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How Outside Factors Can Lead To Iron Deficiency

Jun 2, 2017

Making sure people across the globe have access to proper nutrition is a goal of international organizations like UNICEF and the World Health Organization.

But sometimes, simply acquiring the right nutrients isn’t enough, especially if outside factors get in the way of allowing the body to process nutrients correctly.

Dr. Michael Georieff is a pediatrician and child psychology professor at the University of Minnesota. An expert on nutrition and iron deficiency, Georgieff says people require different doses of nutrients. Additionally, environmental factors can influence how much of a particular nutrient the body will take in. For instance, infections can impede the body’s ability to absorb iron.

“It's a very ancient response by the body because the organisms, like malaria or e coli, or any number of bacteria, many of them love iron and they will replicate faster and you will get more disease burden,” Georgieff told KGOU’s World Views.

Since the body will not absorb iron while infected, Georgieff says it sometimes doesn’t matter how much iron is offered through food or supplements.

“If you're a kid in an area of the world that you're chronically infected or you're chronically at risk for malaria, you're almost by definition [going] to be iron deficient,” Georgieff said.

Children eat a meal at an orphanage in Kazakhstan.
Credit Marina Kroupina / Center for Neurobehavioral Development, University of Minnesota

Proper nutrient intake is crucial for early brain development, which Georgieff says occurs between conception to about two years of age. This is a time of rapid development in the brain. Memory and speed of processing are developing, as well as the scaffolding for more complex behaviors that will take place throughout a human lifetime. Nutrition needs are very high during this period.

“The reason for that is the brain is … the greediest organ. It's the biggest oxygen consumer,” Georgieff said. “It takes the most calories. As you and I sit here, we're using about 20 percent of our calories to make our brains work so we can have this conversation. A baby uses 60 percent of its daily calories.”

Georgieff says many nutrients are critical during this time, including iron. A lack of iron absorption can lead to problems with learning and memory, and will affect mood hormones such as dopamine and serotonin.

“There are long term consequences and they include more depression, more anxiety as an adult, lower job potential as adult,” Georgieff said. “So that's your real cost to society of early life nutrient deficiencies.”

Georgieff participated in a study of children from several different countries who came to an international adoption clinic in Minnesota. A nurse practitioner noticed that many of the orphans suffered from anemia.

“In the United States the rate of iron-deficiency anemia is about 3 percent. Still a lot of kids, but it's about 3 percent. We saw rates of 17 to 25 percent in the kids that were coming. Zinc deficiency in over 50 percent of the kids,” Georgieff said.

Researchers travelled to orphanages in several countries to investigate the diet of the children before they came to the United States. They found that food in Ethiopian orphanages typically lacked, but the nutrition was good in China. Georgieff says there was “a little bit of variability” in Russia and Kazakhstan.

Overall, they determined the children’s diets were pretty good. But they weren’t processing the nutrients well.

“Perhaps the orphanage environment, the stress, potentially repeated infections were changing the dynamics of the body's ability to absorb the nutrients,” Georgieff said.

Children eat a meal at an orphanage in Kazakhstan.
Credit Marina Kroupina / Center for Neurobehavioral Development, University of Minnesota

Georgieff says psychological stress could potentially have the same effect as infection. And that leads to new questions about how best to tackle early childhood iron deficiency. He says there are lots of reasons to continue to build roads and provide delivery packages of micronutrients to children in high risk areas, but perhaps those efforts won’t be as successful in a high-infection, high-stress environment.

“So maybe your best solution isn't providing more iron. Your solution is better hand-washing, better preparation of the foods and so on,” Georgieff said.

Interview Highlights

On the relationship between nutrition, infection and iron

For example, when you are infected you will not absorb iron. It's a very ancient response by the body because the organisms, like malaria or e coli, or any number of bacteria, many of them love iron and they will replicate faster and you will get more disease burden. So the body has learned how to short iron. In other words, not absorbed the iron when you are infected. Well, if you're a kid in an area of the world that you're chronically infected or you're chronically at risk for malaria you're almost by definition to be iron deficient. No matter how much iron you give. Right. So there the solution is to fix the infection problem so that the body is then more receptive to the iron dosing that you give. That would just be one example like that.

On brain development and iron

So nutrition in that first zero-to-three years, and that's where our public health policies are focused, or you'll hear people talk about the first thousand days, “the golden opportunity of the first thousand days,” that's from conception to about two years, nutrient needs are really, really high and particularly for supporting brain development. And the reason for that is the brain is the … greediest organ. It's the biggest oxygen consumer in the brain. It takes the most calories. As you and I sit here, we're using about 20 percent of our calories to make our brains work so we can have this conversation. A baby uses 60 percent of its daily calories. So what supports that metabolism? Oxygen, glucose sugar, iron, amino acids, protein and so on. So there are certain nutrients that are pretty critical and the iron happens to be one of them. So during development, iron is very, very necessary and shorting iron for any period of time, long period of time, will affect things like learning and memory. It'll affect speed of processing and it also affects mood hormones or mood neurotransmitters like dopamine and serotonin.

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FULL TRANSCRIPT

Suzette Grillot: Michael Georgieff, welcome to World Views.

Michael Georgieff: Thank you.

Grillot: It's great to be here. So Michael you're a nutritionist. I'm really excited to talk about international nutrition, something we don't speak about often on this show. But I just want to start with this a very basic human being question. I mean nutrition is a human concern and human beings obviously live all around the world. So nutrition therefore is a is a global issue. But nutritional support can vary significantly from one place to the other, as we well know. There are people around the world that are of course malnourished. So can we have global standards? I mean can we can we study this issue and in any kind of international way so that we establish standards of what every single human needs to have in their body in order to be healthy and well?

Georgieff: Yeah I think that's an excellent question. So UNICEF, World Health Organization are really all about that. As you know we come from a period of malnutrition as human beings, always searching for food, I mean if you look back across the millennia. So the idea of having everybody nutrient sufficient and getting the nutrition that they need for growth and development is is high on people's platter. And public policy is designed I think to get the best read possible, that is, to benefit the most people that you can. Whether everybody around the world needs exactly the same nutrition I think is is a big question, you know. On the one hand policy wants some guidelines to to give out use a certain amount of iron in a certain amount of protein and so on. On the other hand personalized medicine at the other end says that everybody is going to process those nutrients differently. So, yes, I think from a policy standpoint and a delivery standpoint, meaning how do we get those nutrients, those people those are the big questions that are being asked out there.

Grillot: Of course that's totally outside of my wheelhouse right. So I just have to ask I mean is there perhaps genetic issues here that people in different parts of the world evolve in a way that they respond to what kind of nourishment is available to them. Is that correct? I mean you said that you would see a significant amount of variation in what people need around the world?

Georgieff: Or how much you need to give them in order to achieve what you want inside their bodies. So we measure, for example, for sampling, we measure the amount of blood iron for example or zinc or whatever nutrient you want. Different doses will result in different levels in different people based on genetic factors and also based on environmental factors, and the environmental factors can actually be very significant. An example I would give you that is infection. You know, we don't think about infection in nutrition. Those are two separate areas of study, but they actually inform each other. For example when you are infected you will not absorb iron. It's a very ancient response by the body because the organisms, like malaria or e coli, or any number of bacteria, many of them love iron and they will replicate faster and you will get more disease burden. So the body has learned how to short iron. In other words not absorbed the iron when you are infected. Well if you're a kid in an area of the world that you're chronically infected or you're chronically at risk for malaria you're almost by definition to be iron deficient. No matter how much iron you give. Right. So there the solution is to fix the infection problem so that the body is then more receptive to the iron dosing that you give. That would just be one example like that.

Grillot: Obviously treating the body as a whole organism and not just looking at whether one is nourished or not but what might be causing that response. That's very interesting that the infection is affecting iron because that's your area of specialty is iron deficiency and the impact that that has on the brain. Tell us a little bit about that iron deficiency issue.

Georgieff: Right. So there are So we talk about nutrients if you really want to get scary about them you call them substrates or metabolites. But they're nutrients that support brain development and there's some that are particularly important for the young brain. So when we're talking about the young brain we're talking about the mom and her fetus and the newborn and usually think about the first three years. And the reason for that is that that's a period of very rapid brain development. So not only are there basic systems of memory and speed of processing that are actually developing then but they form the scaffold for our more complex behaviors across the lifespan. So nutrition in that first zero to three years, and that's where our public health policies are focused, or you'll hear people talk about the first thousand days the golden opportunity of the first thousand days, that's from conception to about two years, nutrient needs are really really high and particularly for supporting brain development. And the reason for that is the brain is the biggest, it's the greediest organ. It's the biggest oxygen consumer in the brain. It takes the most calories. As you and I sit here, we're using about 20 percent of our calories to make our brains work so we can have this conversation. A baby uses 60 percent of its daily calories. So what supports that metabolism? Oxygen, glucose sugar, iron, amino acids, protein and so on. So there are certain nutrients that are pretty critical and the iron happens to be one of them. So during development, iron is very very necessary and shorting iron for any period of time, long period of time, will affect things like learning and memory. It'll affect speed of processing and it also affects mood hormones or mood neurotransmitters like dopamine and serotonin.

Grillot: So I'm assuming that all of the things that you're discussing are certain consequences of this. Right. If you have an iron deficiency and therefore your brain is not developing as well as it could or should, then there are implications for your schooling. There are implications for your overall health and well-being. There are implications perhaps for your employment. I mean are you are you looking at some of these social outcomes at all when you study a medical issue like iron deficiency?

Georgieff: Right. So it depends who you are. If you are dealing with adults, no, you don't typically think about that. The adult doctor generally says you know you might be a little iron deficient Let's give you some iron and the anemia goes away so iron deficiency usually presents as anemia you give iron it goes away. The problem with that in children is that the problem is not solved. That is the anemia does get better, but that the repletion, or the getting the iron back into the brain and into all of the developing organs, takes some time. And so there's this period of vulnerability of the organs. These organs are developing. They're trying. The brain is trying to make connections and yet it's feeling tired. I mean that's what iron deficiency does. It gives you, it makes the body not work efficiently. And so those connections are not made. So I think the question you're asking is, OK, if I give the iron back in a timely matter will all of that go away? So it shouldn't surprise anybody that you feel … poorly when you're iron deficient. You don't think as well. You may be more emotionally reactive and whatever. But if we give the iron back and that all goes away. Thank goodness there's no long term relevant health problem. The problem is the data both from the models and from studies that Betsy Lozoff has done at Michigan suggests that if you wait until they're anemic and then start to treat the iron deficiency, yes, some symptoms go away. But there are long term consequences and they include more depression more anxiety as an adult, lower job potential as adult. So that's your real cost to society of early life nutrient deficiencies. You know, if all got better by just giving the nutrition problem solved than you know it's not such a big deal you just identify treat. But it's those long term issues that are that are what concerns nutritional people.

Grillot: Well said on that issue you've done some work on children, particularly from China and Kazakhstan, children that were institutionalized there, I presume were living in an orphanage perhaps because then they were adopted . So you've identified children that were living in it in an institution and were adopted and then trying to study their iron levels. Tell us a little bit about that study and what you found and also why you chose to study that particular part of the world or that particular issue.

Georgieff: Well part of that is convenience of course. But it should probably give a shout out to the people who really stimulated that. I was not necessarily studying those populations. But at the University of Minnesota we have I think one of or the oldest international adoption clinic, actually started by one of my newborn intensive care partners in my group, Dana Johnson. And originally the intent of that clinic was to study what infectious diseases and these children were coming over with. There was a concern about hepatitis and HIV. A lot of the kids were coming from Romanian orphanages. And it was pretty much catch as catch can in terms of which areas of the world they were coming from. And as the clinic progressed from the late 80s to its current state, there have been waves of orphans from different or internationally adopted kids from different orphanages from different parts of the world. One of the things that one of our astute nurse practitioners noticed was that there was a lot of anemia in these kids, and things being common things being common. it turned out that it was iron deficiency anemia. So just to give you kind of relative rates in the United States the rate of iron deficiency anemia is about 3 percent. Still a lot of kids, but it's about 3 percent. We saw rates of 17 to 25 percent in the kids that were coming. Zinc deficiency in over 50 percent of the kids. So those were the two big nutrients that we saw we saw some iodine deficiency too. When we looked then. So they approached me about well you know about nutrition in the brain. Tell tell us if this is affecting their behavior. Because many of the kids were coming over with fairly significant behavioral problems and growth problems. We wanted to know whether they the nutrients were deficiencies were playing any part in their cognitive and emotional difficulties. That until that time I think most people thought no this was a product of stress. Stress is bad for the brain. These orphanages were stressful environments. Therefore the behaviors that we're seeing really stress-induced behaviors. And there's no question that that plays probably the major role. But you really didn't need to have nutrient deficiencies on top of that. So we first started by studying the kids when they appeared in the US within two weeks. And so the clinic gets a pretty wide catchment area because it was one of the few that was doing it at that point. And we were able to sample nutrients' status in the kids and their growth and then follow them up six months later to see if things had gotten better and whether there were behaviors that could be ascribed to those nutrients that also got either got better or it didn't get better. So we noticed a lot of iron deficiency and we noticed that the behavior that went with that was a lot of hesitancy and wariness which happened to be exactly what Dr. Lozoff had described in kids who were not in orphanages but who were iron-deficient anemic. And with the zinc we saw less exploratory behavior. They were, again, more hesitant and more and more attentional problems in those kids.

Grillot: As far as causes, did you study at all what was causing this was it a diet? I mean you mentioned stress obviously and the institutional you know experience. But I would presume that perhaps there are nutrition you know in their food was at issue as well?

Georgieff: Yeah it's a it's a great question and it gave us a surprising answer. So it really dependent on where you came from. And and it actually started a foundation. So again I need to give a shout out to these people. There was a woman by then is a woman by the name of Cindy Kaplan who had adopted a child from Kazakhstan. That was the Kazakhstan connection. And that child came over with bad rickets, and as I recall some iron deficiency as well, and that had been diagnosed by her pediatrician. OK. So this whole nutrition research thing had not even started at that point and she was wise enough to say well you know nutrition is something we can actually do something about. And it and she has a foundation called the Spoon Foundation that goes into the orphanages. So the answer was not, let's see what we can repair once the kids are adopted, but there's got to be a much larger issue, particularly for kids who aren't even adopted yet, who are still in the orphanages. Could we attack the problem? And we totally expected we go in there and see these poor diets, not balanced, and that's not what we found. We actually found that many of the diets were perfectly sufficient. And it points out a basic principle about fixing nutritional problems. It isn't always about supply side economics. You have to take into account what is the state of the child. And, like we talked about infection, are there things that are mitigating that child's ability to get those nutrients? And that's that was one of the findings that we had was that in fact a lot of the diets were good. It kind of depended again whether you were in Ethiopia or you were, which was not so dietary good, China which was perfectly sufficient in terms of delivery, or Kazakhstan or Russia where there was a little bit more variability. And it seemed like the kids were not absorbing the nutrients well that perhaps the orphanage environment, the stress, potentially repeated infections were changing the dynamics of the body's ability to absorb the nutrients and that maybe that was the root of the problem.

Grillot: That is a very interesting finding and I think instructive to us all right in that sense that we need to be quite sorry when the words I'm looking for we need to be we need to be paying attention to our own environment and not just what we're consuming. So it's a good lesson for all of us.

Georgieff: And I think UNICEF actually came to that conclusion. They had a meeting in 2014 that I was fortunate enough to present at and what we realized among us who study this was that there are people that study nutrition and development. There are people that study stress and development. There are people that study infection and development. But they were talking to each other and in fact all of these things inform each other. So I told you a little bit about that certain infections will block your ability to absorb iron. Well it turns out that psychological stress may do the same thing. So maybe your best solution isn't providing more iron. Your solution is better hand-washing. You know better preparation of the foods and so on. Now granted around much of the world which is grain based, not meat based, the sources of iron are quite low in the diet. So yes there is a role for building roads and delivering packets of new micronutrients and there's lots of research that's being done on that and whether that's effective or not. But it won't be effective in a high infectious environment for example.

Grillot: Very interesting sounds like smart medicine to me to try to bring that all together in a holistic way. Michael thank you so much for being with us today and talking about a very interesting topic.

Georgieff: Thank you. Thanks for having me. 

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