CHAPTER 13 | Anemia and Its Effects on the Older Adult 205


Anemia and Special Populations


Older Adults Consuming a Plant- Based Diet


Older adults who consume a strict plant-based diet, vegan diet, or diet with very few animal products have an increased risk of vitamin B12 and iron deficiencies. Individuals may consume these diets by choice or as a result of socioeconomic circumstances that make pro- curing meat and animal products difficult. In this sit- uation, inadequate protein intake may also play a role. Iron bioavailability is reduced when the diet exclusively comprises plant-based nonheme sources: only 2% to 10% of iron is absorbed, depending on the presence of extrinsic enhancers and inhibitors of absorption.16


Thus, the Recommended Dietary


Allowance of iron for vegetarians is 1.8 times higher than that for people who eat meat.32


Consumption of


substantial amounts of vitamin C may mitigate this concern because this vitamin enhances nonheme iron bioavailability. Foods fortified with vitamin B12 (eg, fortified nutritional yeasts) and vitamin B12 supple- ments also reduce deficiency risk because the B12 is in the more readily absorbable crystalline form.4,16,18


Individuals With Alcohol Use Disorder


Up to 90% of individuals who chronically consume alcohol have mild macrocytosis (MCV of 100–110 fL), often without anemia, although its cause (eg, liver dis- ease) is unknown. Therefore, testing for macrocytosis is incorporated in the screening of individuals with excessive alcohol intake. Chronic alcohol intake leads to a decline in marrow cellularity, accompanied by moderate macrocytic anemia, mild neutropenia, and moderate to severe thrombocytopenia, all of which may recover after alcohol withdrawal, depending on the degree of injury caused by alcohol ingestion.16 Older adults with alcohol use disorder may con-


sume a poor-quality diet, including insufficient folate intake, and folate deficiency is common in this pop- ulation. Beer is rich in folate; thus, individuals who consume beer as their primary alcohol source may not present with a folate deficiency. Alcohol interferes


with folate absorption and hepatic uptake, accelerates folate breakdown, and increases renal excretion of folate.28


Even moderate daily alcohol consumption


of 240 mL (8 fl oz) red wine or 80 mL (2.7 fl oz) vodka for 2 weeks can substantially decrease serum folate concentrations in healthy males, although not to levels below the cutoff for folate adequacy (3 ng/ mL).29


More research is needed to determine the


cause of macrocytosis in these cases and whether macrocytosis can result from excessive alcohol intake independent of its effect on folate metabolism. Although it is relatively uncommon, iron defi- ciency may also be seen in individuals with alcohol use disorder and is believed to be attributable to gas- trointestinal blood loss rather than reduced dietary iron intake. The exception is in individuals primarily consuming wine as their alcohol of choice. In these cases, iron deficiency is likely if serum ferritin levels are less than 100 ng/mL.16 Anemia of chronic inflammation may also present


as alcohol misuse. Alcohol abuse is a common cause of hyperhomocysteinemia.16


As a result, interpreting


the cause of the anemia can be challenging because the individual may have an iron deficiency creating microcytosis, a folate deficiency creating macrocyto- sis, and then layering upon that anemia of chronic inflammation.


Bariatric Surgery Recipients


Approximately two-thirds of individuals who undergo bariatric surgery may experience postop- erative anemia. Prophylactic iron and multivitamin supplementation is part of the normal postoperative protocol. With the exclusion of immediate postoper- ative bleeding, iron deficiency is the most common etiology of the anemia, followed by folate and vitamin Bl2 deficiencies. Iron deficiency is most common after the Roux-en-Y gastric bypass procedure. Dietary restriction, malabsorption, and gastrointestinal blood loss all contribute to iron deficiency. Malabsorption of iron and vitamin B12 may be associated with gas- tric hypoacidity and removal of absorptive surfaces.16 Because more individuals are living longer and may have had this bariatric surgery earlier in life, the RDN should always ask clients about their medical history and previous surgeries.


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