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Treat and Prevent Iron Deficiency Anemia

Treat and Prevent Iron Deficiency Anemia

Iron deficiency anemia

This is the last in our series on Iron Deficiency and Iron Deficiency Anemia. In parts I, IIIII, and IV, I talked about all aspects of the essentiality of iron. How to diagnose iron deficiency anemia. Various controversies surrounding iron supplementation. And the relationship of iron to various inflammatory states including cancer.  Let’s recap this series with specific treatment routines.  I encourage you to read this final wrap-up containing new and revolutionary medical paradigms.

[If you want the nitty gritty, scroll down to “treatment.”]

Enter Functional Medicine

I want to introduce one more refining and overriding concept. A new paradigm shift in medicine. Functional Medicine.  We need to rethink the entire subject of iron deficiency and anemia.  How and when do we recognize the condition of iron deficiency and progressive anemia? And then what triggers our decision to treat – or prevent?

Functional Medicine is a systems biology–based approach that focuses on identifying and addressing the root cause of disease. Each symptom or differential diagnosis may be one of many contributing to an individual’s illness.   — from the Institute for Functional Medicine

Binary vs. Optimal Choices

In America I see two competing medical paradigms. Structural pathologic medicine based on illness and disease. And functional medicine which is based on dysfunction, suboptimal values with the goal of restoring health and wellness. The goal is not identical.  It leads to totally different approaches for you, the patient.

The functional approach to iron therapy realizes various degrees of iron deficiency rather than a binary choice.  “In the box” or “out-of-the-box.” You’re either low or you are high. In reality virtually all medical paradigms follow a normalized distribution. A continuum from very low to very high. The goal is always optimal — in the middle — values. This is a concept stressing to all my audiences 20 years.

Fortunately, a new model is proposed and advocated in a major publication in the Austrian literature. This paper lays out guidelines for treating iron deficiency anemia in cancer patients using absolute (AID) and functional (FID) iron deficiency.  Seemingly two sets of criteria.

Anemia is common in cancer patients [2]. From a practical viewpoint, two forms of iron deficiency need to be differentiated: absolute iron deficiency (AID) and functional iron deficiency (FID). AID is defined by a TSAT < 20 % and a serum ferritin level < 30 ng/ml in otherwise normal individuals, while in cancer patients a higher cut off level of ferritin levels should be applied (< 100 ng/ml). FID is defined by a TSAT < 20 % and serum ferritin levels of > 30 ng/ml in normal individuals and of > 100 ng/ml in cancer patients.

Great.  Here is a clear path.  The Austrian literature articulates a major shift in modern medical thought. That is my purpose in writing series for you.  Iron therapy is anti-angiogenesis preventing neo-vascularization.

Challenging Standard Definitions

I see so many patients who are relatively anemic and are symptomatic. But they still fall within the “normal range.” And are therefore dismissed.  Not falling within the treatment guidelines.  Ready for the paradigm shift?

Now remember from the previous blogs that iron deficiency will proceed anemia. So here is the continuum of iron from fully sufficient to deficient that precedes anemia .  This is a functional view.   We want optimal values.

continuum from iron deficiency to iron deficiency anemia

Anemia appears only after more severe iron deficiency progresses.  Once iron falls to more severe levels.

Conventionally, your diagnosis of anemia must meet these standard criteria.  Hematocrit values < 35% (women) or <40% (men).  Or Hemoglobin values <13 in men or <12 in women.  Remembering that hemoglobin is oxygen carrying capacity.

But in reality, you won’t be diagnosed or treated until values fall even much lower.  At that point you are really sick.

See figure 2 for “normal values.”  You want optimal values.

Men Women
RBC Count (million/ug) 4.2 – 5.9 3.6 – 5.5
Hemoglobin gm/dl 13 – 17 11 – 15
Hematocrit % 40-52% 34-46%

Treatment Options

This is a re-cap and wrap-up of the previous blogs. All preceding blogs give you a more in depth look at all the issues of iron therapy.

How do we treat knowing that earlier intervention is essential?   The total daily dose for severe cases is 180 mg of elemental iron.  I usually use lower doses.   You will need increased doses of magnesium to prevent constipation.

Heme vs non-heme iron sources in food.  

  • Heme based sources of iron is the most efficient. Best source is red meat or chicken livers or sardines.   Non-heme sources, plant based is a less efficient source of daily iron.

Iron Salts

  • Ferrous sulfate 325 mg (65 mg elemental iron) three times daily. The preferred form.  This may raise hepcidin levels thereby decreasing efficient absorption.³
  • Ferrous gluconate 325 mg (12 mg elemental iron) three time daily
  • Ferrous fumarate 325 mg (107 mg of elemental iron) three times daily

Iron chelates

  • AminoIron – 18 mg elemental iron as bis-glycinate
  • Reacted Iron – 29 mg elemental iron as ferrous bis-glycinate

Iron Infusions

  • Ferric carboxymaltose (injectafer) — the most potent and effective for severe cases and those not responsive to oral consumption.
  • You will need to find a sympathetic and creative hematologist to administer and infuse parenteral (im or iv) iron.  A hematologist who is willing to treat early and not late in the process.

Philip Lee Miller, MD
Carmel, CA
May 24, 2018

  1. Iron metabolism and iron supplementation in cancer patients: Wien Klin Wochenschr (2015) 127:907–919 DOI 10.1007/s00508-015-0842-3
  2. Ludwig H, Müldür E, Endler G, et al. Prevalence of iron deficiency across different tumors and its association with poor performance status, disease status and anemia. Ann Oncol. 2013;24:1886–92.
  3. Iron Dosing for Optimal Absorption:  NEJM Journal Watch Oct 30 2015.
  4. Iron deficiency Anemia  NEJM May 8, 2015 
My Daily Personal Nutrition Routine

My Daily Personal Nutrition Routine

People ask me what is your personal nutrition routine?  What do you take on a daily basis? What supplements and micronutrient do you take yourself for optimal nutrition? To achieve optimal health and well being in a high stress world today.

Personal Goal

A personal goal and my mission for all of you is health and well-being. Longevity with vigor. Protection from cognitive decline. Prevention of diabetes, arthritis and cardiovascular disease.  Growing older without aging.

It was the famous British physician Sir Thomas Sydenham who said.

” you are as old as your arteries.”

Arterial health is a major goal. This is why we strongly advocate CIMT imaging of your carotid arteries here in our office.

My daily routine starts upon arising (on an empty stomach) with fat soluble nutrients.  This includes:

  • 1 tbl of fish oil
  • Vitamin E 1200 units
  • Vitamin K2 15,000 mcg
  • Vitamin D3 10,000 units
  • Thyroid
  • Phosphatidylserine 300 mg and
  • Nattokinase 100 mg to prevent heart attacks and strokes.

These fat soluble nutrients are more efficiently absorbed with fish oil.  They are taken on an empty stomach so they do not interfere with oatmeal for breakfast.

There is a 45 to 50 minute hiatus.  Read my morning emails.  A morning shower after which I apply my first dose of testosterone cream.


Breakfast starts with Bob’s Red Mill gluten-free oatmeal. Cooked to a creamy consistency over a gas stove. Now my first highly fortified protein shake of the day.

  • 2 scoops of whey-based protein
  • 1 tsp (3 grams) of carnitine tartrate
  • 1 tbl phosphatidylcholine
  • 1 scoop of d-ribose
  • l-deprenyl for cognitive enhancement

This is the most efficient and richest source of high quality protein. The protein shake can be mixed with Odwalla orange juice or your favorite base.

Breakfast is fortified with an array of vitamins and micronutrients.

  • Selenomax 200 mcg
  • OptiZinc 30 mg
  • Nutrient 950 multivitamin
  • DHEA 50 mg
  • Diaxinol
  • 4Sight
  • Vitamin B2
  • Methyl folate 1600 mcg
  • B12 10,000 mcg
  • Alpha lipoic acid 300 mg
  • Ginkgo Biloba 60 mg
  • ProBiotic 100
  • Vitamin C as ascorbyl palmitate
  • “Reacted” chelated Iron 58 mg (read my previous series on iron)

It’s quite a handful, but each of these is designed to improve immune function, cardiovascular function, energy and cognitive vigor.


Lunch is a very sparse affair with my second protein shake of the day.

  • 2 scoops of whey-based protein
  • 1 tsp ( 3 grams) carnitine tartrate
  • Gluco-shield.

It is a quick and efficient source of energy.  This carries me through the day until 5:00 or 6:00 pm.


Dinner is a rich source of protein including fish, chicken or organic beef with some vegetables, most especially broccoli and carrots. My preference at night is a combination of chocolate Rice Dream and chocolate Hemp Milk.

At night I might cheat with a tiny source of extra carbohydrate. The goal is always low carbohydrate, high-protein. This is not a ketogenic diet.  It is a modified Paleo diet.

Ketogenic diets do promote weight loss. I am still concerned about the quality of fats being advocated in ketogenic diets.  Usually including large amounts of butter, cheese, bacon, sausage and other sources of potentially inflammatory Omega-6 oils.  Omega-6 fats potentially increase arachidonic acid which promotes a cascade of inflammatory metabolites.

This is the source of another blog soon.

Dinner is also supplemented with:

  • Nutrient 950 multivitamin 3 caps
  • Diaxinol 1 cap
  • 4Sight 1 cap
  • Ginkgo biloba 60 mg
  • Magnesium 400 mg
  • Alpha lipoic acid (a stellar antioxidant) 300 mg


Just before retiring at night I take

  • Magnesium 200 mg
  • Nattokinase 100 mg

Coda – Ask Jack

Jack LaLanne at age 60. Original fitness guru
Jack age 60

Does that sound like too much? We could have asked Jack LaLanne. Our supreme nutrition and exercise experiment. He took all known supplements and micronutrients for well over 70 years.

Jack once said, “I can’t die, [he most famously liked to say]. It would ruin my image.”

I can remember Coach Dees in high school. He was our cross country coach.  On the first day he said, “Now I want all of you to go out and start drinking wheat germ oil.”   This was 1960 when you went into a tiny proto health-food store with an old guy sitting at the bar drinking carrot juice.  Wheat germ oil was supplied in plain unattractive brown bottles.   It was my first source of concentrated Vitamin E.

In Medical School at UCSD a group of us would read Adele Davis.  Then Linus Pauling started writing about OrthoMolecular Medicine.  He was advocating therapeutic, supra-physiologic doses of vitamins, minerals and selected micronutrients.

It’s been a life-long quest.

We all want healthy and robust longevity in a chaotic world. The ultimate goal of the preventive medicine physician is to set an example and show the way.

Thank you for reading. Now what are you taking? Drop me a line. Don’t forget your Fullscript source of all supplements and micro-nutrients.  Then read (or re-read) my bestselling book.  The Life Extension Revolution.

Philip Lee Miller, M.D.

Carmel California

Iron Deficiency Signs and Symptoms -Part IV

Iron Deficiency Signs and Symptoms -Part IV

Symptoms of Iron Deficiency Anemia:

Iron is essential for oxygen carrying capacity.  Iron deficiency and anemia decreases oxygen delivery to all major organs of the body. Most especially the brain, heart and muscles.   Iron deficiency manifests with easily identified symptoms and conditions.  Here is a quick overview followed by a more detailed description.


common symptoms of iron deficiency anemia

Mental Fatigue and Cognitive Impairment.

Iron is an essential cofactor for neurotransmitter and myelin synthesis.  Brain neuronal cells require iron for DNA synthesis, mitochondrial respiration, and other vital processes.  As with each of these conditions, iron deficiency anemia reduces tissue oxygenation.  The brain is vitally dependent on O2 and glucose.

Pale (pallid) or Yellow (sallow) Skin.

Here is a comparison of a well perfused (red blooded) iron sufficient hand with an anemic iron deficient hand.  This is simply a visual sign of arterial oxygenation saturation.  Well oxygenated and perfused blood is red.   Technically, we can measure arterial pO2, pCO2 and pH.   The pO2 is the partial pressure of oxygen.

Pulling the lower eyelid revealing the conjunctival inner surface.  This reveals a lack of normal capillary perfusion.  While I was an Emergency Physician we also used another rapid test.  Pressing a fingernail watching for rapid reperfusion or capillary refilling.

anemia with (pallid) poor conjunctival perfusion pallor of anemia compared to normally perfused hand

Unexplained Fatigue or Lack of Energy

physical and mental fatigue

Heart Failure in Susceptible Individuals with Heart Disease

In individuals with a weak or failing heart, iron deficiency anemia stresses heart function.  Diminished oxygen saturation requires more rapid blood flow to keep up with oxygen requirements.  This increases heart rate.  We call this tachycardia.  This tachycardia in turn stresses an already weakened heart.   The heart is, after all, a large muscular organ.  Lack of oxygen leads to myoglobin deficit.   It is a circular set of reactions as seen in figure 5

iron and heart failure
figure 5

Pagophagia – Craving for Ice or Clay

This is an interesting phenomenon.  And it is not well scientifically explained.  It is possible this increase in alertness is a response to the fatigue of iron deficiency anemia.

pica or pagopahgia is a symptom or iron deficiency

Sore or smooth tongue and cheilitis

A smooth tongue.  The “angles” of the mouth show signs of angular cheilitis.  This appears to be an inflammatory condition.  In the past I thought this was a vitamin deficiency.

glossitis (re tongue) and angular cheilitis are symptoms of iron deficiency

Brittle nails or hair loss

Another interesting phenomenon  indicating the need for iron in hard connective tissue synthesis.  A poorly explained phenomenon.  We think this may be related to injury to the nail plate – the origin of nail growth.  Somehow this may be more susceptible to damage or injury with iron deficiency anemia.

brittle nails are a symptom of iron deficiency

Restless Legs Syndrome

Restless legs is an annoying condition that disturbs healthy and regenerative sleep.  It is nearly synonymous with “periodic limb movement.”  This is an important  observation during a thorough sleep study.  Iron deficiency as a cause is becoming more recognized.  Iron infusions are quite dramatic in their ability to completely resolve this condition.   In the past we have treated this condition with Mirapex, a dopamine agonist, more commonly used to treat Parkinson’s Disease.

restless leg syndrome at night (periodic limb movement)

Additional Symptoms:

Here are further manifestations mostly related to more rapid arterial blood flow in response to diminished oxygen availability:

  • Shortness of breath or chest pain, especially with activity (dyspnea)
  • Unexplained generalized weakness (asthenia)
  • Rapid heartbeat (tachycardia)
  • Pounding or “whooshing” in the ears (pulsatile tinnitis)
  • Headache, especially with activity (exertional headache)

So let’s move on to the final episode: treatment of iron deficiency and anemia.

Previous Pages

 Part I, Part II, Part III


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