Question: Original lab work a year ago shows a hemoglobin at 13.9, MCV 82, MCH 28, RDW high 14, iron saturation low at 17.3.”
Dr. Amy Nett: I’m kind of, that iron saturation would be kind of okay with me.
Question: “Ferritin very low at 4.9”
Dr. Amy Nett: – agree. TIBC and UIBC would probably also be helpful to look at. That hemoglobin is also borderline, so I agree that MCV is small. I’m not sure if the hemoglobin really pushes me towards anemia yet, but I agree a ferritin of 5, I would want to look at those other iron markers.
Question: “Folate also low at 5, ESR 1, CRP 0.1.”
Dr. Amy Nett: ESR and CRP being markers of inflammation, those look fine.
Question: “TSH 0.59”
Dr. Amy Nett: So thyroid looks normal.
Question: “Negative Hemoccult.”
Dr. Amy Nett: Okay so stool test I guess, no occult blood in the stool.
Question: “His prior doctor put him on iron supplementation, and numbers slowly improved.”
Dr. Amy Nett: So hemoglobin is normal, the MCH remain low, and ferritin still very low at 8. I would look at an iron— let’s see, ferritin is still very low, so yes, you have iron and iron saturation. Because if ferritin still low, it sounds like he probably needs to further increase iron. Think about other causes though of small MCV, but with a ferritin of 8, I think you’re probably on track. And then Amber says,
Question: “I’m going to start him on a Paleo diet, but he would rather not eliminate dairy. I was going to run Cyrex Array 3 and 4. Does he need to still eliminate dairy if no antibodies to dairy and anything else you’d recommend doing?”
That’s a tricky one because, I mean, you have to meet patients where they’re at, and if he is coming from more or less the standard American diet, if you can get him grain-free, I would start there. I think because you say psoriasis, yes, the concern is it’s worth a try an autoimmune Paleo diet at some point. Mild psoriasis, so maybe he’s not concerned about it, but one autoimmune condition you think about others. The other thing is remember that dairy is going to be calcium rich, and calcium is going to interfere with iron absorption, so if he’s eating cheeseburgers, then the calcium in the cheese is going to inhibit iron absorption in the red meat. That’s another reason depending on where he’s putting the dairy in his diet that may be interfering with the iron absorption, so something to think about.
Anything else I would do? Well, I mean, you’ve got to fix the insomnia. The question there is what is his stress levels look like? What is the cortisol? What is his bedtime routine? I think until you get the sleep fixed sometimes that can be an uphill battle. Psoriasis, you’re saying mild, so he’s not bothered by it. It’s going to be harder to convince him to go on a Paleo diet, but I would think about the dietary changes that you’re mentioning. You could try something if he wanted to like Meriva or another bioavailable form of curcumin. Even though his CRP and ESR are low, something is triggering his immune system. Also, skin issues, do think about the gut, and then again, if he’s not absorbing iron, why is that? Is there gut inflammation? If he’s open to doing a SIBO breath test or a Doctors Data, maybe a comprehensive stool analysis, that would be really helpful I think looking at those markers of gut information – lysozyme, calprotectin, lactoferrin. Is there a reason that he’s not absorbing some of these nutrients? I would also get him on the folate. You mentioned his folate is low, so I would probably start him on either like a methyltetrahydrofolate, maybe look at his homocysteine levels. If homocysteine is above seven, then you want to think a little bit more about B vitamins support, so maybe also look at a serum B12 level and maybe a methylmalonic acid just seeing if when you start that folate support you want it to be in a B complex, a folate and B12 supplement or folate alone. Hopefully that gives you a couple ideas in terms where to go with him, but I think diet, again, I would love to see him go dairy-free for both improving his iron absorption and also for the psoriasis. But you have to meet with patients where they are, and sometimes you say, “Great. Let’s start with the grain-free diet, and maybe in six months we’ll reevaluate the dairy.” If you try to do too much at once, they may not want to come back and see you.