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iron deficiency, especially in patients who have concurrent infections or other inflammatory disorders.

Iron Deficiency Anemia

Anemia is the most easily identifiable indicator of functional iron deficiency. As discussed above, physiological impairment occurs at this stage of iron deficiency both because of inadequate oxygen delivery during exercise and because of abnormal enzyme function in tissues.

Hemoglobin Concentration and Hematocrit. The hemoglobin concentration or hematocrit is neither a sensitive nor a specific indicator of mild yet functionally significant iron deficiency anemia. Iron deficiency anemia is microcytic (reduced mean erythrocyte volume and mean erythrocyte hemoglobin). However, microcytic anemia is characteristic of all anemias in which the primary abnormality is impaired hemoglobin synthesis. Iron deficiency is only one of the potential causal factors. The diagnosis of iron deficiency anemia, based solely on the presence of anemia, can result in misdiagnosis in many cases.

Garby and coworkers (1969) recognized this fundamental problem. After supplemental iron tablets (60 mg/day) or a placebo were provided to a group of women with mild anemia for 3 months, the women were characterized as having iron deficiency anemia based on a change in hemoglobin concentration in response to the iron supplement that was greater than that which occurred with the placebo. There was a significant overlap between the distribution curves for the initial hemoglobin concentration of the responders (iron deficiency anemia) and the nonresponders (no iron deficiency anemia). A single hemoglobin concentration used as a discriminant value for detecting iron deficiency anemia therefore lacks precision.

Based on NHANES III data (Appendix Table G-1), the median hemoglobin concentration for men was 144 to 154 g/L and 132 to 135 g/L for women. The median hemoglobin concentration was 132 g/L for adolescent girls and 121 g/L for pregnant women. The hemoglobin concentration for pregnant women approaches the cutoff concentration of 120 g/L (IOM, 1990).

Erythrocyte Indexes. Iron deficiency leads to the formation of small erythrocytes. Mean corpuscular hemoglobin (MCH) is the amount of hemoglobin in erythrocytes. The mean corpuscular volume (MCV) is the volume of the average erythrocyte. Both MCH and



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