ANEMIA: A Curable Disease

Do you feel tired all the time? Do you have generalized weakness, frequent headaches or faintness? Do you become breathless or have palpitations on climbing stairs? Are you irritable? Do you have hair fall, weak nails and pale skin, dark circles around eyes or dark spots on nose and cheek?

If answer to any of these questions is yes then you might be suffering from anemia or decreased  hemoglobin, and you need to see your doctor for investigations and treatment.

What is hemoglobin?
It’s an oxygen carrying protein in red blood cells, which binds oxygen with it and delivers it to cells.

What is Anemia?
It is quantitative and qualitative decrease of hemoglobin, for less than 11g/dl or hematocrit (red cell mass) less than 33%.

How common is Anemia?
It affects nearly 40% of world population, out of which majority of people live in underdeveloped whereas around 18% are from developed countries. It’s alarming to see nearly half of world anemic population in subcontinent, here 50% pregnant and 35% non pregnant women are having this problem.

What are the categories of severity of Anemia?
It’s severity is according to hemoglobin levels:

• Mild Anemia with Hb 10 to 10.9 g/dl
• Moderate Anemia with Hb 7 to 10 g/dl
• Severe Anemia with Hb less than 7 g/dl
• Very severe (decompensated) with Hb less than 4 g/dl

What are various causes of Anemia?
Low hemoglobin could be caused by defective formation of hemoglobin, enzyme defects or breakdown of red cells; these are associated with various conditions:

• Nutritional deficiencies and malabsorption’s
  • Iron
  • Folate
  • Vitamin B 12
• Chronic illness
  • Renal diseases
  • Liver disease
  • Infections
  • Malignancy
  • Toxins and Poisons
• Blood diseases
  • Abnormal formation of cells
  • Thalassemia
• Auto-Immune disorders

What are causes of IRON deficiency anemia among females?

• Inadequate intake of iron
  • Malnutrition
  • Malabsorption
• There could be excessive blood loss
  • Heavy, prolonged or irregular periods
  • Hemorrhoids or piles
  • Worm infestation
• It could be due to increase in demand
  • Pregnancy
  • Multiple pregnancy
  • Breast feeding

How a balance of iron is maintained in our bodies?
There is a precise balance between iron intake and loss from body. Iron is lost in feces, urine, sweat, 0.7 mg / day is lost per day during menstruation.

Does our body stores iron?
Yes, its stored in our bodies:

• Iron stores in men = 1000 gm
• Iron stores in women = 300 to 500 mg

What’s the daily requirement of iron?
Our bodies need 30 to 35 mg of iron per day for making red cells:

• 28 to 30 mg comes from recycling the body stores
• Only 1 to 2 mg comes from diet

Iron requirement:

• for Adult males is 8 mg per day
• Adult female 18 mg per day
• Normal pregnancy 30 mg per day
• For iron deficient patients it is 150 to 200 mg per day

Why anemia is common during pregnancy ?
The normal changes in blood during pregnancy, cause more increase (50%) in fluid part (plasma) of blood as compared to red cells, resulting in anemia.

Why iron is needed during pregnancy ?
Iron is needed for increasing maternal red cells mass (500 mg), normal growth, development of fetus and placenta (500 mg). Iron is lost from body, through blood loss at delivery and during lactation, so it’s important to maintain iron stores of body.

Why untreated iron deficiency during pregnancy gets worsen?
Remember placenta entraps maternal blood iron (transferring) and provide it to growing fetus, regardless of maternal stores, this transport becomes maximum in last 4 weeks of pregnancy. Therefore maternal iron stores are rapidly depleted as pregnancy advances.

What are the complications of iron deficiency during pregnancy?
Women have increased risk of:

• Infections
• High blood pressure(pre-eclampsia)
• Pre-term delivery
• Excessive bleeding after delivery (PPH)
• Cardiac failure (in severe cases)

Babies born to iron deficient mothers have:

• Intra uterine growth retardation (IUGR)
• Behavior problems
• Learning difficulties
• Developmental delay
• Risk of high blood pressure in adult life

What are lab tests for iron deficiency anemia?

• Blood complete examination 
• hemoglobin, hematocrit (red cell mass)
• Cell indices
• Peripheral smear for cell shapes and sizes

Iron studies for:

• Serum ferritin level
• Iron binding capacity
• Serum iron
• Serum transferrin level
• Stool examination
• For blood, ova and cysts of womb  

Are there any other tests?
If blood iron tests are normal then Hb electrophoresis is performed on blood to exclude thalassemia and other hemoglobin disorders. Other special blood tests exclude certain chronic  diseases, and in certain cases bone marrow biopsy is indicated.

Sometimes invasive tests like endoscopy or colonoscopy (camera insertion in intestines) are needed to diagnose the problem.

What is the treatment of iron deficiency anemia?
The most appropriate treatment is iron replacement by intake of iron rich diet. There are iron supplements, tablets or syrup; ferrous form of iron is preferred. Intravenous iron is given to patients that are not responding to oral treatment, mal-absorption and in cases for avoiding blood transfusion.

When are iron injections given?
They are given to non-compliant, oral iron intolerant patients with very low iron levels and with low hemoglobin. Iron injections can be given through slow intravenous drips or intramuscular injections.

When blood transfusion is indicated?
In emergency cases of blood loss, severe anemia, hemoglobin less than 8 gm per dl, blood diseases blood transfusions are prescribed.

How should iron treatment response be evaluated?
The response to iron treatment starts with few days and reaches an optimum level after 3 weeks; hemoglobin rises to 0.3 to 1 gm /dl after 10 days of initiation of iron therapy. Please note if the rise of hemoglobin is less than 0.3 gm /dl then further specialized tests should be done to reevaluate the diagnosis.

What are iron therapy complications?
Oral iron causes:

• Nausea, vomiting, diarrhea, constipation
• Pain in abdomen
• Black stools
• Hypersensitivity to iron

Intramuscular or intravenous iron causes:

• Pain, burning or rash at sight of injection
• Headache
• Metallic taste
• Muscle pains
• Decreased or increase in blood pressure and heart rate

Which foods are rich in iron?

• Eggs, lean meat or beef, mutton, fish
• Lentils, chickpeas, kidney and soya beans
• Citrus fruits, apples, dates, mango, kiwi
• Green leafy vegetables like spinach, broccoli, red and orange bell pepper, kale, potatoes
• Nuts like cashew, pistachio, peanuts, seeds like sunflower and pumpkin seeds
• Diary milk, yogurt and cheese

Which foods should be avoided?
There is certain food which impair iron absorption, such as:

• Dairy products: Tea, coffee, milk
• Whole grain cereals containing foods like grapes and corn
• Phytates containing food like whole grain wheat, brown rice
• Oxalic acid containing food: peanuts, parsley, chocolates
• Foods with high gluten content like wheat, barley, pasta, oats

How could be iron absorption increased ?

• Do not take oral iron with milk, tea or coffee
• Do not take calcium tablets along with iron
• Do not overcook green vegetables and meat
• Take Vitamin C, as it increases iron absorption

Remember iron deficiency anemia is preventable and treatable condition, timely treatment is key to prevent maternal and fetal complications.

Dr. Ayesha Azam Khan