Book Review

Diet, Demography, and Disease: Changing Perspectives on Anemia

N Engl J Med 1993; 328:1650June 3, 1993

Article

Diet, Demography, and Disease: Changing Perspectives on Anemia
Edited by Patricia Stuart-Macadam and Susan Kent. 285 pp. Hawthorne, N.Y., Aldine de Gruyter, 1992. $59.95. ISBN: 0-202-01189-5

For many years, iron metabolism languished in the backwaters of biomedical research and teaching, slowly corroding like an old Chevy abandoned near the levee. The prevailing view was that everything of importance about this metal was known, leaving only a few oddities to puzzle the pundits. Recently the pendulum has swung somewhat, reflecting a growing appreciation of the important role of iron in infection, heart disease, and the psychomotor development of children.

This book has been written as an interdisciplinary examination of iron metabolism. The editors have focused the more traditional medical view of iron through an anthropologic prism. Their intent is to explore the complex interplay among human social structure, environment, and disease as they affect iron metabolism and anemia. The book's theme is that depressed plasma iron levels are frequently reactions to chronic disease and inflammation rather than results of iron loss or dietary deficiency. As human social organization changed from a foraging existence to a sedentary, agrarian one, the prevalence of depressed serum levels of iron and of anemia increased. To support this thesis, the editors have combined chapters that fall into two main categories. The first explores the pathophysiology of iron metabolism from a traditional biomedical perspective. The second portion of the book consists of anthropologic case studies that illustrate the interplay among social structure, environment, and iron metabolism in present and prehistoric societies. The result is a unique intermeshing of two traditionally separate areas of scientific inquiry.

Interdigitating disparate areas of science is difficult. Many of the assertions are controversial. This is a book of ideas that challenge dogma. Even the authors disagree on some crucial points. A central controversy surrounds the meaning of “porotic hyperostosis.” A number of the anthropologists contend that these skull lesions, which are characterized by thin bone with many small cortical perforations, reflect iron-deficiency anemia in prehistoric peoples. However, an author in the “biomedical” section of the book is much more circumspect, contending that the lesions can result from many environmental and nutritional insults. Some experts in iron metabolism and anthropology would challenge other ideas in the book. However, it is not a textbook, and the editors do not seek simply to promulgate well-established or accepted ideas in science.

The crispness and clarity of the chapters vary considerably. Overall, however, they are well written. The editors have taken the interesting tack of writing an introductory chapter to orient the reader to the somewhat unorthodox views presented. In a summary chapter, they try to pull the book together under a single theme, a welcome approach in a work that spans disciplines. One major shortcoming is the presence of a number of factual errors. Some are minor, whereas others, such as the assertion that folate deficiency causes pernicious anemia, are egregious. Such errors would be totally unacceptable in a textbook. In this book, the effect is to undermine the credibility of the offending authors. This loss of credibility is not trivial in a work that seeks to challenge the status quo.

Despite these problems, the book is thought-provoking. This interdisciplinary approach to the pathophysiology of iron and anemia provides a refreshing new look at an old problem. I must then ask, At whom is the book aimed? The answer is, anyone with an open mind and an interest in the big picture in this area of biology. Although not all the propositions in the book are necessarily correct, they do provoke serious reflection.

Kenneth Bridges, M.D.
Brigham and Women's Hospital, Boston, MA 02115