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    Iron-Deficiency Anemia (Holistic)

    Iron-Deficiency Anemia (Holistic)

    About This Condition

    Find balance and beat iron-deficiency anemia. Iron deficiency, whether it is severe enough to lead to anemia or not, can result from a number of health issues. According to research or other evidence, the following self-care steps may be helpful.
    • Take iron as directed

      Follow your doctor?s instructions for using iron supplements

    • Get your vitamin C

      Eating vitamin C?rich foods with meals and taking 100 to 500 mg of vitamin C with iron supplements will improve your iron absorption

    • Don?t mix iron with beverage breaks

      Drinking coffee or tea with iron supplements inhibits absorption

    • Find the cause

      Iron deficiency can have many non-nutritional causes, including some serious diseases, so work with your doctor to investigate why you are low in iron

    • Know your iron level

      To avoid possible problems related to iron overload, have your blood tested regularly for both high and low iron while you are taking iron supplements

    About

    About This Condition

    Anemia is a reduction in the number of red blood cells (RBCs); in the amount of hemoglobin in the blood (hemoglobin is the iron-containing pigment of the red blood cells that carry oxygen from the lungs to the tissues); and in another related index called hematocrit (the volume of RBCs after they have been spun in a centrifuge). All three values are measured on a complete blood count, also referred to as a CBC. Iron-deficiency anemia can be distinguished from most other forms of anemia by the fact that it causes RBCs to be abnormally small and pale, an observation easily appreciated by viewing a blood sample through a microscope.

    Iron deficiency also can occur, even if someone is not anemic. Symptoms of iron deficiency without anemia may include fatigue, mood changes, and decreased cognitive function. Blood tests (such as serum ferritin, which measures the body?s iron stores) are available to detect iron deficiency, with or without anemia.

    Iron deficiency, whether it is severe enough to lead to anemia or not, can have many non-nutritional causes (such as excessive menstrual bleeding , bleeding ulcers , hemorrhoids , gastrointestinal bleeding caused by aspirin or related drugs, frequent blood donations, or colon cancer ) or can be caused by a lack of dietary iron . Menstrual bleeding is probably the leading cause of iron deficiency. However, despite common beliefs to the contrary, only about one premenopausal woman in ten is iron deficient.1 Deficiency of vitamin B12 , folic acid , vitamin B6 , or copper can cause other forms of anemia, and there are many other causes of anemia that are unrelated to nutrition. This article will only cover iron-deficiency anemia.

    Symptoms

    Some common symptoms of anemia include fatigue, lethargy, weakness, poor concentration, and impaired immune function . In iron-deficiency, fatigue also occurs because iron is needed to make optimal amounts of ATP?the energy source the body runs on. This fatigue usually begins long before a person is anemic. Said another way, a lack of anemia does not rule out iron deficiency in tired people. Another symptom of anemia, called pica, is the desire to eat unusual things, such as ice, clay, cardboard, paint, or starch. Advanced anemia may also result in lightheadedness, headaches, ringing in the ears ( tinnitus ), irritability, pale skin, unpleasant sensations in the legs with an uncontrollable urge to move them ( restless legs syndrome ), and getting winded easily.

    Eating Right

    The right diet is the key to managing many diseases and to improving general quality of life. For this condition, scientific research has found benefit in the following healthy eating tips.

    Recommendation Why
    Get enough iron
    To add iron to your diet, eat meat, poultry, and fish, dried fruit, molasses, leafy green vegetables, and wine, and cook acidic foods in an iron pan.
    Iron deficiency is not usually caused by a lack of dietary iron alone. Nonetheless, a lack of iron in the diet is often part of the problem, so ensuring an adequate supply of iron is important for people with a documented deficiency. The most absorbable form of iron, called ?heme? iron, is found in , , and . Non-heme iron is also found in these foods, as well as in dried , , leafy green , wine, and most iron supplements. Acidic foods (such as tomato sauce) cooked in an iron pan can leech iron into the food and thus also be a source of dietary iron.
    Add iron to a vegetarian diet
    Vegetarians are more likely to have reduced iron stores, so increase your intake by emphasizing iron-containing foods.

    Vegetarians eat less iron than non-vegetarians, and the iron they eat is somewhat less absorbable. As a result, vegetarians are more likely to have reduced iron stores.2 Vegetarians can increase their iron intake by emphasizing iron-containing foods within their diet (see above), or in some cases by supplementing iron, if needed.

    Don?t mix iron with beverage breaks
    Drinking coffee or tea with iron supplements inhibits absorption.
    Coffee interferes with the absorption of iron .3 However, moderate intake of coffee (4 cups per day) may not adversely affect risk of iron-deficiency anemia when the diet contains adequate amounts of iron and vitamin C .4 Black tea contains tannins that strongly inhibit the absorption of non-heme iron. In fact, this iron-blocking effect is so effective that drinking black tea can help treat hemochromatosis, a disease of iron overload.5 Consequently, people who are iron deficient should avoid drinking tea.
    Avoid taking iron supplements with a high-fiber meal
    High-fiber foods can reduce iron absorption, so avoid taking iron supplements during mealtime if the food is high in fiber.

    Fiber is another dietary component that can reduce the absorption of iron from foods. Foods high in bran fiber can reduce the absorption of iron from foods consumed at the same meal by half.6 Therefore, it makes sense for people needing to take iron supplements to avoid doing so at mealtime if the meal contains significant amounts of fiber.

    Supplements

    What Are Star Ratings?

    Our proprietary ?Star-Rating? system was developed to help you easily understand the amount of scientific support behind each supplement in relation to a specific health condition. While there is no way to predict whether a vitamin, mineral, or herb will successfully treat or prevent associated health conditions, our unique ratings tell you how well these supplements are understood by the medical community, and whether studies have found them to be effective for other people.

    For over a decade, our team has combed through thousands of research articles published in reputable journals. To help you make educated decisions, and to better understand controversial or confusing supplements, our medical experts have digested the science into these three easy-to-follow ratings. We hope this provides you with a helpful resource to make informed decisions towards your health and well-being.

    3 Stars Reliable and relatively consistent scientific data showing a substantial health benefit.

    2 Stars Contradictory, insufficient, or preliminary studies suggesting a health benefit or minimal health benefit.

    1 Star For an herb, supported by traditional use but minimal or no scientific evidence. For a supplement, little scientific support.

    Supplement Why
    3 Stars
    Iron (Menorrhagia)
    100 to 200 mg daily under medical supervision if deficient
    Supplementing with iron decreases excess menstrual blood loss in iron-deficient women who have no other underlying cause for their condition.

    Since blood is rich in iron , excessive blood loss can lead to iron depletion. Iron deficiency can be identified with simple blood tests. If an iron deficiency is diagnosed, many doctors recommend 100?200 mg of iron per day, although recommendations vary widely.

    The relationship between iron deficiency and menorrhagia is complicated. Not only can the condition lead to iron deficiency, but iron deficiency can lead to or aggravate menorrhagia by reducing the capacity of the uterus to stop the bleeding. Supplementing with iron decreases excess menstrual blood loss in iron-deficient women who have no other underlying cause for their condition.7 , 8 However, iron supplements should be taken only by people who have, or are at risk of developing, iron deficiency.

    3 Stars
    Iron
    Consult a qualified healthcare practitioner
    Supplementing with iron is essential to treating iron deficiency.

    Caution: People should not supplement with iron unless diagnosed with iron deficiency, because taking iron when it isn?t needed has no benefit and may be harmful.

    Before iron deficiency can be treated, it must be diagnosed and the cause must be found by a doctor. In addition to addressing the cause (e.g., avoiding aspirin , treating a bleeding ulcer , etc.), supplementation with iron is the primary way to resolve iron-deficiency anemia.

    If a doctor diagnoses iron deficiency, iron supplementation is essential. Though some doctors use higher amounts, a common daily dose for adults is 100 mg per day. Even though symptoms of deficiency should disappear much sooner, iron deficient people usually need to keep supplementing with iron for six months to one year until the ferritin test is completely normal. Even after taking enough iron to overcome the deficiency, some people with recurrent iron deficiency?particularly some premenopausal women?need to continue to supplement with smaller levels of iron, such as the 18 mg present in most multivitamin-mineral supplements . This need for continual iron supplementation even after deficiency has been overcome should be determined by a doctor.

    3 Stars
    Iron (Depression)
    See a doctor for evaluation
    A lack of iron can make depression worse; check with a doctor to find out if you are iron deficient.

    Iron deficiency is known to affect mood and can exacerbate depression, but it can only be diagnosed and treated by a doctor. While iron deficiency is easy to fix with iron supplements, people who have not been diagnosed with iron deficiency should not supplement iron.

    3 Stars
    Liver Extracts
    If deficient: several grams per day for up to one year under medical supervision
    Bovine liver extracts provide the most absorbable form of iron?heme iron?as well as other nutrients critical in building blood, including vitamin B12 and folic acid.

    Liver extracts from beef are a rich natural source of many vitamins and minerals, including iron. Bovine liver extracts provide the most absorbable form of iron?heme iron?as well as other nutrients critical in building blood, including vitamin B12 and folic acid . Liver extracts can contain as much as 3?4 mg of heme iron per gram.

    2 Stars
    Iron (Restless Legs Syndrome)
    Consult a qualified healthcare practitioner
    When iron deficiency is the cause of restless leg syndrome, supplementing with iron may reduce the severity of the symptoms.

    Mild iron deficiency is common, even in people who are not anemic. When iron deficiency is the cause of RLS, supplementation with iron has been reported to reduce the severity of the symptoms. In one trial, 74 mg of iron taken three times a day for two months, reduced symptoms in people with RLS.9 In people who are not deficient in iron, iron supplementation has been reported to not help reduce symptoms of RLS.10 Most people are not iron deficient, and taking too much can lead to adverse effects. Therefore, iron supplements should only be taken by people who have a diagnosed deficiency.

    2 Stars
    Iron (Attention Deficit?Hyperactivity Disorder)
    Consult a qualified healthcare practitioner
    In one study, iron levels were significantly lower in a group of children with ADHD than in healthy children. In the case of iron deficiency, supplementing with the mineral may improve behavior.

    Iron status, as measured by the serum ferritin concentration, was significantly lower in a group of children with ADHD than in healthy children. Ferritin levels were below normal in 84% of the children with ADHD, compared with 18% of the healthy children.11 Since iron deficiency can adversely affect mood and cognitive function, iron status should be assessed in children with ADHD, and those who are deficient should receive an iron supplement. In a case report, a young boy with both ADHD and iron deficiency showed considerable improvement in behavior after receiving an iron supplement.12 Iron supplementation was also beneficial in a double-blind study of children with ADHD and iron deficiency.13

    2 Stars
    Iron (Athletic Performance)
    Consult a qualified healthcare practitioner
    Iron is a component of hemoglobin, which transports oxygen to muscle cells. In cases of iron deficiency, taking iron may restore levels and improve athletic performance.

    Iron is important for an athlete because it is a component of hemoglobin, which transports oxygen to muscle cells. Some athletes, especially women, do not get enough iron in their diet. In addition, for reasons that are unclear, endurance athletes, such as marathon runners, frequently have low body-iron levels.14 , 15 , 16 However, anemia in athletes is often not due to iron deficiency and may be a normal adaptation to the stress of exercise.17 Supplementing with iron is usually unwise unless a deficiency has been diagnosed. People who experience undue fatigue (an early warning sign of iron deficiency) should have their iron status evaluated by a doctor. Athletes who are found to be iron deficient by a physician are typically given 100 mg per day until blood tests indicate they are no longer deficient. Supplementing iron-deficient athletes with 100 to 200 mg per day of iron increased aerobic exercise performance in some,18 , 19 , 20 though not all,21 , 22 double-blind studies. A recent double-blind trial found that iron-deficient women who took 20 mg per day of iron for six weeks were able to perform knee strength exercises for a longer time without muscle fatigue compared with those taking a placebo.23

    2 Stars
    Iron (Breast-Feeding Support)
    Consult a qualified healthcare practitioner
    Iron may be required for infants with low iron stores or anemia.
    If a doctor diagnoses iron deficiency, iron supplementation is essential. Though some doctors use higher amounts, a common daily dose for adults is 100 mg per day. Even though symptoms of deficiency should disappear much sooner, iron deficient people usually need to keep supplementing with iron for six months to one year until the ferritin test is completely normal. Even after taking enough iron to overcome the deficiency, some people with recurrent iron deficiency?particularly some premenopausal women?need to continue to supplement with smaller levels of iron, such as the 18 mg present in most multivitamin-mineral supplements. This need for continual iron supplementation even after deficiency has been overcome should be determined by a doctor.
    2 Stars
    Iron (Canker Sores)
    Consult with your doctor
    Talk to your doctor to see if your recurrent canker sores might be related to iron deficiency.

    Several preliminary studies,24 , 25 , 26 , 27 though not all,28 have found a surprisingly high incidence of iron and B vitamin deficiency among people with recurrent canker sores. Treating these deficiencies has been reported in preliminary29 , 30 and controlled31 studies to reduce or eliminate canker sore recurrences in most cases. Supplementing daily with B vitamins?300 mg vitamin B1 , 20 mg vitamin B2 , and 150 mg vitamin B6 ?has been reported to provide some people with relief.32 Thiamine (B1) deficiency specifically has been linked to an increased risk of canker sores.33 The right supplemental level of iron requires diagnosis of an iron deficiency by a healthcare professional using lab tests.

    2 Stars
    Iron (Celiac Disease)
    Consult a qualified healthcare practitioner
    The malabsorption that occurs in celiac disease can lead to multiple nutritional deficiencies. Supplementing with iron may correct a deficiency.

    The malabsorption that occurs in celiac disease can lead to multiple nutritional deficiencies. The most common nutritional problems in people with celiac disease include deficiencies of essential fatty acids, iron , vitamin D , vitamin K , calcium , magnesium , and folic acid .34 Zinc malabsorption also occurs frequently in celiac disease35 and may result in zinc deficiency, even in people who are otherwise in remission.36 People with newly diagnosed celiac disease should be assessed for nutritional deficiencies by a doctor. Celiac patients who have not yet completely recovered should supplement with a high-potency multivitamin-mineral . Some patients may require even higher amounts of some of these vitamins and minerals?an issue that should be discussed with their healthcare practitioner. Evidence of a nutrient deficiency in a celiac patient is a clear indication for supplementation with that nutrient.

    After commencement of a gluten-free diet, overall nutritional status gradually improves. However, deficiencies of some nutrients may persist, even in people who are strictly avoiding gluten. For example, magnesium deficiency was found in 8 of 23 adults with celiac disease who had been following a gluten-free diet and were symptom-free. When these adults were supplemented with magnesium for two years, their bone mineral density increased significantly.37

    2 Stars
    Taurine
    1,000 mg daily
    Taurine has been shown to improve the response to iron therapy in young women with iron-deficiency anemia.

    Taurine has been shown, in a double-blind study, to improve the response to iron therapy in young women with iron-deficiency anemia.38 The amount of taurine used was 1,000 mg per day for 20 weeks, given in addition to iron therapy, but at a different time of the day. The mechanism by which taurine improves iron utilization is not known.

    2 Stars
    Vitamin A and Iron
    Consult a qualified healthcare practitioner
    Taking vitamin A and iron together has been reported to help overcome iron deficiency more effectively than iron supplements alone.

    Taking vitamin A and iron together has been reported to help overcome iron deficiency more effectively than iron supplements alone.39 Although the optimal amount of vitamin A needed to help people with iron deficiency has yet to be established, some doctors recommend 10,000 IU per day.

    2 Stars
    Vitamin C and Iron
    Take 100 to 500 mg of vitamin C with iron supplements with a doctor's supervision
    Taking vitamin C with iron supplements has been shown to improve iron absorption.

    Caution: People who are not diagnosed with iron deficiency should not supplement with iron. Taking iron when it isn?t needed has no benefit and may do some harm.

    Vitamin C increases the absorption of non-heme iron.40 Some doctors advise iron-deficient people to take vitamin C (typically 100?500 mg) at the same time as their iron supplement.41
    1 Star
    Betaine Hydrochloride and Iron
    Refer to label instructions
    Hydrochloric acid produced by the stomach improves the absorption of non-heme iron. Some practitioners recommend betaine hydrochloride to enhance iron absorption.

    A high degree of association between iron-deficiency anemia and vitamin D deficiency in Asian children has been previously reported.42 In three different ethnic groups living in England, iron-deficiency anemia was found to be a significant risk factor for low vitamin D levels in children.43 These findings suggest that children with iron-deficiency anemia should be screened for vitamin D deficiency and be given vitamin D supplements if necessary.

    1 Star
    Iron (Dermatitis Herpetiformis)
    Refer to label instructions
    Talk to your doctor to see if supplementing with iron can counteract the nutrient deficiency that often occurs as a result of malabsorption.

    People with DH frequently have mild malabsorption (difficulty absorbing certain nutrients) associated with low stomach acid (hypochlorhydria) and inflammation of the stomach lining (atrophic gastritis).44 Mild malabsorption may result in anemia 45 and nutritional deficiencies of iron , folic acid ,46 , 47 vitamin B12 ,48 , 49 and zinc .50 , 51 , 52 More severe malabsorption may result in loss of bone mass.53 Additional subtle deficiencies of vitamins and minerals are possible, but have not been investigated. Therefore, some doctors recommend people with DH have their nutritional status checked regularly with laboratory studies. These doctors may also recommend multivitamin-mineral supplements and, to correct the low stomach acid, supplemental betaine HCl (a source of hydrochloric acid).

    1 Star
    Iron (Female Infertility)
    Refer to label instructions
    Even subtle iron deficiencies have been tentatively linked to infertility. Women who are infertile should consult a doctor to rule out the possibility of iron deficiency

    In preliminary research, even a subtle deficiency of iron has been tentatively linked to infertility.54 Women who are infertile should consult a doctor to rule out the possibility of iron deficiency.

    References

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    2. Sullivan JL. Stored iron and ischemic heart disease. Circulation 1992;86:1036 [editorial].

    3. Morck TA, Lynch SR, Cook JD. Inhibition of food iron absorption by coffee. Am J Clin Nutr 1983;37:416?20.

    4. Mehta SW, Pritchard ME, Stegman C. Contribution of coffee and tea to anemia among NHANES II participants. Nutr Res 1992;12:209?22.

    5. Kaltwasser JP, Werner E, Schalk K, et al. Clinical trial on the effect of regular tea drinking on iron accumulation in genetic haemochromatosis. Gut 1998;43:699?704.

    6. Cook JD, Noble NL, Morck TA, et al. Effect of fiber on nonheme iron absorption. Gastroenterology 1983;85:1354?8.

    7. Samuels, AJ. Studies in patients with functional menorrhagia: the antimenorrhagic effect of the adequate replication of iron stores. Isr J Med Sci 1965;1:851?3.

    8. Taymor ML, Sturgis SH, Yahia C. The etiological role of chronic iron deficiency in production of menorrhagia. JAMA 1964;187:323?7.

    9. O?Keeffe ST, Gavin K, Lavan JN. Iron status and restless legs syndrome in the elderly. Age Ageing 1994;23:200?3.

    10. Davis BJ, Rajput A, Rajput ML, et al. A randomized, double-blind placebo-controlled trial of iron in restless legs syndrome. Eur Neurol 2000;43:70?5.

    11. Konofal E, Lecendreux M, Arnulf I, Mouren MC. Iron deficiency in children with attention-deficit/hyperactivity disorder. Arch Pediatr Adolesc Med 2004;158:1113?5.

    12. Konofal E, Lecendreux M, Deron J, et al. Effects of iron supplementation on attention defecit hyperactivity disorder in children. Pediatr Neurol 2008; 38:20-6.

    13. Konofal E, Lecendreux M, Deron J, et al. Effects of iron supplementation on attention deficit hyperactivity disorder in children. Pediatr Neurol 2008;38:20?6.

    14. Mechrefe A, Wexler B, Feller E. Sports anemia and gastrointestinal bleeding in endurance athletes. Med Health R I 1997;80:216?8.

    15. Clarkson PM. Micronutrients and exercise: anti-oxidants and minerals. J Sports Sci 1995;13:S11?24 [review].

    16. Smith JA. Exercise, training and red blood cell turnover. Sports Med 1995;19:9?31.

    17. Smith JA. Exercise, training and red blood cell turnover. Sports Med 1995;19:9?31 [review].

    18. Brownlie T 4th, Utermohlen V, Hinton PS, et al. Marginal iron deficiency without anemia impairs aerobic adaptation among previously untrained women. Am J Clin Nutr 2002;75:734?42.

    19. Friedmann B, Weller E, Mairbaurl H, Bartsch P. Effects of iron repletion on blood volume and performance capacity in young athletes. Med Sci Sports Exerc 2001;33:741?6.

    20. Hinton PS, Giordano C, Brownlie T, Haas JD. Iron supplementation improves endurance after training in iron-depleted, nonanemic women. J Appl Physiol 2000;88:1103?11.

    21. Zhu YI, Haas JD. Altered metabolic response of iron-depleted nonanemic women during a 15-km time trial. J Appl Physiol 1998;84:1768?75.

    22. Nielsen P, Nachtigall D. Iron supplementation in athletes. Current recommendations. Sports Med 1998;26:207?16 [review].

    23. Brutsaert TD, Hernandez-Cordero S, Rivera J, et al. Iron supplementation improves progressive fatigue resistance during dynamic knee extensor exercise in iron-depleted, nonanemic women. Am J Clin Nutr 2003;77:441?8.

    24. Porter SR, Scully C, Flint S. Hematologic status in recurrent aphthous stomatitis compared to other oral disease. Oral Surg Oral Med Oral Pathol 1988;66:41?4.

    25. Palopoli J, Waxman J. Recurrent aphthous stomatitis and vitamin B12 deficiency. South Med J 1990;83:475?7.

    26. Wray D, Ferguson MM, Hutcheon WA, Dagg JH. Nutritional deficiencies in recurrent aphthae. J Oral Pathol 1978;7:418?23.

    27. Barnadas MA, Remacha A, Condomines J, de Moragas JM. [Hematologic deficiencies in patients with recurrent oral aphthae]. Med Clin (Barc) 1997;109:85?7 [in Spanish].

    28. Olson JA, Feinberg I, Silverman S, et al. Serum vitamin B12, folate, and iron levels in recurrent aphthous ulceration. Oral Surg Oral Med Oral Pathol 1982;54:517?20.

    29. Weusten BL, van de Wiel A. Aphthous ulcers and vitamin B12 deficiency. Neth J Med 1998;53:172?5.

    30. Porter S, Flint S, Scully C, Keith O. Recurrent aphthous stomatitis: the efficacy of replacement therapy in patients with underlying hematinic deficiencies. Ann Dent 1992;51:14?6.

    31. Wray D, Ferguson MM, Mason DK, et al. Recurrent aphthae: treatment with vitamin B12, folic acid, and iron. Br Med J 1975;2(5969):490?3.

    32. Nolan A, McIntosh WB, Allam BF, Lamey PJ. Recurrent aphthous ulceration: vitamin B1, B2 and B6 status and response to replacement therapy. J Oral Pathol Med 1991;20:389?91.

    33. Haisraeli-Shalish M, Livneh A, Katz J, et al. Recurrent aphthous stomatitis and thiamine deficiency. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:634?6.

    34. Connon JJ. Celiac disease. In: Shils ME, Olson JA, Shike M, eds. Modern Nutrition in Health and Disease, 8th ed. Philadelphia: Lea & Febiger, 1994, 1062.

    35. Crofton RW, Glover SC, Ewen SWB, et al. Zinc absorption in celiac disease and dermatitis herpetiformis: a test of small intestinal function. Am J Clin Nutr 1983;38:706?12.

    36. Solomons NW, Rosenberg IH, Sandstead HH. Zinc nutrition in celiac sprue. Am J Clin Nutr 1976;29:371?5.

    37. Rude RK, Olerich M. Magnesium deficiency: possible role in osteoporosis associated with gluten-sensitive enteropathy. Osteoporos Int 1996;6:453?61.

    38. Sirdah MM, El-Agouza IMA, Abu Shahla ANK. Possible ameliorative effect of taurine in the treatment of iron-deficiency anaemia in female university students of Gaza, Palestine. Eur J Haematol 2002;69:236?2.

    39. Mejia LA, Chew F. Hematological effect of supplementing anemic children with vitamin A alone and in combination with iron. Am J Clin Nutr 1988;48:595?600.

    40. Ajayi OA, Nnaji UR. Effect of ascorbic acid supplementation on haematological response and ascorbic acid status of young female adults. Ann Nutr Metab 1990;34:32?6.

    41. Hunt JR, Gallagher SK, Johnson LK. Effect of ascorbic acid on apparent iron absorption by women with low iron stores. Am J Clin Nutr 1994;59:1381?5.

    42. Grindulis H, Scott PH, Belton NR, Wharton BA. Combined deficiency of iron and vitamin D in Asian toddlers. Arch Dis Child 1986;61:843?8.

    43. Lawson M, Thomas M. Vitamin D concentrations in Asian children aged 2 years living in England: population survey. BMJ 1999;318:28.

    44. Yancy KB, Lawley TJ. ?Immunologically Mediated Skin Diseases.?Harrison?s Online. 1999. http://www.harrisonsonline.com/hill-bin/Chapters.cgi (Jan 10, 2000).

    45. Kastrup W, Mobacken H, Stockbrugger R, et al. Malabsorption of vitamin B12 in dermatitis herpetiformis and its association with pernicious anaemia. Acta Med Scand 1986;220:261?8.

    46. Gawkrodger DJ, Ferguson A, Barnetson RS. Nutritional status in patients with dermatitis herpetiformis. Am J Clin Nutr 1988;48:355?60.

    47. Hoffbrand AV, Douglas AP, Fry L, Stewart JS. Malabsorption of dietary folate (Pteroylpolyglutamates) in adult coeliac disease and dermatitis herpetiformis. Br Med J 1970;4:85?9.

    48. Davies MG, Marks R, Nuki G. Dermatitis herpetiformis?a skin manifestation of a generalized disturbance in immunity. Q J Med 1978;47:221?48.

    49. Kastrup W, Mobacken H, Stockbrugger R, et al. Malabsorption of vitamin B12 in dermatitis herpetiformis and its association with pernicious anaemia. Acta Med Scand 1986;220:261?8.

    50. Crofton RW, Glover SC, Ewen SW, et al. Zinc absorption in celiac disease and dermatitis herpetiformis: a test of small intestinal function. Am J Clin Nutr 1983;38:706?12.

    51. Gawkrodger DJ, Ferguson A, Barnetson RS. Nutritional status in patients with dermatitis herpetiformis. Am J Clin Nutr 1988;48:355?60.

    52. Hoffbrand AV, Douglas AP, Fry L, Stewart JS. Malabsorption of dietary folate (Pteroylpolyglutamates) in adult coeliac disease and dermatitis herpetiformis. Br Med J 1970;4:85?9.

    53. Di Stefano M, Jorizzo RA, Veneto G, et al. Bone mass and metabolism in dermatitis herpetiformis. Dig Dis Sci 1999;44:2139?43.

    54. Rushton DH, Ramsay ID, Gilkes JJH, Norris MJ. Ferritin and fertility. Lancet 1991;337:1554 [letter].

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