Anemia (When Iron Deficiency is the Cause)Anemia (When Iron Deficiency is the Cause)

By: Dr. ABDULLAH T. AL-MOHAMADI

DEMONESTRATOR

King Abdulaziz University Hospital

Jeddah, K. S. A.

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Today’s Agenda● Definition of Anemia● Magnitude of the problem and its impact● Prevalence● Functions of iron● Normal iron cycle● Causes of iron deficiency anemia● Factors that modify iron absorption● Symptoms● Signs● Stages of iron deficiency● Diagnosis● Prevention● Treatment● Treatment failure● Recommendations

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Anemia is defined as hemoglobin concentration lower than the established cut off defined by WHO

Anemia is defined as hemoglobin concentration lower than the established cut off defined by WHO

Less than 11g/dl; for pregnant women

and for children 6 months – 5 years of age.

Less than 12g/dl; for non pregnant women.

Less than 13g/dl; for adult males.

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Most Common Nutritional Disorder in the World

Most Common Nutritional Disorder in the World

Has negative effects on work capacity and

physical labor.

Diminishes motor, mental and growth

development in infants and children.

Might cause low birth weight and preterm

delivery or even maternal and fetal death *Haas and Brownlie, 2001*

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It is common in developing countries.

Prevalence was observed in the United

States among certain population such as

toddlers and females of childbearing

age.(●) (Table -1-)

Iron deficiency anemia has a prevalence of

2-5% among adult men and post-menopausal

women in the developed word.*(●) looker et al, Prevalence of iron deficiency in the United States. JAMA, 1997.

(*) WHO.Iron deficiency anemia. Assessment, prevention and control. A Guide for Program Managers Geneva. 2001.

Magnitude of the Problem

Prevalence of Iron Deficiency-United States-National Health and Nutrition

Table 1 1988-1994 1999-2000

Sex/Age group (yrs) No. % (95%CI+) No. % (95% CI)

Both sexes 1-2 3-5 6-11

1,3392,3342,813

932

(6 - 11) (2 - 4)(1 - 3)

319363882

754

(3-11) (2 - 7) (1 – 7)

Males 12-15 16-69 > 70

6916,6351,437

1 1 4

(0.1 - 2)(0.6 - 1) ( 2 - 3)

5472,084381

523

(2-8) (1-3) (2-7)

Females** 12-49 12-15 16-19 20-49

5,982 786 7004,495

11 91111

(10-12)(6-12)(7-14)

(10-13)

1,950535466949

1291612

(10-14) (5 - 12) (10-22) (10-16)

White, non-Hispanic Black, non-Hispanic Mexican American 50-69 >70

1,8272,0211.8452,0341,630

8151957

(7-9)(13-17)(17-21)(4-7)(5-8)

573498709611394

10192296

(7 - 13)(14-24)(17-27)(5 - 12)(4 - 9)

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World Health Organization (WHO)World Health Organization (WHO)

Estimates that most preschool children and pregnant women in developing countries are iron deficient.* (Table 2)

(*) WHO report, Iron deficiency anemia. Assessment, Prevention and Control. A Guide for Program Managers. Geneva. 2001.

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Table -2- Updated Regional and Global Prevalence (%) and Numbers Affected by Anemia(2001)

RegionPopulations

(millions)*

Population affected by anemia

Number

% Prevalence

(millions)

Africa53524446

Americas75114119

Eastern

Mediterranean

40818445

European8608410

South East Asia136477957

Western Pacific157459838

Total5491203037

The prevalence of anemia in developing

countries is three to four times higher than

that for developed countries.

Prevalence of anemia in the Gulf region

ranged from 15-48% in women childbearing

age mostly attributed to iron deficiency(●)

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Magnitude of the Problem: cont.

Magnitude of the Problem: cont.

In Saudi Arabia the overall country prevalence of anemia was 30-56%(●)

Cross sectional study, conducted in Riyadh among school girls showed that IDA prevalence was 40.5% among female adolescents (16-18) years old.*

(●) Verster A, Pols J. Anemia in Mediterranean region “1995”(*) Al-Shehris.Health Profile of Saudi adoloscent Schoolgirls. “1996 “(*) Joharah, M. Al-Quaiz. Iron deficiency anemia. A study of Risk factors. Saudi Med J 2001.

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WHO/UNICEF jointly adopted nutritional goals, aiming to control iron deficiency by the turn of the century.

(●) WHO, UNICEF, INACG. Guidelines for use of iron supplements to prevent and treat iron deficiency anemia, 1998

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Recent report from WHO indicates that the prevalence of anemia has not changed much over the years, (It is a persisting public health problem).

Iron, is one of the most common elements constituting about 5% of the earth crust.

Essential for all living organisms.

It has several vital functions in the body .

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Iron and Functions

Iron and Functions: cont.

Storage and carrier of oxygen to tissue by

red blood cell hemoglobin or to muscles by

myoglobin

Some important enzymes contain iron like

that catalyze the redox reaction required

for the generation of energy eg.

Cytochrome.

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Fig (2)

Heme Hemoglobin

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Fig (2) Normal Iron Cycle

Dietary ironUtilization Utilization

Duodenum(average, 1 - 2 mg

per day)

Muscle(myoglobin)

(300 mg)

Liver(1,000 mg)

Bone marrow(300 mg)Circulating

erythrocytes(hemoglobin)

(1,800 mg)

Reticuloendothelialmacrophages

(600 mg)

Sloughed mucosal cellsDesquamation/Menstruation

Other blood loss(average, 1 - 2 mg per day)

Storageiron

Plasmatransferrin

(3 mg)

Iron loss

(Ferritin)

(TIBC)

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Causes of Iron Deficiency AnemiaCauses of Iron Deficiency Anemia Blood loss

Menorrhagia is one of the most frequent causes of iron deficiency and should always be

suspected as the cause in women during reproductive life.

(*)Query Specific points in the

menstrual history

(*) The use of intra-uterine devices (IUCD).

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Daily iron losses and requirements (mg)

Daily Loss Requirement Total Loss

for Growth (=Requirement)

Urine, skin,

Faeces, etc. menses

Infant (0-4 months) 0.5 0.5

(5-12months) 0.5 0.5 1.0

Child 0.5 0.5 1.0

Adolescent male 0.9 0.9 1.8

Adolescent female 0.9 1.0 0.5 2.4

Menstruating female 0.9 1.9 2.8

Adult male 0.9 0.9

Post menopausal female 0.9 0.9

Causes of iron deficiency anemia: cont Losses can increase with colorectal cancer, polyps,

diverticular disease, excessive use of certain medication, Hook worm infestation and frequent blood donation.

(●) Common cause of referral to gastroenterologist.

(●) Blood loss from the (GI) tract is the commonest

cause of iron deficiency anemia in adult men and

post-menopausal women

Most common cause of Iron Deficiency Anemia, in America and North America

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Causes of Iron Deficiency Anemia : cont

high physiological requirement such as in infancy, early childhood, puberty and Pregnancy: Blood in the body expands until it is about

50% or more

Most women start pregnancy without

sufficient iron store

Increase demand for iron particularly in

the second and third trimesters

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Pregnancy: cont.Pregnancy: cont.

● Higher risk with morning sickness

● Two or more pregnancies close together

● Pregnancy with more than one baby

● Iron poor diet or if prior pregnancy

menstrual flow was heavy.

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■ Diet ● Rarely is the sole cause of iron deficiency.

● Vegetarians are more likely to develop iron deficiency anemia.

● Various food can influence the absorption of dietary iron. Vit. C can increase the absorbtion of iron. Tea, coffee and cocoa drinking especially with food reduce the absorbtion of dietary iron.

Causes of Iron Deficiency Anemia cont

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Causes of Iron Deficiency Anemia: cont.

● Calcium intake can inhibit iron absorption. A cross sectional study among girls and young women in 6 European countries showed that dietary calcium intake had a consistent inverse association with iron store.*

* Van de Vijver LpL et al. Calcium intake is weakly but consistently negatively associated with iron status in girls and women in six Eusropean countries. J Nut 1999.

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Causes of Iron Deficiency Anemia: cont.

Malabsorbtion ■ Hypo-or achlorohydria, H. Pylori

colonisation

■ Coeliac disease

■ Gastrectomy, Gut resection and Gastric

bypass surgeries and others.

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Factors that Modify Iron Absorption Physical State (bioavailability)heme>Fe2+>Fe3+

High Gastric pH

hemiastrectomy, vagotomy, pernicious anemia

Histamine H2 receptor blockers, calcium-based antacids

Disruption of Intestinal StructureCrohn’s disease, celiac disease (non-tropical sprue)

InhibitorsPhylates, tannins, soil clay, laundry starch, iron overload

Competitorscobalt, lead, strontium

Facilitatorsascorbate, citrate, amino acids, iron deficiency

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● Iron deficiency develops after gastric

bypass for several reasons:

(●) Intolerance for red meat

(●) Diminished gastric acid secretion

(●) Exclusion of the duodenum from the

alimentary tract

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■ In a case control study of risk factors for IDA

among Saudi women of childbearing age (87

patients and 203 controls)

● Poor dietary habits

● Menorrhagia

● History of ingestion of NSAID

or antacids were the most important

risk factors.

J M. Al—Quaiz-Iron deficiency anemia, A Study of risk factors Saudi Med J. 2001

Symptoms■ Seldom appear before Hb <10g/dl.■ Tiredness, palpitation, lack of stamina,

shortness of breath, dizziness, headache, irritability, depression and excessive hair loss. ■ soreness and burning of the tongue and a sensation that the tongue feels swollen. ■ Vertigo, tinnitus, tendency to faint, anginal pain, gastrointestinal discomfort, loss of

appetite or perversion of the appetite (pica)

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Cont.

Pica ● Occurs variably in patients with iron deficiency ● Precise pathophysiology of the syndrome is unknown ● Patients consume unusual items eg. laundry starch, ice, soil clay ● Clay and starch can bind iron in the GIT, exacerbating the deficiency.

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Physical Examination

■ Pallor■ Dryness or roughness of the skin, or it may

be more transparent and thinner than normal.■ Brittle, soft and flattened or spoon shaped

koilonychia ■ Lips are often dry and cracked and the

surface may become uneven.■ Painful, moist cracks at the angles of the mouth

occurs in about 15%.

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•

Cont.

■ 50% of patients suffer smooth, glossy,

reddening of the tongue vesicles or erosions

develop.

■ The hair may be brittle, splitting at the ends

with marked thinning.

■ Cold intolerance develops in one fifth of

patients

■ 5 – 20% of patients with long standing iron

deficiency anemia develop dysphagia.

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Stages of Iron Deficiency ● prelatent iron deficiency occurs when stores are depleted without a change in hematocrit or serum iron levels. This stage

of iron deficiency is rarely detected.

● latent iron deficiency occurs when the serum iron drops and the TIBC increases without a change

in the hematocrit. This stage is occasionally detected by a routine

check of the transferrin saturation.

● frank iron deficiency anemia is associated with erythrocyte microcytosis and hypochromia. Iron

deficiency attracts medical attention most commonly at this stage.

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Diagnosis of Iron Deficiency

very vague■ symptoms such as fatigue and tiredness may be attributed

to overwork or disregarded completely. ● Complete blood count~Hb level

* documents severity of microcytic hypochromic indices ( MCV, MCH, MCHC) and red cell distribution width.

● Platelets may be normal. Increased or reduced in rare cases. ● The WBC count is usually within reference range.

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Anemia Normal blood

Iron Deficiency AnemiaFig (1)

Diagnosis of Iron Deficiency: cont. ● Assessment of body iron profile (serum iron, total iron-binding capacity (TIBC) and ferritin) low SF is diagnostic of iron deficiency. ● The serum transferrin receptor assay is a relatively new approach to measuring iron status at the cellular level.

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Cont.

Search for the underlying cause.

Upper and lower GI investigations should be considered in all post-menopausal female and all male patients , unless there is a history of significant overt non-GI blood loss (Grade B evidence).

Celiac disease serology if positive, should be confirmed by small bowel biopsy.

(●) BSG Guidelines in Gastroentrology for the Management of iron deficiency anemia, May 2005.

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Prevention of Iron Deficiency

Evidence are accumulating , strongly suggest a

relationship between iron deficiency and

brain development. IQ of school children and

attention deficit disorder.

Functional defects affecting learning and

behavior cannot be reversed by giving iron

later on.

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● WHO strategies.

(1) Food education.

(2) Iron supplementation ~giving iron

tablets to certain target group such

as pregnant women and pre-school

children.

(3) Iron fortification of certain foods.

Several Factors Determine the Feasibility and Effectiveness of

Different Strategies

(1) Health infrastructure.

(2) Economy.

(3) Access to iron fortification.

(4) Food education.

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Treatment of Iron Deficiency

(1) Blood transfusion should be reserved for

patients with or at risk of cardiovascular

instability.

(2) Food education

(3) Treatment of the underlying cause.

(4) Correction of the deficiency by therapy with

inorganic iron.

Keep iron supplements highly capped and away

from children’s reach.

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Treatment of Iron Deficiency: cont.

Types of inorganic iron:

(1) Ferrous sulphate

(2) Ferrous gluconate

(3) Ferrous fumarate

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Treatment of Iron Deficiency: cont.

200 mg ferrous sulphate – 63 mg iron

300 mg ferrous gluconate or ferrous fumarate - 35 mg iron

Simultaneous intake of ascorbic acid will enhance the iron absorption.

2-3 times /day , 3-6 months to correct the deficit.

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Treatment of Iron Deficiency: cont.

Side effects related to amount of iron

epigastric pain and nausea

diarrhea, constipation

rarely skin eruptions

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Parentral Therapy

- unnecessary

lack of compliance because of side effects

malabsorbtion

late pregnancy

when hemorrhage is likely to continue

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Parentral Therapy:contParentral Therapy:cont

Intravenous preparation , Iron dextran (Imferon)

Intramascular preparation , Iron sorbitol

(jectofer)

Sodium ferric gluconate (ferrlecit) sucrose (venofer)

•

Parentral Therapy: cont.

Side effects

(1) systemic anaphylaxix (0.6-0.7%)

(2) local inflammation, phlebitis

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Poor Response to Therapy(●) Non compliance

(●) On-going blood loss, infection or occult

malignancy.

(●) Incorrect diagnosis ~thalassemia trait. Anemia of chronic disorder.

(●) Other nutritional deficiencies~B12 and or folate.

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Recommendations: I ■ Educational programs to improve public awareness of this problem and it’s causes “greater food availability does not necessarily equal better nutrition and health status”.

■ Physician education is needed to ensure a greater awareness of iron deficiency and the testing needed to establish diagnosis as well as underlying causes.

■ Screening for iron deficiency in high risk groups in our community.

■ Healthy dietary habits

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Recommendations: II

■ Preventive dose of iron tablet for women presenting with heavy period. ■ Encouraging mothers to breast feed their infants and to include iron-enriched food in the diet of infants and young children.

■ Prescription of NSIAD or antiacid should be carried out with causion.

■ Future research is needed to evaluate dietary iron adequacy in Saudi diet.

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Conclusions● Iron deficiency anemia has remained a widespread public

health problem.

● One in five women and about half of all pregnant women are iron deficient accordingto the last Mayo Clinic report.

● Simple and easily treatable health problem under diagnosed ~undertreated problem.

● Primary health care specialist should advocate a fight against an old enemy.

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