hemoglobin level of 16 g/dL (hematocrit of 4 7 % ) is reached in adult men and 14 g/dL (hematocrit of 42%) in adult

women.

These are mean values, however, and any normal population of men or women will vary around the mean in a Gaussian dis t
r i b u t i o n ( F i g u r e 2 - 3 ) . T h e r e fo r e , i t i s c o m m o n p r a c t i c e t o s t a t e 95% confidence limits (2 standard
deviations [SO) ) for the meannormalvalue.Forthepurposeofclinicaldecisionmaking, it is best to focus on a set of lower limit
of normal values that best separates normal from anemic individuals. As shown in Table 2-2, data from Scripps-Kaiser and
NHANES studies have been used to derive a set of lower limits of normal for adults liv
ingatsealevel,whichshouldexcludeallbut5%ofnormalindi viduals (95% confidence limit). At the same time, the lower limits
of normal for apparently healthy American black men and women are approximately 1 g/dL lower ( 1 2.9 g/dL for black
menand 11.5g/dLforblackwomen).

The probability that a patient's hemoglobin is normal will also depend on the incidence of disease in any population, as

illustrated in Figure 2-3 . When the prevalence of a hematolog ical abnormality is high, for example, as in the inheritance of
a hemoglobinopathy, the overlap of abnormal and normal popu lations will increase, thereby reducing both the sensitivity
and s p e c i f i c i t y o f t h e h e m o g l o b i n a n d h e m a t o c r i t m e a s u r e m e n t s . This effect may well play a role
in determining the lower limits ofnormal for black men and women. A higher incidence of iron deficiency and a.-thalassemia
has been detected in the Scripps Kaiser population studies, which, at least in part, explains the difference between white and
black values. Normal values for the hemoglobin and hematocrit are also influenced by several environmental and
physiologic factors. Populations living at higher altitudes have predictable increases in their hemoglobin levels of
approximately 1 g/dL of hemoglobin for each 3 %-4% decrease in arterial oxygen saturation. The same effect is pro duced
by cigarette smoking because carbon monoxide decreases the hemoglobin-oxygen saturation. A patient who smokes more
than one pack of cigarettes per day will show an increased

pg

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