A Consultant Haematologist and lecturer at the College of Medicine, University of Lagos, Lagos, Dr Ademola Adewoyin, discusses anaemia and its management in this interview with GODFREY GEORGE
W hat is the best way to define anaemia?
Anaemia is bloodlessness or shortage of blood. It comes from two Latin root words ‘an’ which means ‘without’ and ‘haima’, which means ‘without blood’. So, it is a condition that shows bloodlessness. It is the easiest way to define it. To be more technical, we would say anaemia is a condition whereby a person’s haemoglobin is lower than expected for the person’s age, gender and geographical location with a functional consequence of decreased oxygen-carrying capacity of the blood.
Following these parameters mentioned above, what would be the normal level of blood for each of these age grades and sexes?
For age, it is graded into newborn to six months; six months to one year; one year to six years; six years to 13 years; and everything above 13 years is graded as an adult in anaemia.
For kids, it is highly variable. We may have newborns, and the anaemia cut off in them is 13.5. This means when the haemoglobin level is less than 13.5, that is anaemia. But for an adult lady with 12, it is not anaemia. It is normal.
Why is this so?
In neonatal haematology, these babies are just coming outside life (extra-uterine life). They have been inside the womb for nine (or 10 months), where the level of oxygen they get is less compared to the oxygen they get when they have been born. In the womb, the baby is dependent on oxygen circulation from the mother, but as soon as you take your first breath and there is a good supply of oxygen, the haemoglobin level will drop. If you go to Kenya from Nigeria, you will notice some changes in your body because of the change in geographical location. If you look at people who stay at higher altitudes, their haemoglobin levels would be more. That is why they are better athletes. If you take a Kenyan to come run in Nigeria, (s)he is going to beat us hands down, because there are higher haemoglobin levels. You know the higher you go, the lower the oxygen circulation. This is why the kids have higher haemoglobin in the womb because of the low oxygen level and when they are born, it begins to normalise.
What should be the normal blood level for an adult male?
For an adult male, 14.0 and above is good. It is not a static thing. The body creates a balance. There is always something we call reference intervals. For a man, between 13 to about 17 is what we expect. For a lady, 11.0 to about 15 is what we expect. A lady at 12 is good, but a man at 12 is anaemic.
What are things that can lower a person’s blood level?
To make it more structured, any time there is a shortage of blood in a human being, it is either one of three possibilities. It could be that the person is losing blood, i.e. bleeding. The blood loss can be acute, that is if someone has a road accident and bleeds a lot. It can also be chronic if it happens over a long period of time, like a man who has haemorrhoids (piles) or a woman who is menstruating. Blood loss is either acute or chronic. Secondly, it could be that they are producing enough red blood cells but which are dying prematurely. Normally, the red blood cells live three months (100 – 120 days) after they are produced from the bone marrow. Anything that shortens their survival means that they are dying faster than the rate the body is producing a replacement. That is what we call decreased red blood survival or accelerated destruction. If that happens, that is a second major cause of blood shortage. Thirdly, when the bone marrow is not functioning well, it could lead to decrease production of red blood cells. If the bone marrow is diseased or non-functional such that it is producing red blood cells as it should normally do, then this may result in blood shortage.
Some of these causes are quite natural, like women going through their monthly circle. Is there some kind of remedy for this special set of people who naturally have to lose blood?
Apparently, ladies lose blood every month as a natural part of being a lady. It is normal; it is physiologic and well-defined. But it can also be excessive where there is a problem and that can lead to blood shortage. If a menstruating lady is bleeding beyond five days, then it is abnormal. The quantity, too, also matters. For a lady who bleeds more than 20–80mls of blood in a month, using several changes of tampons or sanitary pads, there is a problem. Technically, when a lady changes her pads more than three times per day and sees thick blood clots down there, those are all suggestive that the lady is bleeding excessively. This means something is responsible. We may have to involve a gynaecologist to make a diagnosis. The commonest cause may be fibroids.
Speaking of the bone marrow, what exactly may be responsible for it not functioning as it is supposed to and how can that be corrected?
The commonest reason in women of childbearing age and children is nutritional deficiency. This is what causes nutritional anaemia. For red cells to form, there are several controls and elements that are involved. One of them is micronutrients which are required in very minute quantities, but as minute as they are and required, not having them can wreck the entire system. It is like a tiny leak that can sink a mighty ship in the ocean. There are a couple of them. We have iron which is one of the commonest elements in the earth crust but it is also the common cause of this deficiency. We have folic acid, which is also required in pregnancy. We also have the B-vitamins (B6, B9, B12) which are required for red blood cell formations. If they are not there, the cells would not form properly. I would also like to mention that if there is a suppression of the bone marrow by infiltration, it could be a problem. For instance, cancer as a global health concern goes to the bone marrow and crowds out the regular marrow cells and establishes itself there. So, the normal function of the bone marrow doesn’t happen again and there is going to be a shortage. This is why anaemia happens in cancer. Generally, we call them hypo-generative anaemia.
There is also what we call anaemia of chronic inflammation. Some authorities call it anaemia of chronic disease. It is a chronic phenomenon that can be an inflammatory disease. Some people have inflammatory bowel syndrome and all sorts of auto-immune diseases and some other allergies. It is associated with some other bone marrow issues. There can also be chronic infections that can come from myriads of organisms including bacteria like tuberculosis and some parasitic infections. That is another category of anaemia that is from a non-functional bone marrow. We can also have anaemia of chronic renal disease because if the kidney fails, it can no longer produce erythropoietin which drives red cell formation. That is why athletes use it as a doping agent. There are things like sideroblastic anaemia which is an entity where is there is a failure of utilisation. The body is taking in the mirconutrient which gets into the body but the body cannot utilise it.
Nutritional deficiency is divided into four. For people in the low economic class who do not even have the money to get these nutrients, they may have this deficiency. That is the case of poor intake. There are those who eat good food but the body doesn’t absorb it because of some problems, like irritable bowel syndrome and some other gut conditions that do not allow these micronutrients to absorb it. Some others who take good food, the body will absorb it, but when it gets into the body, the body does not utilise it. Finally, some people take good food which is absorbed and used by the body, but they lose it a lot. You see this with people with kidney failure. Because their kidneys are down and they have to get dialysis, when they do so, all the micronutrients are also removed with the bad waste products. This is why we give them all sorts of nutrients in order to replenish their bodies and keep red cell formation functional.
How is weight loss related to anaemia?
It is a question of body mass – what consists of the body mass? If it is fat, it is not blood. The way it works is that the blood only circulates in blood vessels. Of course, the bigger you are, the bigger your blood volume should be, which is about 70mls/kg for an adult. So a 70kg adult would have about 4,000 units of blood which is on the average five litres of blood. There is also the concept of lean mass and lean body weight and all that. Being fat is not necessarily having more blood. It also does not mean the person cannot be anaemic. Anaemia is also defined relative to your size. To be a bit technical, there are different parameters that one can use to define anaemia. The one we have been talking about is just haemoglobin. Sometimes, we talk about red cell mass, circulating red cells or red cell counts. For haematologists, there are different things we are looking at when we are differentiating and defining anaemia. It clearly establishes that having a big size does not translate to having more blood.
How true is it that the level of blood in the body affects the activeness of the penis during sexual intercourse? How does this work?
The life of the flesh is in the blood. Blood is life. So, blood has to go to every part of the body. The same goes for the male organ, the penis. So, for there to be an erection, there must be a gush of blood to the area. There is a kind of relaxation of the blood vessel. This process is both psychological and physical. When the blood vessels within the penile area relax – induced by some chemicals that are released – there is a gush of blood into the vessels. So, once this happens, it makes the organ to be turgid. That turgidity is what is called an erection.
How does this affect people who have anaemia?
Of course, it would affect them, depending on the level of anaemia. For one that is severely anaemic, there is no blood to even make it happen. They would not even have the energy to even do anything. Once there is shortage of blood, the energy level reduces. How can someone who doesn’t have blood have good sexual performance? Sex is physically demanding. For somebody who is walking around with a haemoglobin level of five or six, where would he have the energy for sex when he is already collapsing or fainting? That kind of person is not qualified.
What are some of the symptoms one has to look out for to show that they are losing blood?
Because blood is short, there would be reduced energy levels. There will be easy fatigue. Such persons cannot climb stairs. Before they get up the stairs, they are already tired and panting. With reduced energy levels, easy fatigue would be the order of the day. They would experience palpitations and they would become aware of their heartbeat. Some of them would experience dimness of vision because enough blood is not getting to the eyes. They can even faint or have fainting spells or episodes. Some may have angina (chest pain). That would typically exist in people who have preexisting heart conditions. Those are some of the general symptoms of anaemia.
What is the diagnosis like when you meet a person who presents with these symptoms?
We are going to ask questions, take history and examine the person. The examination would mean that we would check for signs of anaemia and they include paleness of the eye. Those who have haemolysis may have jaundice. There are other things specific to some kind of anaemia like spoon-shaped nails, swelling of the tongue or painful tongue. We are also going to look at physical history that must be suggestive of underlying diseases.
I should emphasise that anaemia is never a diagnosis. Anaemia is a symptom of an underlying disease. So, when we see it, we have to look for what is causing the anaemia so we can tackle it.
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