What does it mean to be Anemic?

Part 2-Let’s Talk Vitamins (and Iron)

Last week we started talking about anemia, vitamin C, and vitamin B1, about supplements, and briefly about iron.  If you missed part 1, click here.

This week, we will discuss what is needed for healthy red blood cells and what symptoms could be a sign of nutrient deficiencies.

Anemia happens when you don’t have enough red blood cells or your red blood cells don’t work as they should. Your red blood cells carry oxygen throughout your body. Oxygen powers your cells and gives you energy. Without healthy red blood cells that do their job, your body doesn’t get the energy it needs to function. While some types of anemia are short-term and mild, others can last for a lifetime. Left untreated, anemia may be life-threatening.

-Cleveland Clinic

Anemia can be caused by low stomach acid, low iron, low vitamin B9 and/or B12, malabsorption, a fatty acid deficiency, heavy bleeding, parasites, an autoimmune illness, heart disease, and medications.

What is needed to create red blood cells, and what is needed to keep them healthy?

First, we need to know how and when red blood cells are created, how long they live, and what else they do other than carry oxygen.

Red blood cells, called erythrocytes, are cells made in the bone marrow. When low oxygen is detected, the kidneys release a hormone to stimulate the bone marrow to create red blood cells. Red blood cells contain the protein hemoglobin which is needed to transport oxygen from the lungs to all of our cells and carry away carbon dioxide back to the lungs.  Each red blood cell lives for about 120 days, this is why it usually takes about 3 months for some blood tests to show a difference. A standard CBC, Complete Blood Count, usually checks hemoglobin and RBC, red blood count, in addition to other markers for anemia and infection. You usually have these checked at an annual physical or anytime you are hospitalized.

Anemia is when there aren’t enough healthy red blood cells to carry sufficient oxygen, or hemoglobin is too low. This can cause someone to feel weak and tired, short of breath, dizzy, have headaches, sore tongue, cold hands and feet, and/or brittle nails. Now, these symptoms can be caused by many other things, as well, so if you have any or all, it doesn’t necessarily mean you’re anemic, but it is something to consider.

Hemoglobin is made of iron and protein.  When hemoglobin is attached to oxygen, it become red giving blood it’s red color.  To create hemoglobin, the body needs iron, vitamin B12, vitamin B9, vitamin B6, and amino acids.

Iron is required for growth and healing and immune function, so it is vital for our red blood cells and health, but we can get too much.  I do not recommend iron supplementation without consulting a medical provider!  The body does NOT have a system in place to eliminate excess iron, and high amounts of iron are toxic.  Iron is a PRO-oxidant, the opposite of an anti-oxidant. Excess amounts damage cells and accumulate in the brain and liver leading to cancer and high risk of infection.  Signs of too much iron can be gastrointestinal upset, constipation, and vomiting which are very difficult to relate to iron without a blood test.  

It is safest to get your iron from foods.  Iron is found in peas, lentils, beans, dark leafy greens, and dried fruits like raisins and prunes.  It is also found in red meats, but we are encouraged to limit or eliminate red meats for optimal health.

To increase the absorption of iron, it is best to consume iron-rich foods with foods that are high in vitamin C which is all of your raw fruits and vegetables. Vitamin C is highest in tomatoes, red bell peppers, kiwi, and raw greens like spinach.  Iron absorption is inhibited by high amounts of calcium, high amounts of soy, antibiotics, diuretics, and vitamin A deficiency. It is important to maintain a healthy vitamin A status, but supplementing with vitamin A is not always a healthy choice.  To enhance iron absorption, eat iron-rich foods with vitamin C-rich foods (raw fruits and vegetables) and not with high calcium-rich foods.

  • Eat a kale salad topped with green peas and red peppers
  • Eat cooked collards with black-eyed peas and side salad
  • Eat a green smoothie bowl with slices of kiwi

For healthy red blood cells, we also need vitamin B12.

Vitamin B12 is difficult to get these days. It is made in the body from bacteria that we eat, BUT we eat really clean foods and foods grown on soils that have been treated to prevent bacterial growth. It is recommended that everyone age 50 and older to supplement with B12 regardless of dietary choices. B12 is very difficult to absorb and requires a high concentration of stomach acid and intrinsic factor which is depleted as we age; therefore, it is more difficult to maintain the amount needed as you age.  AND…if you don’t eat any animal products, you should supplement at ALL ages.  Those who eat animal products eat the animal that ate bacteria from dirty foods.

Vitamin B12 is needed to produce energy.  This is why some people feel more energetic after a B12 shot. The B12 doesn’t give them energy, but it is necessary for the pathways that create energy from our foods.  Vitamin B12 also lowers homocysteine, an inflammatory marker, protects nerve cells, supports the myelin sheath that protects our nerves, aids in protein metabolism, and supports the production and repair of our DNA and RNA.  It is very important to get enough vitamin B12.

Symptoms of a vitamin B12 deficiency include fatigue, neurological disorders, sensory loss, dementia, psychiatric disorders, weakness, diarrhea, weightloss, fever, numbness and tingling in the hands and feet, loss of balance, and confusion and moodiness.

Who’s at risk of vitamin B12 deficiency?

Anyone with an impaired stomach from H pylori, ulcers, or gastritis has difficulty absorbing vitamin B12.  Those with Crohn’s, IBD/IBS, pancreatic illnesses, bariatric surgery, or other intestinal issues will not absorb vitamin B12 well. Vegans and vegetarians take in a lot less vitamin B12 than meat eaters.  Those with medical conditions like diabetes, autoimmune illnesses, and the elderly are all at a higher risk.  

There are several medications that can deplete vitamin B12.  Anti-seizure medications, chemotherapy, medicines for gout, cholesterol lowering medicines, medicines to lower stomach acid, diabetes medications like Metformin, proton pump inhibitors like Nexium, and antibiotics all inhibit vitamin B12 absorption.  If you are on any of these meds, consider supplementing with vitamin B12 AND consult your medical provider before taking any supplements.

Can I test my vitamin B12?

Tests for vitamin B12 are not accurate.  A blood test, only shows what’s in the serum, not what is in the cells.  The best test for vitamin B12 is a methylmalonic acid test. I have actually had this done through a blood test by my medical doctor and through a urine organic acids test through my schooling.  The body produces methylmalonic acid when it doesn’t have the vitamin B12 that it needs, so if you test high for methylmalonic acid, you most likely need vitamin B12. Other health conditions can cause methylmalonic acid to rise, too, though.

How should I get my vitamin B12?

There are foods that contain vitamin B12 such as sardines, salmon, and tuna.  There are also herbs that supposedly contain vitamin B12 like alfalfa, dandelion, hawthorn berries, hops, bladderwrack, and white oak bark, but I would not rely on these for your vitamin B12. As with any supplements, always consult your medical provider.  Supplements for B12 are well tolerated in most populations.  Just like everything, there is no one-size-fits-all.  I like to look for supplements with 2-3 types of vitamin B12.  Depending on genetics, methylated forms are more easily absorbed, but other forms are usually more easily absorbed, so I buy B vitamins that contain a combination of methylcobalamin, adenosylcobalamin, and/or hydroxocobalamin. The RDA is only 2.4 MICROgrams, so you only need a little. I take a little everyday, but some people prefer to take a larger dose once or twice a week. Excess vitamin B12 is excreted through the urine.

We need vitamin B6 to absorb vitamin B12.We also need vitamin B6 to attach oxygen to hemoglobin and is important for hemoglobin synthesis. Vitamin B6 is essential to over 100 enzymes.  It is needed to make neurotransmitters like serotonin, norepinephrine, and melatonin, and it is involved in brain development and function. It is needed to convert amino acids into dopamine and GABA.

Deficiencies in vitamin B6 can not only affect neurotransmitters, but they can also lead to cardiovascular inflammation and cognitive decline. A high protein diet depletes vitamin B6; however, a vitamin B6 deficiency can be due to a low protein diet. Malabsorption, alcoholism, corticosteroids, and other meds can lead to a deficiency. Health conditions like hyperthyroidism can increase the need for more vitamin B6, and genetic disorders can affect its metabolism.

Signs of a vitamin B6 deficiency include peripheral neuropathy, dermatitis, inflammation of the tongue, cracks in the corner of the mouth, depression, confusion, seizures, and other anemias.

The RDA for vitamin B6 is 1.3 mg per day for healthy adults.  Excess vitamin B6 can lead to sensory changes, difficulty with coordination and balance, allergic skin reactions, numbness, loss of appetite, nausea, stomach pain, and sensitivity to sunlight. Most of these symptoms are reversable.

There are several foods that contain vitamin B6.  Sweet potatoes, sunflower seeds, spinach, bananas, salmon, and tuna are all good sources.  Herbs like alfalfa, catnip, and oat straw are also good sources.

Vitamin B9 aka Folate is crucial for forming red blood cells.

Folate, not to be confused with folic acid, is needed for red blood cell production, DNA repair, and brain health. Folate is needed to convert amino acids to create DNA which is necessary for red blood cell production and for cells to be able to divide.  Vitamin B9 is also needed to create vitamin B12.  If one of these vitamins is deficient, a person will quickly become anemic. Vitamin B9 is needed for the cells to mature.  Red blood cells start out large, then they divide slowly.  We can tell from a standard CBC if your blood cells are maturing or not by looking at your MCV.  BUT an iron deficiency also leads to small red blood cells, so one blood marker is never to be used alone.

Folate is very common in foods.  I like to think of FOLiage when thinking of foods high in folate.  Leafy greens like Brussels sprouts, spinach, and kale are high in folate, avocado, citrus fruits, nuts and seeds, and legumes are all great sources of vitamin B9.  Depending on the form, some are destroyed by heat. The folate in cooked lima beans is highly absorbable, but the folate in romaine is not, so it is very important to eat a variety of these foods and some cooked and some raw (always eat lima beans cooked). To increase absorption of vitamin B9, eat those foods with foods high in zinc and vitamin C. 

There are several health conditions linked to folate. Folate is essential in fetal development.  Most of us are familiar with the term “folic acid” from prenatal supplements.  It was found that birth defects are strongly tied to a deficiency in folate.  Folic acid was then added to prenatal supplements and many of our packaged foods to prevent birth defects, but the added folic acid is not right for everyone and has been shown to increase cancer cell growth. Folate can prevent cancer and repair DNA.  Folate is what our body needs NOT folic acid.

Common vitamin B9 supplements contain Folic Acid.  This is also what is in fortified foods. Folic acid is not the same as folate and is oxidized, which can be harmful to the body.

Who is at risk of a vitamin B9 deficiency?

Someone with a zinc deficiency, Celiac disease, Crohn’s or other intestinal disorders, bacterial overgrowth, or a lowered HCL is at a higher risk.  Those who are pregnant need to take a folate supplement, not folic acid.  Alcohol and medications interfere with absorption.  People on dialysis, on cancer drugs, and who lack fresh fruits and vegetables or who cook their vegetables too long are at risk of vitamin B9 deficiency.

Can I take Vitamin B9, Folate, supplements?

Vitamin B9 is a water soluble vitamin, so it is excreted in the urine if consumed in excess. As always, check with your medical provider before supplementing.  The RDA for folate is 400 MICROgrams for a healthy adult. It is easy to get the folate you need if you eat a diet rich in leafy greens, beans, and seeds.  Garbanzo beans and lentils appear to be the best sources for folate.  1 cup of lentils gives you 358 mcg of folate, so it is just shy of the entire day’s requirement. If you struggle with eating these foods, then consider a supplement. You can also get folate from green herbs like nettle, parsley, and basil. Supplements containing folate may have listed folate, quatrefolic, or methytetrahydrofolate.  As always, check with your medical provider before taking supplements.

How do I know if I need to take folate?

Many symptoms of a vitamin B9 deficiency are similar to the others.  Weakness, fatigue, headaches, heart palpitations, sore tongue or inside of the mouth, restless leg syndrome, neural tube defects, and low birth weight are all symptoms.

Did you know that your thyroid can also be affected by low folate?

If you don’t have adequate folate, homocysteine can build up which can lead to thyroid receptor resistance.  Someone may think they have a thyroid problem when it is actually a vitamin B9 deficiency.

Iron, vitamin B6, B9, and B12 the key vitamins related to anemia.  As you can see, there are many foods that contain all of these important vitamins.  Eating a diet rich in leafy greens, raw and cooked, raw fruits and vegetables for vitamin C and better absorption of some other vitamins, and beans and other healthy sources of protein will provide the nutrients needed for healthy red blood cells.

One response to “What does it mean to be Anemic?”

  1. […] “It.” Most of those were already mentioned in Part 1:What Does It Mean to be Anemic?, Part 2: Anemia: Let’s Talk Vitamins (and Iron) , and Part 3: What Other Vitamins and Minerals are Important? One of them is very […]


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