Anemia

Iron deficiency most common form

of malnutrition in world affecting >
2 billion people globally.
 Groups at Risk
• Young children 6-24 months
• Women of reproductive age
• Older children and adolescents
• Adult men and elderly
• Iron def. occurs when iron stores
exhausted and supply of iron to tissues is
compromised
 Prevalence
• Major PH problem in most countries of the
world especially those in Africa and Asia.
• Globally: about 51% of pregnant women
are anemic
• Africa – 63% of pregnant women anemic
• S. Asia – 65%; E/Asia – 20%
• Europe –14%
 Anemia prevalence
• Pacific – (Kiribati, Solomons, Vanuatu,
Marshalls, FSM) highest reported
prevalence of vitamin & mineral
deficiencies; suspected anemia most likely
from iron deficiency.
• Also potential malaria in Solomons and
Vanuatu; zinc and iodine deficiencies in
some provinces of Vanuatu
 Anemia Prevalence in Pacific
• The evidence for causal links between
u/nutrition during periods of i/uterine
growth & early childhood with later
o/weight and NCD, and the association
between VMD and increased <5 morbidity
and mortality indicate that intervention
targeted during pre-pregnancy and early
childhood need urgent review and
improvement in the 5 countries.
 Fiji Situation 1990 NNS
• 27.2% of total population anemic
• Among women overall – 39.1% anemic;
Among pregnant women: 62% Indians and
52% Fijians anemic.
• Among Indian women of child bearing age,
40% anemic;
• Among children <5 yrs - 40% anemic
• Older children and teenagers – 29.4%
 Fiji Situation cont.
• 22.9% of those 15-19 yrs anemic
• Among men overall – 16%
• Comparing urban and rural populations,
29.8% anemic in urban setting, and 25.9%
in rural setting
• Proportion of population found to be
anemic generally higher in Indo-Fijians
than in Fijians and others.
 Hb and hematocrit cut offs used to
define anemia WHO/UNICEF/UNU,
1997
• Age HB below Hematocrit
g/dl below (%)
___________________________________
Children 6m-5yrs 11.0 33
Children 5-11 yrs 11.5 34
Children 12-13 yrs 12.0 36
Non-preg women 12.0 36
Preg. women 11.0 33
Men 13.0 39
 Defining the Problem
• Iron essential in production of Hb, which
functions in delivery of oxygen from lungs
to body tissues,
• in electron transport in cells, and
• in synthesis of iron enzymes required to
use oxygen for the production of cellular
energy.
 Iron balance
• Determined by body’s iron stores, iron
absorption, and iron loss
• Two thirds of body iron is functional iron, mostly
Hb within circulating red blood cells
• Some as myoglobin in muscle cells and parts of
iron-containing enzymes
• Remaining body iron is storage iron (existing as
ferritin and hemosiderin) that serves as deposit
to be mobilized when needed.
 Causes of anemia
• Inadequate iron intake
• Poor bioavailability of iron consumed from
cereal based diets and
• High rates of intestinal worm infection
• Increased requirements at certain stages
in the life cycle, e.g. during pregnancy and
during rapid early childhood and
adolescent growth
 Causes cont.
• Blood loss due to menstruation and
childbirth, amplified by repeated and
closely spaced pregnancies, and parasites
(e.g. hookworm)
• Deficiencies of folate (neural tube defect),
vitamins A and B12
• Infections especially current chronic
infections can interfere with food intake
and the utilization of iron
 Other Causes
• Hemolytic anemia occurs when RBCs are
being destroyed prematurely, bone
marrow cannot keep up with body’s
demand for new cells. Can be due to
infections or certain medications – such as
antibiotics or anti-seizure medicines.
• Autoimmune hemolytic anemia – immune
system mistakes RBCs for foreign
invaders and begins destroying them.
 Sickle Cell Anemia
• Severe form of anemia commonly found in
people of African heritage, although can
affect others (Indians, Caucasians,
Mediterranean descents). Leads to
premature destruction of RBCs,
chronically low levels of Hb, and recurring
episodes of pain, as well as problems that
can affect virtually every other organ
system in the body.
 Thalassemia
• Usually affects people of Mediterranean,
African, SE Asian descent. Marked by
abnormal and short-lived RBCs
• Thalassemia major – RBCs rapidly
destroyed and iron deposited in the skin
and vital organs
• Thalassemia minor involves only mild
anemia and minimal RBC changes.
 Aplastic anemia
• Occurs when bone marrow cannot make enough
RBCs. Can be due to viral infection, or exposure
to certain chemicals, radiation, or medications
(such as antibiotics, antiseizure drugs, or cancer
treatments).
• Some childhood cancers can also cause aplastic
anemia, as can chronic diseases that affect the
ability of the bone marrow to make blood cells.
 Iron deficiency anemia
• Most severe degree of iron deficiency and
ensues if Hb concentration falls below
11g/dL for pregnant women
• Iron essential for hemoglobin production.
Poor dietary intake (or excessive loss from
body) can lead to iron deficiency anemia.
• Iron deficiency anemia most common
cause of anemia in children at any age,
especially under 2 years old.
 Iron Requirements
• Differ with age, gender, and physiologic
state
• Proportion of dietary iron that can be
absorbed depends on nature of the diet
and levels of iron in body e.g. heme iron
better absorbed than non-heme iron; more
iron absorbed in an individual with less
iron stores.
 Iron requirements cont.
• Pregnant women partic. at risk of
becoming anemic due to high iron needs
because of increased blood volume and
growth of fetus, placenta, and other
maternal tissues
• Fetus uses mother’s RBCs for growth and
development especially in last trimester of
pregnancy
 Iron Requirement
• Iron needs will increase 5x her pre-
pregnancy requirement in late pregnancy
• Women without iron stores, or with
minimal stores, going into pregnancy will
require supplements to avoid impairment
in synthesis of amounts of Hb required.
• Excess red blood cells stored in bone
marrow before pregnancy can be used
during pregnancy to meet baby’s needs.
 Infancy
• Full term newborn baby has sufficient iron
stores, along with highly bioavailable iron
from breast milk for first 4-6 months if
mother was healthy.
• Risk of infant developing iron deficiency
anemia is heightened by practice of
premature clamping of umbilical cord-
deprives the infant of an additional ⅓ of
infant’s total blood volume.
 Infancy Iron Requirement
• In first 2m of life, there is minimal dietary
iron absorption and stores are mobilized to
meet iron requirements
• By 4-6m of age, iron stores have been
depleted and diet now becomes critically
important.
• A LBW baby will have low iron reserves
and require extra iron from 3m of age with
exclusive breastfeeding for first 6 months.
 Consequences of Iron Deficiency
Anemia
In pregnant women
• Increased risk of maternal mortality and
morbidity
• Fetal morbidity and mortality
• Intrauterine growth retardation (IUGR)
 Consequences
• Fetal growth retardation and prenatal and
perinatal mortality
Anemia is directly related to risk of preterm
delivery, inadequate gestational weight
gain, and increased perinatal mortality.
The more severe the anemia, the greater
is the risk that mother will deliver a LBW
baby because of poor intrauterine growth.
 Consequences of Iron Deficiency
Anemia
• LBW babies have a higher risk of dying in
infancy and early childhood. There’s also
increasing evidence of heightened risk of
CHD in later life. Severe maternal anemia
has been associated with increased child,
as well as maternal mortality.
 Consequences of Iron Deficiency
Anemia
c. Compromised development in young
children. Fe is present in key enzymes in
several neurotransmitter systems in the
brain (e.g. dopamine and serotonin
systems). Damage to fetal brain arising
from maternal anemia takes place early
in pregnancy, and studies suggest that
anemia in pregnancy more damaging
than anemia during lactation.
 Consequences of Iron Deficiency
Anemia
• Peak prevalence of iron deficiency
among young children coincides with
latter part of the spurt in brain growth (6-
24 months) when motor and cognitive
abilities take shape.
 Consequences of Iron Deficiency
Anemia
• Children with iron-deficiency anemia
perform less well on psychomotor tests
than non-anemic counterparts.
• An infant who becomes anemic through
iron deficiency is at high risk of long-term,
even permanent impairment in mental and
motor development.
 Consequences of Iron deficiency
anemia
d. Child growth failure and poor physical
development
• Severe maternal anemia leads to fetal
iron deficiency and lower fetal iron
reserves. Such infants require more iron
than can be supplied by breast milk alone
by age 2-3 months.
 Consequences of Iron deficiency
anemia
• Children born of iron-deficient, anemic
mothers have been found to have
significantly higher risk of being iron
deficient or anemic by their first birthday
(Colomer et al. 1990)
e. Lowered physical activity, mental
concentration, and productivity
 Consequences
• Energy metabolism, particularly in muscle
cells, is impaired by iron-deficiency
anemia. Work capacity, and hence earning
capacity of adults is considerably reduced
by anemia.
• Lowered attention span will adversely
affect mental concentration, which can
further reduce productivity.
 Consequences of Iron deficiency
anemia
g. Increased morbidity:
Iron deficiency anemia may adversely affect
specific cell-mediated immunity. Lowered
resistance manifests itself in increased morbidity
(both incidence and severity) from diarrheal,
respiratory, and other infections.
Subsequent raising of iron status of iron-deficient
children through supplementation or fortification
can reduce morbidity.
 Consequences cont.
• Iron deficiency also associated not only
with increased absorption of iron, but
also of other toxic heavy metals including
lead and cadmium. Children living in
polluted urban environments particularly
at risk.
• Also associated with altered
gastrointestinal function relating to
malabsorption of vitamin D and fat.
 Strategies
Iron status may be improved through:
1. food-based strategies (primarily
fortification and dietary modification) and
2. nonfood-based strategies (primarily
supplementation and parasitic disease
control)
 Strategies
3. Supplementation
• Infants and young children – 2mg/kg body
wt from 6m to 24 m. if LBW starts at 3
months of age.
• Pre-school children (2-5 yrs) with IDA –
2mg/kg body wt. daily (up to 30mg iron)
• School children and adolescent girls with
IDA – 60mg/wk with 0.35 mg folic acid, or
30mg/day with 0.35 mg folic acid
 Recommended iron
supplementation
• Women of child bearing age with IDA evidence –
60 mg/day with 0.35 mg folic acid
• All pregnant women – 60 mg/day with 0.40 mg
folic acid starting as soon as possible after 3 rd
month of gestation
• Lactating women – continue with weekly 60 mg
doses plus 0.40 mg folic acid between
pregnancies.
Source: WHO/UNICEF/UNU (1996)
 Food-based Strategies
• Most desirable and sustainable of all
preventive strategies with potential for
multiple nutritional benefits
Two different types:
1. Dietary modification: a strategy for
improving either amount of food-iron
ingested in diet or its bioavailability.
 Dietary modification
• Includes food processing, preparation and
consumption; breastfeeding; and
appropriate complementary food
preparation and feeding practices.
• Agricultural production and extension,
including selective plant breeding.
 Food-based Strategies
2. Fortification: addition to nutrients of
foodstuffs that may or may not be present
naturally in food to improve its overall
nutritional quality.
• Primary objective is to prevent iron
deficiency or sustain adequate iron stores
of population over medium to long term.
 Food based strategies

• Amount of iron absorbed from diet

dependent on composition of diet – i.e.
quantities of substances that
enhance/inhibit iron absorption
 Food based strategies
• Tea, coffee inhibit iron absorption when
consumed with meal or shortly after a
meal
• Heme food sources, red meat contain
highly absorbable iron and promote
absorption of iron from other less
bioavailable food sources
• Vit. C also an enhancer of iron absorption
from non-meat foods
 Food based strategies
• Germination and fermentation of cereals
and legumes improve bioavailability of iron
by reducing content of phytate.
• Bioavailability: refers to the availability of a
substance from the diet for use in normal
metabolic processes and functions.
 Dietary iron content
• Iron dose is generally inversely related to
the percentage that is absorbed, both with
dietary iron and iron supplements. The
higher the level of iron to which the
intestinal mucosal cells have been
exposed, the lower is the relative
efficiency of iron absorption. Providing that
iron is in assimable form, actual amount
absorbed will rise progressively with
increasing dietary intake.
 Heme/non-heme iron
• Dietary iron exists as either heme iron or
non-heme iron. Both forms absorbed in
different pathways and with different
degrees of efficiency.
• Heme iron is 20-30% absorbed in normal
individuals (40-50 % in iron-deficient
subjects).
 Non-heme iron
• Absorption of non-heme iron is governed
by its solubility in the upper part of the
small intestine, which in turn is highly
dependent on the balance of absorption
inhibitors and enhancers.
 Heme and non-heme iron
• Non-heme iron absorption may be as low
as 5% in many cereal-based diets
commonly consumed in developing
countries.
• Some non-heme iron derives from
contamination during food preparation e.g.
through use of iron cooking pots in
fermentation.
 Helminth control
• Anthelminthic therapy where hookworm infection
is endemic.
• Prevalence and intensity of h/worm infection
increases with age, effect is greatest on iron
status of school age children, adolescents, and
adults including pregnant women.
• MCH: anthelminthic therapy combined with Fe
and folate supplementation enhances Hb
response to iron supplementation.
 Food Sources of iron
Good food sources include:
• Meats – beef, pork, lamb, liver and other
organ meats
• Poultry – chicken, duck, turkey, liver
• Fish – shellfish including clams, mussels,
oysters, sardines, anchovies
• Green leafy vegetables, legumes (peas,
beans), fortified foods (flour
 Symptoms of Anemia
• Pale skin, lips, nails, palm of hands, or
underside of eyelids
• Fatigue
• Vertigo or dizziness
• Labored breathing
• Rapid heartbeat (tachycardia)
Note: Above symptoms may resemble other
conditions or medical problems
 Enhancers and inhibitors
Absorption Enhancers:
• Vit. C and citric acid
Pawpaw, guava, banana, mango, salad, orange,
lemon, lime, pear, apple, pineapple juice
• Malic, tartaric acids: carrots, potatoes, pumpkin,
tomato, cabbage
• Cysteine-containing peptides: beef, lamb, liver,
pork, chicken, fish
• Fermentation products: soy sauce,sauerkraut
 Absorption inhibitors
• Phytate: wheat bran, rice, oats,
milk chocolate, nuts, legumes
• Polyphenols: tea, coffee, spinach, nuts,
legumes, red wine
• Calcium and phosphate: milk, cheese