Everything you Need to Know About Anemia


General Information

Anemia is a condition that occurs when your red blood cell count is lower than what is considered normal.  The red blood cell count is also represented in blood work by the hemoglobin level.

Red Blood Cells are made inside the bone marrow.  They live on average about 100 to 120 days, so our body is constantly making new blood cells. 

Globally, anemia affects 1.62 BILLION people which equates to almost 25% of the World Population, with over 900 MILLION of these being adults.  Anemia has also been increasing in the United States – nearly doubling over the last decade.  This means that there are more than 23 MILLION people in the United States alone who have Anemia.

This is important because our life sustaining (and health promoting!) OXYGEN is carried on our Red Blood Cells.  Since every organ and proper functioning of our organs are dependent on Oxygen for day to day health, conditions from Hearing Loss to Heart Failure are associated with Anemia.   A recent studied published identified a twofold risk of death for patients who suffered a stroke if they also have Anemia.

The possibility of Anemia is also a more common problem as we age.  Unfortunately, it has many possible causes, which sometimes can make it difficult to figure out the cause.   This is important because less oxygen reaching our organs and brain, means  that our organs have to work harder to compensate for having less oxygen. 

When thinking about all the different possibly reasons that cause Anemia, it’s best to start by thinking of the three general categories in which it can occur.

1.  Our body isn’t making enough red blood cells.

2.  Our body is destroying red blood cells too quickly.

3.  Our body is actually LOSING blood somewhere.

The best treatment for anemia is to address and resolve the cause whenever possible, so let’s take a look at each of these a little further.

Our body is not making enough red blood cells.


Since Red Blood Cells are made in the bone marrow, any medical condition that affects the bone marrow can potentially cause Anemia.  That means if the bone marrow isn’t making Red Blood Cells fast enough, anemia can develop.  Some blood cancers such as Leukemia and Lymphoma can cause Anemia.  Tumors that have spread from other parts of the body to the bone marrow can also cause Anemia.

Nutrition and Anemia 

The bone marrow also needs very specific nutrients in order to make Red Blood Cells.  For instance, B12, Folic Acid and Iron are critical nutrients that are required to make Red Blood Cells. 

It may surprise you to find out that B12 is actually a very common nutrient deficiency – even when we are young in our 40’s and 50’s.  This nutrient is actually not a very common nutrient in food.  B12 is mostly concentrated in red meats.  And since many of us have reduced our red meat consumption, B12 deficiencies have become quite common. 

B12 also becomes more difficult to absorb as we age.  A very specific cell in the stomach, called the parietal cell, must be functioning well in order for the stomach to absorb B12.  And this particular cell is often not functioning well after the age of 50, and sometimes even begins to atrophy before age 50. 

B12 is a critical nutrient for many other functions of the body as well, especially in brain and nerve function.  If you have a B12 deficiency that has caused Anemia, you may also notice a decline in memory, mood and be experiencing numbness or pin prink sensations in your feet.  This numbness or pin prink sensations is called peripheral neuropathy.

When you replace B12 and get your levels back to normal, your bone marrow can begin making Red Blood Cells, your memory and mood improves, but unfortunately the damage done to the nerves from the B12 deficiency will not recover.  Once nerve damage has occurred and peripheral neuropathy has developed, replacement of B12 will not help.

So, you can see why it is critical to make sure you get adequate B12.

Folic Acid is another important nutrient our bone marrow needs to make Red Blood Cells.  Fortunately, Folic Acid is actually much easier to absorb than B12.  But the problem we see with Folic Acid is that this nutrient is mostly in foods many are not eating on a regular basis. 

Foods high in Folic acid include: Legumes (like lentils, peas and beans), Wheat Germ, Leafy greens, Asparagus, Beets, Citrus Fruit, Broccoli, Brussel Sprouts, Avocado, Papaya, and to a lesser extent, Bananas, Nuts, and Eggs provide some Folic Acid. 

Iron is another nutrient necessary for the bone marrow to make Red Blood Cells.  Many of the same foods that contain either high amounts of Vitamin B12 or Folic Acid, often act as a good source of Iron.  Red meat is the best source of Iron.  Dark turkey meat is next, though white meat has only negligible amounts of Iron.  Quinoa, Lentils, Beans have some iron as well, so these are good vegetarian sources of iron. 

Vitamin C is very important for the body’s ability to absorb iron, and thus inadequate Vitamin C can actually result in an iron deficiency which then results in Anemia.  Common foods rich in Vitamin C Acerola Cherries, Guavas, Kiwifruit, Bell Peppers, Strawberries, Oranges, Papaya, Broccoli, and Kale.

In addition to these nutrients, making sure you get sufficient Complete Proteins in your diet is also very important for Red Blood Cell production.  Protein is a macronutrient that the body breaks down into Amino Acids to make other Proteins, Hormones, Immune System Cells, and Neurotransmitters to name a few.

As you are about to find out in the next section, Hormones play a critical role in the bone marrow’s ability to produce Red Blood Cells.  And our body’s ability to make Hormones is dependent on our Protein consumption. 

Unfortunately, Protein is often decreased in our diet as we age.  Or we find that the type of Protein that is primarily consumed is of poor quality.  Hang in there, I’ll be sharing knowledge on how to consume healthy, complete Protein in posts to come! 

So, let’s now take a look at our ever-important Hormones and see how they play a role in Red Blood Cell production and the prevention of Anemia.

Hormones and Anemia 

In addition to the Bone Marrow needing certain nutrients to make Red Blood Cells, the Bone Marrow also depends on HORMONE signals to make Red Blood Cells. 

The Kidneys release a hormone called Erythropoietin, which is the hormone that tells the bone marrow to make Red Blood Cells.  As we age, our Kidney function declines which results in less Erythropoietin production.  And without the right amount of Erythropoietin, the bone marrow does not make enough Red Blood Cells resulting in chronic Anemia.

Eating adequate protein is critical for the Kidney’s ability to produce Erythropoietin!  Without complete protein consumed on a daily basis, Erythropoietin is suppressed and Red Blood Cell production declines.  3.   Isn’t it amazing how everything in the body works in a series of one reaction after another in order to get one big job done!

The Bone Marrow also depends on at least two SEX Hormones -Testosterone and Estrogen - to make Red Blood Cells.  Testosterone and Estrogen decrease a substance called Hepcidin, which is a substance in the body that prevents the bone marrow from utilizing iron.  And when the bone marrow is unable to use iron, it is unable to make Red Blood Cells. 

Sex Hormones naturally decline as we age.  Women’s Estrogen declines much more rapidly than Men’s Testosterone levels.  After menopause, if a woman does not supplement with Hormone Replacement, her Estrogen levels are significantly low for the rest of her life, and thus predisposes her to the development of Anemia. 

It’s not as simple for men because there is controversy on what constitutes low Testosterone in men.  For some men, Testosterone levels decline more rapidly than other men.  Some men may see their Testosterone levels decline just like women, during their midlife years, whereas other men may have normal (and adequate) Testosterone levels way into their 70’s.  Most men will have some decline in their Testosterone levels at this time, but there is such a large “normal reference range” for Testosterone levels in Conventional Medicine that there is a lot of controversy about what is actually “normal” or “low” levels.  (I will share with you a LOT of information about Hormones in many blogs and posts to come.)

This topic, Testosterone in men as they age, is a very important topic when discussing Anemia because we know that Testosterone stimulates Erythropoietin - thereby stimulating Red Blood Cell Production.  Without adequate Testosterone, Red Blood Cell Production in the bone marrow declines and anemia develops.  1. This can lead to even more complicating medical conditions such as memory loss, more rapid kidney disease, and even heart failure.

So, as you see, even our Sex Hormones, Estrogen in Women and Testosterone in Men, are critical players in the body’s ability to make Red Blood Cells and prevent Anemia.

Another hormone that is important for the production of Red Blood Cells in both men and women is Thyroid Hormone.  If you really want to think about the importance of adequate Thyroid hormone, picture this!

Thyroid hormones (particularly Free T3) is a key hormone controlling our metabolism.  Up to 50% or more of women past menopause have declining Thyroid hormone production and function.  This phenomenon is less frequent in men until they are older – usually in their 70’s and up, which at that time begin to catch up with women.  

Thyroid hormone has been discovered to be the bone marrow’s final regulating signal that tells the Red Blood Cells to fully mature.  Until this step takes place, Red Blood Cells are unable to perform their function.   6

So, you see, hormones, Erythropoietin, Estrogen, Testosterone, and Thyroid hormone, are all critical players in the development and maturation of Red Blood Cells!  Don’t you just love it?!

Medications and Anemia 

It never ceases to amaze me at just how many medications people are on.  As a geriatrician who has cared for older patients who have endured an illness severe enough for them to require further care in rehabilitation, I often see lists of medications that include 10-20 daily medications!  

These include medications for important and complicated conditions such as multiple medications for resistant high blood pressure, blood thinners, antibiotics, diabetes medications, a sleep medication, one or more antidepressants, and one or more medications for constipation.  This is actually more common than not!

And though some of these medications are obviously beneficial, we are now understanding that the growing problem with Anemia is caused by an actual suppression of the bone marrow BY medications. 

As we age, chronic illness often requires multiple medications.  In fact, 40% of adults over 65 use 5 or more medications weekly and 12% use 10 or more medications weekly.

Often what happens is our great medical knowledge that has expanded into having so many knowledgeable specialists, has resulted in each specialist adding their concoction of drugs to help people control the chronic medical condition that each specialist manages.  And so often, there is no one watching for the interactions of these medications with one another.

One medication may have a small effect on the body’s bone marrow to make Red Blood Cells, but when mixed with multiple other medications, this effect becomes quite significant – resulting in a serious risk of bone marrow suppression and resultant chronic Anemia!

Examples of medications that may suppress the bone marrow’s ability to make Red Blood Cells include ACE Inhibitors (such as lisinopril, enalapril, captopril and all the other “pril” medications in this group), Angiotensin Receptor Blockers, also called ARB’s (such as losartan, telmisartan, valsartan and all the other “tan” medications in this group) some antibiotic such as Bactrim (or Septra) and certain medications used for seizures.

Our body is destroying red blood cells too quickly.

The second general category that can cause Anemia is when the body destroys its Red Blood Cells too quickly.  The bone marrow is making adequate Red Blood Cells, but something else in the body is actually destroying them before their 100 – 120-day life cycle is completed.

Hemolytic anemia is a general term used to describe many different conditions when the body destroys and removes Red Blood Cells faster than the bone marrow makes them. 

Sometimes a person is born with a form of Hemolytic Anemia that causes the body to destroy Red Blood Cells.   Sickle cell anemia and thalassemia are examples of inherited conditions where the blood cells have particular abnormalities which in turn cause the body develop Anemia. 

However, there are also times when the body can start destroying Red Blood Cells from conditions that are not inherited.  In fact, anyone at any age can develop Anemia caused by the body’s reaction to certain things that then set off a cascade of events that destroy Red Blood Cells. 

Examples that may destroy Red Blood Cells causing Hemolytic Anemia include autoimmune conditions, infections, prosthetic heart valves, snake or spider venom, advanced liver or kidney disease, and blood cancers such as Leukemia and Lymphoma.   Even severe stress to the body such as severe infections causing sepsis (a full-blown blood infection requiring IV antibiotics), severe burns, uncontrolled very high blood pressure (180/110 or greater), or exposure to toxins can set off the body’s self-destruction of Red Blood Cells. 

And as you might expect, there are medications that are very common medications we often take for granted which can cause Hemolytic Anemia.  And just because you may have taken one of these medications without a problem in the past, it can still happen when taken in the future.  ALL of the events that are happening inside the body at any one time play a role in how you are affected by a drug. 

Examples of medications that can cause Anemia, include:

Antibiotics including Cephalosporins like Keflex, Penicillin, Nitrofurantoin, and Levofloxacin and rifampin. 

Nonsteroidal anti-inflammatory medications that are available over the counter, like ibuprofen (Advil, Motrin) and acetaminophen (Tylenol).

Parkinson medications such as Levodopa and Methyldopa.

immune stimulating medications and emergency cardiac drugs.

Our body is actually LOSING blood somewhere.

The only way to lose Red Blood Cells is through the loss of blood.  This can occur with Menstrual bleeding, Gastrointestinal bleeding such as ulcers in the stomach or intestine, tumors that bleed (such as cancers in the colon or bladder), blood loss from trauma such as a major cut or fall resulting in a large hematoma, bone fracture or even bleed in the brain, Also, surgery that results in blood loss can cause Anemia.

Basically, anything that bleeds or causes bleeding can result in Anemia.  Diverticulosis, which are thin walled out-pockets of the colon wall can slowly bleed, especially if they become infected and inflamed (for which we then call it diverticulitis).  Any type of Inflammation in the stomach or bowel can bleed. Wounds can bleed.  And Arterio-Venous Malformations (called AV Malformations) can bleed.  A-V Malformations is a condition that occurs when an artery and vein form an open communicating connection between them.  This is a real problem because there is a lot higher pressure on the Arterial side of our vascular system compared to the Venous side – and this results in blood oozing out of from the A-V Malformation.

Additional causes of Anemia:  

There are additional causes of Anemia as well. 

Too much alcohol can cause inflammation in the stomach and bowel which then results in very slow oozing of blood from the stomach.  In addition to blood loss, alcohol can cause malnutrition.  Due to the inflammation that occurs from alcohol, the cells that are responsible for absorbing nutrients cannot function properly, even if adequate nutrition is consumed.  This results in malnutrition, particularly of two very important nutrients for Red Blood Cells, B12 and Folic Acid.

Nonsteroidal Anti-Inflammatories, (NSAIDS), such as ibuprofen and naproxen as well as steroidal anti-inflammatories also thin the mucosal surface of the stomach and bowel and can cause chronic oozing of blood with a resultant Anemia.  These medications can also cause full blown ulcer formation, which may result in a severe immediate bleeding episode requiring emergency blood transfusions.  Indeed, the number one cause of GI bleeding are NSAIDS available over the counter.

Past Chemotherapy as well as medications may also cause Anemia.  Blood thinners such as Coumadin and the newer blood thinning medications such as Xarelto, Pradaxa and Eliquis can cause Anemia by causing a very slow oozing of blood from bruises, stomach, bowel and urinary blood loss.

Other medications such as those used to prevent seizures can cause Anemia.

Liver disease, autoimmune diseases, mononucleosis, and even exposures to toxins can affect your bone marrow’s ability to make adequate Red Blood Cells, but fortunately these are less common.

Symptoms of Anemia:

If anemia develops slowly, you may not realize it.  Fatigue and weakness are the first signs you may notice, but many push through these symptoms out of the simple necessity of a busy life.  This is the usual case for most people.  They are going about their daily lives feeling more sluggish month after month or even year after year. 

Though mild Anemia may also bring on a general feeling of “blah” and “brain-fog”, full blown Depression, Dizziness, and Memory Loss can also occur as anemia worsens.  Skin color can become paler, as well as the mucous membranes along the gum line and eyelids appear paler.  And as Anemia becomes severe, serious symptoms often occur such as chest pain and shortness of breath even without adding increased activity.

If you already have heart disease, Anemia may be even more dangerous, as it may cause heart failure.  You can imagine how much harder it is for the heart to pump under an Anemic condition with less Oxygen to assist it.  This may bring on ankle swelling, feeling more short of breath, and having more difficulty breathing when lying flat. 

On the other hand, if Anemia develops quickly, symptoms are a bit more obvious, as the body has not had the opportunity to adjust to the lower levels of Red Blood Cells. 

Caring for Anemia

Mild Anemia is so common as we age, that many doctors do not pay enough attention to slightly low levels of Red Blood Cells.  But this really should not be the case. As you have discovered here, Anemia plays a role in almost all medical conditions because our organs and their function DEPEND on Oxygen, which is carried through the Red Blood Cell. 

When you first find out that you are developing Anemia, THIS is the time to get to work and find out why.  It is stressful for all of your organs to function to their full capacity when they are doing their work with less Oxygen.  So, this is indeed the time you want to investigate what could be causing the Anemia.

In addition to checking all of the usual blood work your physician will be checking, make sure your Hormone levels and the key nutrients discussed here are tested.

The primary treatment for Anemia is in determining the CAUSE and thereby treating the cause.  Most commonly, a nutritional or Hormone deficiency could be at least one of the causes and is very easy to resolve by supplementation and diet changes.  Your doctor can determine fairly easily through blood work alone if you have a nutritional or Hormone deficiency, as well as determine easily if you are making enough red blood cells from your bone marrow.  That’s the easy part. 

Figuring out the specific cause of any abnormal lab values is a bit more challenging.  Stool samples should also always be checked to assure you are not losing blood from your Gastrointestinal system (stomach or bowel). 

Assessment almost always can start with your Primary Care Physician, Internal Medicine or Geriatric Specialist.  Sometimes, they will refer you to a Hematologist, who specializes in Blood disorders.

Keep watching for additional vital information on exactly what and how to supplement vitamin and Hormone deficiencies in future articles.


1.  Testosterone Induces Erythrocytosis via Increased Erythropoietin and Suppressed Hepcidin: Evidence for a New Erythropoietin/Hemoglobin Set Point

Eric Bachman, 1 Thomas G. Travison, 2 Shehzad Basaria, 1 Maithili N. Davda, 2Wen Guo, 2 Michelle Li, 2 John Connor Westfall, 1 Harold Bae, 1 Victor Gordeuk, 2 and Shalender Bhasin 3

2.  Testosterone alters iron metabolism and stimulates red blood cell production independently of dihydrotestosterone

Luke A. Beggs,1,4 Joshua F. Yarrow,1,4 Christine F. Conover,1 John R. Meuleman,2Darren T. Beck,7 Matthew Morrow,3 Baiming Zou,5 Jonathan J. Shuster,6 and Stephen E. Borst2,4

3. Depressed response of the erythropoietin-responsive splenic cell population to erythropoietin in acutely protein restricted mice. In Vivo. 1995 Jan-Feb;9(1):71-3.

4.   Jelkmann W, Kurtz A, Bauer C., Effects of fasting on the hypoxia-induced erythropoietin production in rats. Pflugers Arch. 1983 Feb;396(2):174-5.

5.  Foley JE, Gross DM, Nelson PK, Fisher JW. The effects of arachidonic acid on erythropoietin production in exhypoxic polycythemic mice and the isolated perfused canine kidney. J Pharmacol Exp Ther. 1978 Nov;207(2):402-9.

6.  https://www.hammernutrition.com/knowledge/endurance-library/diet-for-increasing-natural-epo

7.  Probl Gematol Pereliv Krovi. 1975 Aug;20(8):45-51.

8.  Humoral regulation of erythropoiesis (review of the literature); Istamanova TS, Almazov VA, Kanaev SV.  PMID: 1099577

9.  Nihon Rinsho. Sex hormones and bone marrow functions; 1974 Nov 10;32(11):3346-9 Yamamoto M, Hayashi Y, Yamada K.

10.  World health Organization – anemia

11.  Xiaofei Gao et al. Thyroid hormone receptor beta and NCOA4 regulate terminal erythrocyte differentiation, Proceedings of the national Academy of Sciences (2017)

DOI: 10.1073/pnas.1711058114

12.  https://my.clevelandclinic.org/health/articles/8964-aging--anemia