The article made me wonder about the basics of iron health. How much of this stuff do we need? How do we get it? If you always feel pooped, how likely is “iron poor blood” to blame?
One-quarter of the world’s population is anemic, meaning they don’t get enough iron to produce the red blood cells and oxygen-carrying hemoglobin needed to nourish their myriad cells.
In developed nations like the United States, iron-poor blood is uncommon. Anemia attributable to iron deficiency affects perhaps 1% to 2% of American adults. “Because our country usually has a problem of eating too much, most adults meet the minimum requirements for iron intake,” says nutrition researcher Howard Sesso, an associate professor of epidemiology at Harvard Medical School.
In the United States, blood loss is the main cause of iron deficiency and anemia. Among women, heavy menstrual periods and childbirth account for this. Among those age 65 and older, the causes of iron deficiency and anemia are likely to be internal bleeding, difficulty absorbing iron and other nutrients, and eating a less varied diet.
The average American man harbors about 3.5 grams (one-eighth of an ounce) of iron in his body. The average woman has about 2.5 grams.
Where do we keep this iron? Roughly 60% of it is held by the oxygen-carrying hemoglobin protein in red blood cells. The next largest storehouse is ferritin, a protein that latches onto iron and sequesters it in the liver, spleen, and bone marrow. When the body needs to draw on its iron account, it comes out of the ferritin bank.
Without enough stored iron, an individual can develop anemia. Symptoms include fatigue, loss of stamina, shortness of breath, weakness, dizziness, and a pale, unhealthy complexion. So precious is iron for your health that the body uses a protein called transferrin like a scrap metal collector to scrounge iron from old red blood cells before they are destroyed.
Keeping the reservoir full
Most of us get the iron we need from food. Proponents of the Paleo or “cave man” diet should be cheered to know that red meat, poultry, and fish contain the most easily absorbed form of dietary iron—called heme iron. This is iron attached to the hemoglobin protein. The body absorbs heme iron more easily than the iron found in plants.
“In the typical American diet, the main sources of iron tend to be animal products,” Sesso says. “Typical meat consumption in the United States is usually more than adequate to meet one’s iron requirements.”
In plant foods, iron is not attached to such a protein. The body doesn’t absorb non-heme iron from fruits, vegetables, beans, and other plant foods as easily as it absorbs heme iron. That means those who eat little or no meat must take in more iron from leafy greens, legumes, whole grains, mushrooms, and other iron-rich plant foods. They also need to get enough vitamin C, which helps the body absorb iron from food.
The USDA recommends that women between the ages of 19 and 50 get 18 mg of iron a day, while women ages 51 and older and men 19 years and beyond need 8 mg a day. Moderate amounts of meat plus fruits and vegetables can provide that amount, helped along by the many foods fortified with iron and other vitamins and minerals, like milk, flour, and breakfast cereals. And half of all Americans get some iron from a daily multivitamin.
One caution about iron: If you don’ think you are getting enough iron, or feel pooped out and assume it’s your “tired blood,” you may be tempted to pop an iron supplement as insurance. But beware. The body does not excrete iron rapidly. That means it can build up over time and, in some people, becomes toxic. The genetic disorder hemochromatosis causes iron to build up in organs, causing heart failure and diabetes.
So don’t just prescribe yourself an iron supplement on a whim; ask your doctor if you need it.
Good sources of iron
Food Portion Iron content (milligrams)
Fortified cold breakfast cereal 3 ounces 30 to 60
Spirulina seaweed 3 ounces 28
Oysters 3 ounces 9
Soybeans, cooked 1 cup 9
Cream of Wheat 1 serving 9
Pumpkin seeds 3 ounces 8
Spinach, boiled and drained 1 cup 7
Lentils, cooked 1 cup 7
Soybeans, cooked 1 cup 5
Kidney beans, cooked 1 cup 4
Beef, ground 4 ounces 3
Turkey, ground 4 ounces 3
Whenever I read or write about the overuse of so-called opioid painkillers it is with mixed feelings. As a lifelong back-pain patient who once depended on them for pain relief, I appreciate the challenge posed by opioids to people in pain and their doctors. People in agonizing pain want it to stop, but opioids are often a poor long-term solution. Doctors want to help their patients, so they may prescribe opioids for extended periods despite well-founded reservations.
At the same time, the epidemic of abuse of these painkillers has led to numerous deaths. Like many Americans, I know people whose lives were destroyed—who ended up in rehab, the legal system, or the grave—because of prescription painkiller abuse. An article this week in the New England Journal of Medicine pegs the toll at nearly 17,000 fatalities in 2010.
Hydrocodone (Vicodin) and oxycodone (Oxycontin, Percocet, Percodan) are the most widely used and abused of the opioids. Others in this family of drugs are codeine, fentanyl (Duragesic patch), hydromorphone (Dilaudid), meperidine (Demerol), morphine (MS Contin), and tramadol (Ultram). These drugs block pain perception in the brain.
Doctors are learning to say no to opioids, but at the same time have limited scientific guidance on when and how to best use opioids for chronic pain, according to a report published online in the Annals of Internal Medicine this week by a National Institute of Health expert panel. It follows on the heels of a position statement published in September 2014 by the American Academy of Neurology, stating that the harms of opioids often outweigh the benefits for treating chronic noncancer pain.
Dr. James Rathmell, the Henry Knowles Beecher Professor of Anesthesia at Harvard-affiliated Massachusetts General Hospital, sums up the doctor’s dilemma this way: “The patient is in terrible pain and wants to try it. Who am I to say no?”
At the same time, Dr. Rathmell emphasizes that whenever opioids are prescribed, the focus needs to be on limits. “We should never use these drugs unless they’re the only thing that will be effective,” he says, “and then when we use them we should prescribe them for the shortest possible time.”
More isn’t better
How much of an opioid is needed to block pain perception in the brain is a moving target—and the trajectory is always upward. After a brief honeymoon of profound pain relief when you first start taking opioids, their pain-numbing effect fades and the dose escalates rapidly. In months, you can end up taking dangerously high doses just to maintain the same level of relief.
“This isn’t a good long-term solution—but not because it doesn’t work today or tomorrow,” Dr. Rathmell says. “What do we do when it’s not working as well next month? The knee jerk response is to raise the dose, but where do we stop? Do we stop when you are falling asleep in your soup every night at dinner? Do we stop when you fall down and break your hip?”
In my case, the dose I needed to quell my severe back pain kept getting higher. I vividly remember the daily clock-watching between doses and the embarrassing pleading for more refills. Fortunately, surgery to repair a herniated disc worked. I successfully tapered off the drugs. Since then, regular exercise and stretching, plus good sitting and working habits, have reduced my back pain flare-ups to one or two a year. They last a week or two and require no more than hefty doses of ibuprofen and hot baths.
When opioids help (for a while)
No one is proposing to withhold opioids during the “acute” phase of a pain condition that would be relieved by these drugs. This means the hours, days, and weeks it takes your body to heal from an injury or surgery.
The general rule of thumb is to use them for four to six weeks, then taper off and switch to other options. People recovering from a flare-up of back pain, a severely injured joint, or surgery can often transition to acetaminophen (Tylenol) or a nonsteroidal anti-inflammatory drug (NSAIDs) like ibuprofen (Advil, Motrin) or naproxen (Aleve).
What’s at issue is treating chronic pain—pain that just won’t go away, doesn’t get better, or worsens. For the more common pain conditions—like back pain, chronic headache, and fibromyalgia—opioids may at some point offer little or no relief but cause side effects. Opioids can cause severe constipation as well as dangerous sedation. A person who takes an opioid can become cognitively impaired and confused. Accidental overdose can happen if someone hoards a few extra pills to pop in hope of a good night’s sleep, or if opioids are combined with other prescription drugs that sedate. Opioids and alcohol are notoriously deadly mix.
The rules are different for long-term pain from cancer. Carefully managed but increasing doses of opioids may be the best option.
Get extra help
So what should you do if you have chronic pain and start to hit the limits of opioids? “If there has been no benefit from other approaches and you have moderate to severe pain that is ongoing, you may want to see a pain specialist and talk about the various options,” Dr. Rathmell says. Pain specialists are often anesthesiologists by training, and have special expertise in the safe use of opioids and deploying other options for long-term pain control.
What may be needed is not a single pill, but a portfolio of tools. For example, certain antidepressants and antiseizure drugs can help control chronic pain from injured nerves. Specialized psychological counseling as well as complementary and alternative treatments, like acupuncture and meditation, can also help people with unremitting pain cope better.
If you are a sociable soul, here’s some interesting news about exercising with others: A study published online in the British Journal of Sports Medicine shows that being part of an outdoor walking group can improve health in many ways, including improvements in blood pressure, resting heart rate, total cholesterol, body weight, body fat, physical functioning, and risk of depression.
There are different kinds of walking groups. One is a collection of individuals who participate in regular outdoor walks headed by a trained but non-medical leader. Other walking groups are less formal. Previous studies have found that walking groups are effective at promoting regular physical activity.
Two researchers from Norwich Medical School in Norwich, England, combined the results of 42 studies that evaluated the health effects of walking groups. This meta-analysis showed that walking groups offer a range of health benefits. The analysis showed that people who were part of a walking group tended to keep exercising and not slack off. They also had low rates of adverse effects from walking, mostly falls.
The findings are interesting because walking group participants reaped health benefits even though many of the groups did not meet international guidelines for moderate activity. This supports the idea that any activity is better than none, something that Dr. Howard LeWine explored last week in the Harvard Health blog.