Nutritious diets, awareness, early detection, prevent anaemia | Sunday Observer

Nutritious diets, awareness, early detection, prevent anaemia

15 November, 2020

As Sri Lanka continues to be praised for its outstanding performance in combatting and eradicating several contagious diseases in recent years, one issue that has been sidelined or not recognised as a priority health issue has become a cause for concern among health officials: namely, the  rise in iron deficiency leading to Anaemia.  Unless the risks of those vulnerable to this condition, mainly women and girls. are minimised according to medical guidelines , it could lead to severe complications, warns a leading Haematologist .

In an interview with the Sunday Observer Consultant Haematologist National Hospital Colombo, Dr. Bhaddika Jayaratne explains what anaemia is and how it can be prevented.


Q. Anaemia is a subject that is not well understood.  Define Anaemia.

A. Anaemia is defined by low haemoglobin concentration which results in a defective oxygen carrying capacity, insufficient to meet the body’s physiological need.

Q. Is it a condition or a disease? How is it caused?

A. It is a condition that can result due to many causes. Deficiency of essential minerals such as iron, copper (Cu), zink (Zn), manganese (Mn) or vitamin B12 and folateetc is called deficiency anaemia. Acute or chronic blood loss is an important cause of iron deficiency anaemia. It could also result in chronic diseases such as kidney and liver failure, chronic infections, autoimmune diseases and underlying malignancies. Immature destruction of red cells is called haemolytic anaemia which can be due to acquired, congenital or inherited causes such as haemoglobinopathies and red cell membrane abnormalities.

Q. Who are those most at risk of becoming anaemic, gender wise and age wise? Why?

A. Women at reproductive age group are particularly at risk of suffering iron deficiency anaemia due to excessive menstrual blood loss, high requirement of iron due to fetal demand during pregnancy and blood loss at delivery. At infancy and teenage, the demand for iron increases due to rapid growth and hormonal changes in the body. At any age or gender the risk of iron deficiency is high if there is chronic bleeding. If iron deficiency anaemia is detected in the elderly, it is important to look for chronic bleeding due to an underlying malignancy in the gastro-intestinal or genito-urinary tracts.

Q.  At what age should they look for symptoms?   

A. Women can develop iron deficiency anaemia particularly in the reproductive age than the post-menopausal age due to physiological bleeding at menstruation and childbirth in addition to reasons common in other age groups. Young girls at menarche are more prone to iron deficiency anaemia due to rapid growth and hormonal changes that increase the demand for iron in addition to monthly blood loss. If a woman at her post-menopausal age presents with significant iron deficiency anaemia, it is worth excluding invisible vaginal or gastro-intestinal bleeding secondary to a gynaecological or gastro-intestinal malignancy.

Q. We are in the midst of the Covid-19 pandemic. Are anaemic patients more vulnerable to this virus?

A. There is no exact association of Covid-19 infection and anaemia, or any complication of the disease causing anaemia directly. The Covid-19 infection is an acute infection that has more thrombotic than bleeding manifestations. There is no direct reason for them to be iron deficient during or following the infection.

Q. Are there different levels of anaemia? What are the health complications of each stage?

A. According to WHO criteria, haemoglobin level of 13 g/dl is accepted as normal for men and 12 g/dl for women. Haemoglobin level down to about 11 g/dl is considered as mild, 10.9 g/dl to 8 g/dl as moderate and less than 8 g/dl as severe anaemia. The severity of the manifestations of anaemia depends on whether anaemia is of acute or chronic onset.

Some patients with chronic iron deficiency anaemia, can present with minimum or no complaints as their circulatory system and the tissues get adapted to low oxygen supply over a period of time. They can go into heart failure with heart muscle hypertrophy and changes in vasculature if not treated promptly. Manifestations such as shortness of breath in walking or climbing stairs, feeling their own heartbeat and most seriously heart failure are common with acute anaemia.  

Q. What about pregnant women? 

A. The accepted normal haemoglobin level is lower in pregnancy due to physiological dilutional effect on haemoglobin. Usually 11 g/dl of haemoglobin is considered as normal in the first trimester, 10.5 g/dl in the second and third trimesters and 10 g/dl in the postpartum period. The commonest anaemia in pregnancy is iron deficiency though folate deficiency is also common. Asymptomatic mild haemoglobinopathy may manifest symptoms in pregnancy due to its dilutional effect of haemoglobin.

Q. Can children be anaemic? How?

A. The demand for iron is high in childhood and infancy due to their fast growth. If the mother is iron deficient in her pregnancy, the infant can be born with inadequate iron stores. Weaning at the correct age in proper order is important as breast milk does not contain iron in required amount and unnecessarily prolonged breastfeeding cause iron deficiency anaemia. Poor diet and gastro-intestinal bleeding due to hook worm infestation with poor sanitary conditions are common in children of the third world. Deficiency anaemia appears often around puberty as their bone growth and hormonal activity demand more micro nutrients and vitamins.

Q. Is poor diet and malnourishment linked to anaemia?

A. Not only poor diet but income and the level of education play major roles in developing anaemia. It is always important to eat a qualitative meal than a large quantity. Red meat, red fish, chicken, liver contain heam iron which is easily absorbable. Dark green vegetables and eggs are also good sources of iron. The absorption of iron is facilitated by citrus fruits such as lime, orange and mandarin rich in vitamin C. Drinking tea or coffee just after meals can reduce iron absorption. Vitamin B12 is rich in meat, fish and dairy products but not available in vegetables. Folate is abundant in yeast, liver, cereals, legumes and green vegetables. It is common to see vitamin B12 and iron deficiencies in long term vegans.

Q. Can one inherit anaemia?

A. Inherited anaemias are mainly haemolytic anaemias such as haemoglobinopathies, red cell membrane disorders and red cell enzyme deficiencies. Iron deficiency anaemia is not an inherited anaemia except a very rare form that does not respond to iron treatment.

Q. Symptoms of anaemia?

A. Symptoms are fatigue, lethargy, shortness of breath on exertion, feeling their own heartbeat. The severity of symptoms depends on the severity of anaemia and co-morbidities. There are specific symptoms identified in iron deficiency anaemia such as appearing white, brittle nails (Kilonychia), abnormal craving of eating substances not normally eaten such as raw rice, chalk, soil, clay, etc. (Picca) at the early stages.

Chronic iron deficiency anaemia present with difficulty in swallowing due to presence of esophageal webs with angular stomatitis and burning sensation of the tongue is called Plummer Vinson syndrome. This is rare but seen exclusively in women. Poor performance in studies can be observed in children due to poor cognitive function and decline of psycho-motor development and neuro developmental impairment in neonates. Iron deficiency in the late pregnancy is associated with premature birth and impaired motor, cognition and language development in the neonate.

Q. Can early detection reduce or prevent anaemia?

A. Depletion of body iron stores takes place prior to manifest symptoms or decline of the haemoglobin level. If iron deficiency is diagnosed on serum ferritin level, iron replacement therapy can be commenced before anaemia develops. Combined ferrus fumerate and folic acid tablets with vitamin C are given as a supplementary measure in schools from Grade 1 to 13 as a blister pack of 24 tablets, to prevent iron deficiency at young age. Iron and folate supplementation is an island wide health approach to prevent iron and folate deficiency in pregnancy. De-wormation of children and pregnant women is also part of the program.

Q. How is anaemia detected?

A. Testing blood for full blood count will show low haemoglobin level indicating anaemia. Red cell indices, red cell count and red cell distribution width are also indicators in the full blood count that are important to differentiate types of anaemia. Serum tests of ferritin level and iron profile are used to confirm iron deficiency. Facilities for testing iron deficiency anaemia are available island wide up to the level of divisional hospitals. These tests are reasonably economical compared to other laboratory investigations.

Q. How is anaemia treated?

A. Acute, severe and symptomatic anaemia may be treated with red blood cell transfusions under the supervision of an authority. Iron deficiency anaemia should be treated with oral iron therapy for recommended duration. Oral iron therapy is the most cost effective and convenient therapy for iron deficiency.

Intra-venous iron therapy can be used for a quick response or for those intolerant of oral tablets. It is equally important to treat the underlying cause of iron deficiency as a protocol of comprehensive management for the expected outcome.

Q. Once treated can an anaemic patient get a recurrence of the disease?

A.  The physical and mental status becomes well and normal if the recommended protocol of iron therapy is completed and the underlying causative factor/s are managed properly. However, impaired motor and cognitive functions of neonates may not be reversible even with proper iron therapy. 

Q. What are your follow up programs on treated patients?    

A. Iron deficiency patients can be followed up and monitored at any public or private hospital. Once the haemoglobin level, serum ferritin level become normal and the causative factor for iron deficiency anaemia is treated, further monitoring is not necessary.

Q. So far we concentrated mostly on anaemic women. What about males?

A. Iron deficiency anaemia in men is less common than women. Acute or chronic gastrointestinal bleeding due to hemorrhoids, gastric ulcerations, esophageal varices and malignancies are causes for iron deficiency in men, also for hospital admissions. Patients with renal failure on haemodialysis can present with coexisting iron deficiency anaemia.

Q. Do you see any shortcomings in delivery of optimal care for anaemic patients?

A. The present health system is well equipped with knowledge, skills and technology for laboratory diagnostic tests, treatment and supportive management of iron deficiency anaemia country wide, although there is inadequate knowledge about iron deficiency and a drive to prevent it.

Q. Your message to our readers to combat anaemia? 

A. At individual level, it is important to improve knowledge about the conditions for nutritional eating habits, sanitary facilities, and identifying risk factors. Public health interventions for prevention and control of iron deficiency anaemia should be based on careful surveillance studies and their recommendations.

Equally important factors are, optimising maternal nutrition, prevention of low birth weight and prematurity, infant feeding, control of parasites, food security and socioeconomic status.