Hemorrhage-Adjusted Iron Requirements, Hematinics and Hepcidin Define Hereditary Hemorrhagic Telangiectasia as a Model of Hemorrhagic Iron Deficiency

BACKGROUND: Iron deficiency anemia remains a major global health problem. Higher iron demands provide the potential for a targeted preventative approach before anemia develops. The primary study objective was to develop and validate a metric that stratifies recommended dietary iron intake to compensate for patient-specific non-menstrual hemorrhagic losses. The secondary objective was to examine whether iron deficiency can be attributed to under-replacement of epistaxis (nosebleed) hemorrhagic iron losses in hereditary hemorrhagic telangiectasia (HHT). METHODOLOGY/PRINCIPAL FINDINGS: The hemorrhage adjusted iron requirement (HAIR) sums the recommended dietary allowance, and iron required to replace additional quantified hemorrhagic losses, based on the pre-menopausal increment to compensate for menstrual losses (formula provided). In a study population of 50 HHT patients completing concurrent dietary and nosebleed questionnaires, 43/50 (86%) met their recommended dietary allowance, but only 10/50 (20%) met their HAIR. Higher HAIR was a powerful predictor of lower hemoglobin (p = 0.009), lower mean corpuscular hemoglobin content (p<0.001), lower log-transformed serum iron (p = 0.009), and higher log-transformed red cell distribution width (p<0.001). There was no evidence of generalised abnormalities in iron handling Ferritin and ferritin(2) explained 60% of the hepcidin variance (p<0.001), and the mean hepcidinferritin ratio was similar to reported controls. Iron supplement use increased the proportion of individuals meeting their HAIR, and blunted associations between HAIR and hematinic indices. Once adjusted for supplement use however, reciprocal relationships between HAIR and hemoglobin/serum iron persisted. Of 568 individuals using iron tablets, most reported problems completing the course. For patients with hereditary hemorrhagic telangiectasia, persistent anemia was reported three-times more frequently if iron tablets caused diarrhea or needed to be stopped. CONCLUSIONS/SIGNIFICANCE: HAIR values, providing an indication of individuals' iron requirements, may be a useful tool in prevention, assessment and management of iron deficiency. Iron deficiency in HHT can be explained by under-replacement of nosebleed hemorrhagic iron losses

‘Alternative Hedonism’:Exploring the Role of Pleasure in Moral Markets

Fair trade’, ‘ethical’ and ‘sustainable’ consumption emerged in response to rising concerns about the destructive effects of hedonic models of consumption that are typical of late capitalist societies. Advocates of these ‘markets for virtue’ sought to supplant the insatiable hedonic impulse with a morally restrained, self-disciplining disposition to consumption. With moral markets currently losing their appeal, we respond to the tendency to view hedonism as an inhibitor of moral market behaviour, and view it instead as a potential enabler. Drawing upon the concept of ‘alternative hedonism’ (Soper, 2007, 2008, 2016, 2017), we illustrate how consumers experience both morality and pleasure concurrently; show how they attempt to reconcile these aspects of the experience; and elucidate the implications of so doing. Using the moral market for ethical tourism as an exemplar of ‘alternative hedonism’, we identify three ‘self-managing strategies’ – moderating, abiding and levelling – that re-structure the moral order of consumption in meaningful ways and with profound outcomes. In the context of anxieties about personal, social and ecological consequences of consumption, we show empirically how self managing strategies reify a less contradictory framing of consumption by tapping into alternative cultural discourses on morality. We discuss the consequences of these strategies, highlighting how they may legitimize and sustain consumption via moral markets despite the reproduction of social inequality and ecological threats