell destruction or impair the ability of the GI tract to absorb nutrients?), under-lying health problems, and family medical history that might reveal predisposition for anemia or other significant illnesses. Blood tests are run (CBC - a 'complete blood count') that will give your doctor information on the hemoglobin, hematocrit, and other tests (MCV etc) that are clear indicators of the health and function of the red cells. I would guess that testing for iron, ferritin, and folate blood levels will also be done.


Teens are growing at astronomical rates and are at higher risk to become anemic if their diet doesn't keep pace supplying all the important vitamins and minerals like calcium and Vitamin D, iron, and Vitamin C. Ever notice how these vitamins and minerals show up paired? It is because Vitamin D increases the absorption and utilization of calcium from food and supplement sources as does Vitamin C impact absorption of iron! But here's a problem - calcium and the foods that are rich in it often inhibit the uptake and absorption of iron whether from food or vitamin/supplement form. Let's look at the foods that are strongest for iron and then we'll talk about strategies for managing this paradox. The goal here is 12mg. of iron daily for male, and 15mg. a day for female teens.

'Heme'-rich Iron Sources (ie those from animal source - wouldn't it be great if there were heme-rich iron in energy drinks?! Fat chance.) Chicken livers top the list at 7mg/serving followed by oysters at 4.5mg and drops from there.
  • Meats - beef, pork, lamb and liver, and especially organ meats

  • Poultry - chicken, turkey, and duck, especially the dark meats and liver

  • Fish - shellfish like clams, oysters and mussels are great; sardines, anchovies, other fish

Non-Heme Iron Sources:

  • Leafy green veggies of the cabbage family - broccoli, kale, turnip greens, collards, chard

  • Legumes - lima beans, green peas, dry beans like pinto, black-eyed peas, canned baked beans

  • Whole wheat bread and rolls

  • Iron enriched bread, pasta, rice and cereal

Note: the iron absorbed from Heme-rich food sources is 15-30% more efficient than non-heme iron which is absorbed at only a rate of 5%. Eating some of both is a good idea. In the Non-heme iron list, fortified cereals can carry 18mg/serving, legumes 4-8mg, but remember it is less fully absorbed than its 'heme' cousins.


When you read the list of non-heme iron containing foods, you may notice that many of these plant based foods are also good sources of calcium. Even foods like orange juice are being fortified by calcium supplements which can raise the odds of us meeting the target of 1300mg/day for teens. One source commented that most adults never reach their daily intake target for calcium, so why are we surprised that our kids don't either? Good point. Another source claims only 10% of female teens meet the goal for calcium intake - read "I don't want to get fat" here? In addition to deep green leafy veggies, milk and other dairy foods are the biggest source of calcium in the American diet. Fat free and low fat versions generally work as well as the high fat milk and cheeses. But here is our paradox showing up - milk and dairy products are often a significant contributing factor to iron deficiency anemia!


Ok...here's the list.

  • Salmon and sardines
  • tofu, rhubarb

  • deep greens like okra, spinach, collards, kale, broccoli, peas, brussel sprouts

  • legumes/peas/beans

  • NUTS! Hurrah - almonds, sesame seeds

  • Soy milk

  • cereals, oatmeal, instant breakfast, oj

I keep wondering how we expect to get sardines, liver, tofu and kale into these kids? Even I wouldn't eat some of it! I guess creative cooks have added hidden ingredients to sauces, pancake mix, and casseroles forever. A case of what we don't know is there will help us, and we may never even taste it! But back to the paradox of calcium/dairy blocking absorption of iron...my suggestion at this point is to alternate what gets eaten - if you're doing lots of dairy, have your iron food several hours later or an hour before you ingest what will block absorption. If need be, ask your doc if adding a multi-vitamin is a good idea or find at the health food stores the protein powder mixes that can be buzzed into a smoothie with fruit to add more of the building blocks to your young person's diet. Or yours! Most of all, start reading food labels if you haven't already made it a habit. There is a wealth of information to be had there and I am betting it will bring you to being more mindful about what you choose to take home from the store, and what you put into your mouth or the mouths or your family.

If any reader has ideas about how a teen might metamorphize from a junk food junkie or king of energy drinks to a healthy eating nut, I'd love to hear about it. I'm reminded that our kids learn far more about living from seeing what we DO than by what we tell them or force them to do. Good luck, Sacramento Gal, with your teen who is entering the mysteries of feeding his body in appropriate ways during these teen years. Check back and let me know how it's unfolding - my email is asknursedeb@gmail.com or leave me a comment on this thread!

1 comment:

  1. Thank you so much for your inspiring and thorough response. There's much to "eat" here and I'm going to print this out and review it, and then go shopping!

    Thanks for your great help!

    Sacramento Gal