1

ANAEMIA

Anaemia (meaning lack of blood) is a decrease in number of red blood cells

(RBCs) or less than the normal quantity of haemoglobin in the blood. However,
it can include decreased oxygen-binding ability of each haemoglobin molecule
due to deformity or lack in numerical development as in some other types of
haemoglobin deficiency.

Because haemoglobin (found inside RBCs) normally carries oxygen from the
lungs to the tissues, anaemia leads to hypoxia (lack of oxygen) in organs. Since
all human cells depend on oxygen for survival, varying degrees of anaemia can
have a wide range of clinical consequences.
 2

Anaemia is the most common disorder of the blood. The several kinds of
anaemia are produced by a variety of underlying causes. It can be classified in a
variety of ways, based on the morphology of RBCs, underlying etiologic
mechanisms.
 3

The three main classes include

1. excessive blood loss (acutely such as a haemorrhage or chronically

through low-volume loss),

2. excessive blood cell destruction (haemolysis)

3. deficient red blood cell production (ineffective haematopoiesis).

CLASSIFICATIONS OF ANEAMIAS
 4

CAUSES OF ANEAMIAS

Broadly, causes of anaemia may be classified as –

• Impaired red blood cell (RBC) production,

• Increased RBC destruction (hemolytic anaemia),
• Blood loss and fluid overload (hypervolemia).
• Dietary inadequacy (iron deficiency anaemia)
 5

1. Impaired production

a) Disturbance of proliferation and differentiation of stem cells

• Pure red cell aplasia (PRCA) or erythroblastopenia refers to a type of

anaemia affecting the precursors to red blood cells but not to white blood
cells. In PRCA, the bone marrow ceases to produce red blood cells.
• Aplastic anaemia affects all kinds of blood cells.
• Anaemia of renal failure by insufficient erythropoietin production
• Anaemia of endocrine disorders

b) Disturbance of proliferation and maturation of erythroblasts

• Pernicious anaemia is a form of megaloblastic anaemia due to vitamin B12

deficiency dependent on impaired absorption of vitamin B12. Lack of
dietary B12 causes non-pernicious megaloblastic anaemia
• Anaemia of folic acid deficiency, as with vitamin B12, causes
Megaloblastic anaemia
 6

•
• Anaemia of prematurity, by diminished erythropoietin response to
declining hematocrit levels, combined with blood loss from laboratory
testing, generally occurs in premature infants at two to six weeks of age.
• Iron deficiency anaemia, resulting in deficient heme synthesis
• Thalassemias, causing deficient globin synthesis
• Congenital dys-erythropoietic anaemia, causing ineffective erythropoiesis
 7

2. Increased destruction

a) Intrinsic (intra corpuscular) abnormalities cause premature

destruction

• Hereditary spherocytosis is a hereditary defect that results in defects in the

RBC cell membrane, causing the erythrocytes to be destroyed by the
spleen.

• Enzyme deficiencies
1) Pyruvate kinase and hexokinase deficiencies, causing defective
glycolysis
2) Glucose-6-phosphate dehydrogenase deficiency and glutathione
synthetase deficiency, causing increased oxidative stress
• Hemoglobinopathies causing unstable hemoglobins
• Sickle cell anaemia
• Paroxysmal nocturnal hemoglobinuria (Paroxysmal nocturnal hemoglobinuria is an
acquired disorder that leads to the premature death and impaired production of blood cells.)

b) Extrinsic (extra corpuscular) abnormalities

• Antibody-mediated

1) Warm autoimmune hemolytic anaemia is caused by autoimmune attack

against red blood cells, primarily by IgG. It is the most common of the
autoimmune hemolytic diseases. It can be idiopathic, that is, without any
known cause, drug-associated or secondary to another disease such as
 8

systemic lupus erythematosus, or a malignancy, such as chronic

lymphocytic leukemia.

2) Rh disease, one of the causes of hemolytic disease of the newborn

3) Transfusion reaction to blood transfusions

• Mechanical trauma to red cells

1) Micro angiopathic hemolytic anaemia, including thrombotic

thrombocytopenic purpura and disseminated intravascular coagulation
2) Infections, including malaria
3) Heart surgery

4) Blood loss
• Anaemia of prematurity from frequent blood sampling for laboratory
testing, combined with insufficient RBC production
• Trauma or surgery, causing acute blood loss
• Gastrointestinal tract lesions, causing a rather chronic blood loss
• Gynaecologic disturbances, also generally causing chronic blood loss
• From menstruation, mostly among young women

5) Fluid overload

Fluid overload (hypervolemia) causes decrease haemoglobin concentration

and apparent anaemia:

General causes of hypervolemia include-

 9

• excessive sodium or fluid intake

• Sodium or water retention
• Fluid shift into the intravascular space.
• Anaemia of pregnancy is induced by blood volume expansion experienced
in pregnancy.

6) A wide assortment of bone marrow diseases can cause anaemia

• cancers of the bone marrow (such as leukemia or multiple myeloma) can

cause the bone marrow to inadequately produce red blood cells, resulting in
anaemia.
• Certain chemotherapy for cancers can also cause damage to the bone
marrow and decrease red blood cell production, resulting in anaemia.
• Certain infections may involve the bone marrow and result in bone
marrow impairment and anaemia.
• Patients with kidney failure may lack the hormone necessary to stimulate
normal red blood cell production by the bone marrow.
• Chronic alcohol consumption may lead to anaemia via different pathways
and thus, anaemia is commonly seen in alcoholics.

7) ANEAMIA DUE TO DIETARY INADEQUACY

IRON DEFICIENCY ANAEMIA

Iron-deficiency anaemia is a common anaemia (low red blood cell level) caused
by insufficient dietary intake and absorption of iron, and iron loss from
 10

intestinal bleeding, parasitic infection, menstruation, etc. Red blood cells

contain iron and are not formed when iron is deficient. Anaemia is one result of
advanced-stage iron deficiency. When the body has sufficient iron to meet its
needs (functional iron), the remainder is stored for later use in all cells, but
mostly in the bone marrow, liver, and spleen. These stores are called ferritin
complexes and are part of the human (and other animals) iron metabolism
systems. Ferritin complexes in humans carry approximately 4500 iron atoms and
form into 24 protein subunits of two different

CAUSES OF IRON DEFICIENCY ANAEMIA

Iron deficiency causes approximately half of all anaemia cases worldwide, and
affects women more often than men. World estimates of iron deficiency
occurrence are somewhat vague, but the true number probably exceeds one
billion persons.

The causes are-

• PARASITIC WORMS: hookworms, whipworms, and roundworms.

Worms cause intestinal bleeding which isn't always noticeable in faeces and
is especially damaging to growing children. Malaria, hookworms and
vitamin A deficiency contribute to anaemia during pregnancy in most
under-developed countries.
• In women over 50 years old the most common cause of iron-deficiency
anaemia is chronic gastrointestinal bleeding from no parasitic causes, such
as gastric ulcers, duodenal ulcers or gastrointestinal cancer.

• Iron deficiency anaemia occur when body's iron stores run low in the
following condition
 11

a) Inadequate intake of iron rich foods

b) Less absorption of dietary iron due to intake of excessive intake of
tannin, phytate & oxalate rich foods that hinder iron absorption
c) Inadequate intake of vitamin-c rich foods like- citrus fruits, which
accelerate iron absorption
d) Low intake of iron during the period of pregnancy & infancy when
iron required is maximum.
• The body may not absorb enough iron in the diet due to:
e) Celiac disease
f) Crohn's disease
g) Gastric bypass surgery
h) Taking too many antacids that contain calcium
• Iron loss can be due to bleeding. Common causes of bleeding are:
i) Heavy, long, or frequent menstrual periods
j) Cancer in the oesophagus, stomach, or colon
k) Oesophageal varices
l) The use of aspirin, ibuprofen, or arthritis medicines for a long time,
which can cause gastrointestinal bleeding
m) Peptic ulcer disease

VITAMIN B-12 DEFICIENCY ANAEMIA

• Vitamin B12 deficiency or hypo cobalaminemia is a low blood level of
vitamin B12. It can cause permanent damage to nervous tissue if left
untreated long enough.
 12

• Vitamin B12 itself was discovered through investigation of pernicious

anaemia, which is an autoimmune disease that destroys parietal cells in the
stomach that secrete intrinsic factor.

• Pernicious anaemia, if left untreated, is usually fatal within three years of

its introduction into the body.

• Once identified, however, the condition can be treated successfully and

with relative ease; although, it cannot be cured and ongoing treatment is
required.

• Intrinsic factor is critical for the normal absorption of B12 in amounts that
occur in foods; and thus, a lack of intrinsic factor, as occurs with pernicious
anaemia, causes a vitamin B12 deficiency.

• Other more subtle types of vitamin B12 deficiency have been elucidated,
including the biochemical effects, over the course of time in significant
numbers.

• This typically causes macrocytic (large blood cell volume) anaemia.

Vitamin B12, along with folate, is involved in making the heme molecule
that is an integral part of haemoglobin.

Causes & Prevalence

• Strict vegetarians are at risk if they do not take adequate vitamin

supplements.
• Long-term alcoholics.
 13

• People who have abnormal structure or function of the stomach or

intestines leading to impaired B12 absorption despite adequate intake.
• Eating a vegetarian diet
• Poor diet in infants
• Poor nutrition during pregnancy

• inadequate absorption during following condition-

a) Chronic alcoholism
b) Crohn's disease, celiac disease, infection with the fish tapeworm, or other
problems that make it difficult for your body to digest foods
c) Surgeries that remove certain parts of your stomach or small intestine, such
as some weight-loss surgeries
d) Taking antacids and other heartburn medicines for a long period of time
e) Selective impaired absorption of vitamin B12 due to intrinsic factor
deficiency. This may be caused by the loss of gastric parietal cells in
chronic atrophic gastritis (in which case, the resulting megaloblastic
anaemia takes the name of "pernicious anaemia"), or may result from wide
surgical resection of stomach (for any reason), or from rare hereditary
causes of impaired synthesis of intrinsic factor.
f) Impaired absorption of vitamin B12 in the setting of a more generalized
malabsorption or maldigestion syndrome. This includes any form of
structural damage or wide surgical resection of the terminal ileum (the
principal site of vitamin B12 absorption).
g) Forms of achlorhydria which is a condition where the production of gastric
acid in the stomach is absent or low (including that artificially induced by
 14

drugs such as proton pump inhibitors) can cause B12 malabsorption from
foods, since acid is needed to split B12 from food proteins and salivary
binding proteins. This process is thought to be the most common cause of
low B12 in the elderly, who often have some degree of achlorhydria
without being formally low in intrinsic factor. This process does not affect
absorption of small amounts of B12 in supplements such as multivitamins,
since it is not bound to proteins, as is the B12 in foods.
h) Surgical removal of the small bowel (for example in Crohn's disease) such
that the patient presents with short bowel syndrome and is unable to absorb
vitamin B12. This can be treated with regular injections of vitamin B12.
i) Coeliac disease may also cause impaired absorption of this vitamin, though
this is due not to loss of intrinsic factor, but rather damage to the small
bowel.
j) The diabetes medication metformin may interfere with B12 dietary
absorption.
k) Some studies have shown that giardiasis, or similar parasitic infections may
be a cause of vitamin B12 deficiency.
l) Nitrous oxide abuse.

FOLIC ACID DFICIENCY ANEAMIA

The most common cause of folic acid deficiency is a low daily intake from foods.
This may be from a lack of fresh green vegetables, legumes and enriched grains,
or from food processing or preparation. Prolonged storage and cooking can cause
a 50% to 95% loss of folate.
 15

• Causes
1) Situational

Some situations that increase the need for folate include:

• certain anaemia
• kidney dialysis
• liver disease
• malabsorption, including celiac disease
• pregnancy and lactation (breastfeeding)
• tobacco smoking
• alcohol consumption

2) Pharmacological

Medications can interfere with folate utilization, including:

• anticonvulsant medications (such as phenytoin, and primidone)

• metformin (sometimes prescribed to control blood sugar in type 2 diabetes)
• methotrexate, an anti-cancer drug also used to control inflammation
associated with Crohn's disease, ulcerative colitis and rheumatoid arthritis.
• sulfasalazine (used to control inflammation associated with Crohn's disease,
ulcerative colitis and rheumatoid arthritis)
• diuretic)
• oral contraceptives

3) Other causes of folic acid deficiency

• Not eating enough foods that contain folic acid.

 16

• the elderly are more susceptible due to a low intake, malnutrition and
existing medical conditions.
• Alcoholics and drug addicts are particularly at risk.,
• it is found in teenagers who eat nothing but junk food.
• In periods of rapid growth the body needs more folic acid – for example, in
childhood and during pregnancy. Folic acid also helps to protect the foetus
against spina bifida (problems with the spinal cord system not developing
completely).
• In some kinds of hereditary anaemia, such as haemolytic anaemia, the body
breaks down red cells very quickly. To compensate for this, the body
produces more blood cells in response and uses up all its stores of folic
acid.
• Chronic dialysis for kidney patients can remove folic acid from the blood.
• Diseases of the small intestine, such as gluten intolerance (coeliac disease)
and Crohn's disease (inflammation of the intestine), can reduce its ability to
absorb folic acid.
• Other nutrient deficiencies: zinc, riboflavin (vitamin B2), niacin (vitamin
B3) and vitamin B12. These may affect folate absorption and metabolism

Treatments OF ANEAMIA

Treatments for anaemia depend on severity and cause.

Iron deficiency from nutritional causes is rare in men and postmenopausal

women. The diagnosis of iron deficiency mandates a search for potential sources
of loss, such as gastrointestinal bleeding from ulcers or colon cancer.
 17

Dietary Iron and Iron Supplements

✓ Iron is a mineral that's necessary for life. Iron plays a key role in the
making of red blood cells, which carry oxygen. There's good evidence that
iron supplements can treat anaemia caused by- pregnancy, heavy
menstrual period, kidney disease and chemotherapy
✓
✓ Iron supplements are commonly recommended for infants and toddlers,
teenage girls, and women who are pregnant or of childbearing age.
✓
✓ Mild to moderate iron-deficiency anaemia is treated by oral iron
supplementation with- ferrous sulphate, ferrous fumarate, or ferrous
gluconate.
✓
✓ Iron supplementation can cause stomach upset and darkening of stool. This
can be alleviated by taking the iron with food.
✓
✓ Vitamin –C aids in iron absorption. So taking iron supplementation with
orange juice or any types of vit-c rich foods can increase iron absorption.
✓
✓ Strict vegetarians may need to take in higher levels of iron.

At high doses, iron is toxic. For adults and children ages 14 and up, the upper
limit -- the highest dose that can be taken safely -- is 45 mg a day. Children under
14 should not take more than 40 mg a day.

The American Academy of Paediatrics suggests that -- starting at 4 months of

age -- breastfed infants should be supplemented with 1 mg/kg per day of oral
 18

iron. This should continue until iron-containing complementary foods, such as

iron-fortified cereals, are introduced in the diet.

Also beginning at 4 months of age, partially breastfed infants (more than half of
their daily feedings as human milk) who are not receiving iron-containing
complementary foods should receive1 mg/kg per day of supplemental iron.

IRON RICH FOODS

The best way to prevent and treat anaemia is to consume iron rich foods. The
treatment of anaemia may also be successful with the usage of iron supplements.
When it comes to iron-rich nutrition, we can recognize two types of iron:

Heme iron: Iron found in haemoglobin in blood, therefore red meat .

Non-heme iron: (iron found in vegetables) is harder to absorb than heme iron
(found in meat) and that is why vegetarians are at a greater risk of developing
iron deficiency anaemia.

• Fortified cereals, grains and pasta

• Beans and lentils
• Pumpkin seeds
• Canned beans

Iron rich foods that are good sources of non-heme iron include:

For most people, a good diet provides enough iron. Natural food sources of iron
include:

• Meat, fish, and poultry

• Vegetables, like spinach, kale, and broccoli
 19

• Dried fruits and nuts(Raisins, Dates, almonds, walnut,

cashew nuts,)
• Beans, lentils, and peas
• Beef, chicken and pork liver
• oysters
• Fish and shrimp
• Turkey, chicken, beef and pork

Iron is also added to many fortified foods, such as cereals and enriched
breads.

Recommended Dietary Allowance (RDA) for iron

Category Recommended Dietary Allowance (RDA)

CHILDREN

7-12 months 11 mg/day

1-3 years 7 mg/day

4-8 years 10 mg/day

9-13 years 8 mg/day

FEMALES

14-18 years 15 mg/day

19-50 years 18 mg/day

 20

51 years and over 8 mg/day

Pregnant 27 mg/day

Under 19 years: 10 mg/day

Breastfeeding 19 years and over: 9 mg/day

MALES

14-18 years 11 mg/day

19 years and up 8 mg/day

ADVERSE EFFECT OF TAKING IRON SUPPLEMENTATION

• Side effects- Normal doses should be taken otherwise, iron supplements

may cause upset stomach, stool changes, and constipation.
• Risks. This supplement should be taken when doctor will advise. That's
especially true if you have a chronic health condition. Women who plan to
become pregnant should also check with a doctor before they start daily
iron supplements.
• Interactions. Iron can interact with many different drugs and supplements.
They include antacids, anti-inflammatory painkillers, antibiotics, calcium,
and others. If you take daily medicine, ask your doctor if it’s safe for you to
take iron supplements.
• Overdose. Iron overdose is a common cause of poisoning in children. It
can be fatal. Signs of an iron overdose include severe vomiting and
diarrhoea, stomach cramps, pale or bluish skin and fingernails, and
weakness. Iron overdose is a common cause of poisoning in children. It can
 21

be fatal. Treat these signs as a medical emergency. Call poison control and
get medical help.

Vitamin supplements given orally (folic acid) or intramuscularly (vitamin B12)

will replace specific deficiencies.

In severe cases of anaemia, or with ongoing blood loss, a blood transfusion may
be necessary.

Blood transfusions

In severe, acute bleeding, transfusions of donated blood are often lifesaving.

Improvements in battlefield casualty survival are attributable, at least in part, to
the recent improvements in blood banking and transfusion
techniques.Transfusion of the stable but anaemic hospitalized patient has been
the subject of numerous clinical trials.

ABSORPTION INHIBITORS

The following foods inhibits iron absorption-

Eggs: A common food source that inhibits iron absorption is eggs. Eggs contain
phosvitin, a protein compound that binds iron molecules together and prevents
the body from absorbing iron from foods. According to the Iron Disorders
Institute, one boiled egg can reduce iron absorption by as much as 28 percent.

Milk: Milk can prevent our body from absorbing an adequate amount of
iron. Milk contains calcium, an essential mineral and the only known
substance to inhibit absorption of both non-heme and heme iron. One cup of
 22

milk contains approximately 300 mg of calcium. Calcium has little or no effect

on iron absorption when less than 50 mg is ingested, but it can inhibit heme iron
and non-heme iron absorption when 300 to 600 mg is consumed on a daily basis.
Large amounts of calcium can also be found in yogurt, cheese, sardines, canned
salmon, tofu, broccoli, almonds, figs, turnip greens and rhubarb.

Tea: Excessive intake of tea can hinder iron absorption.Tea contains oxalates --
oxalic acid compounds that impair the absorption of non-heme iron. Oxalates
can also be found in spinach, kale, beets, nuts, chocolate, wheat bran, rhubarb,
strawberries and herbs such as oregano, basil and parsley.

Cocoa and Coffee: Cocoa and coffee are food sources that can inhibit iron
absorption in the body. These foods sources contain polyphenols or phenolic
compounds, antioxidants that help remove damaging free-floating cells from the
body. According to the Iron Disorders Institute, cocoa can inhibit 90 percent of
iron absorption in the body, while one cup of coffee can prevent iron absorption
by as much as 60 percent. Phenolic acid can also be found in apples, peppermint
and some herbal teas, spices, walnuts, blackberries, raspberries and blueberries. It
is important to note that these foods should not be consumed two hours prior to,
or following, main iron-rich meal.

Walnuts: Walnuts can reduce the amount of iron our body absorbs from iron-
rich foods. Walnuts contain phytates -- compounds found in soy protein and
fibre. Even low levels of phytates have a strong inhibitory effect on our body's
ability to absorb iron from foods. According to the Iron Disorders Institute,
phytates can reduce iron absorption from food by approximately 50 to 65
percent. Phytates can also be found in almonds, sesame, dried beans, lentils,
peas, cereals and whole grains.
 23

IRON ABSORPTION ENHANCER

Eating some types of food may enhance the absorption of iron. These are-

Vitamin C: Foods high in vitamin C (ascorbic acid) enhance the absorption

of both animal sources of iron and non-animal sources of iron in the diet. These
foods include citrus fruits, papaya, Brussels sprouts, cauliflower, kale, bell
peppers and strawberries. Cantaloupe and kiwifruit also provide ample
vitamin C.

Because vitamin C is not stored in the body and because there is little risk of
reaching a toxic level of Vitamin C from eating foods high in this nutrient, those
who wish to enhance their absorption of iron should eat plenty of vitamin C-rich
foods throughout the day.

Vitamin A: Our body needs sufficient oxygen to function correctly.

Haemoglobin, the part of our blood that carries oxygen to our brain and other
parts of your body, may benefit from increased iron levels when you consume
foods rich in vitamin A. In addition, consuming vitamin A in conjunction with
iron may reduce anaemic conditions quicker than consuming iron alone.

Foods high in vitamin A include fish, veal, turkey, lean beef, goose and lamb.
Vitamin A also is available in some fruits and vegetables, such as sweet potatoes,
carrots, broccoli, peas, beets, apricots, peaches and lemons. Oatmeal is another
source of vitamin A.
 24

SOME OTHER MANAGEMENT

➢ Some iron rich foods are not only rich in iron, but they are also rich in
copper which helps enormously with the absorption of iron. These foods
include seafood, liver, green vegetables, dried figs, apricots, etc.

➢ For example: nuts, hazelnuts and almonds are a good source of iron and we
can add curry, rosemary, cinnamon and sesame seeds to our daily diet to
improve iron levels in our body. There are also many vegetables that can be
added to this list of iron-rich foods and they include broccoli, parsley,
Brussels sprouts, swiss chard etc.

➢ minimal consummation of alcohol, coffee, cocoa, aerated drinks and tea,

are the best way to prevent anaemia.

➢ Vitamin B12 is found in foods from animals, such as meat, seafood, milk
products, poultry, and eggs should be taken adequately to prevent vitamin
B-12 deficiency anaemia. It is not in foods from plants unless it has been
added to the food (fortified). Some foods, like cereals, are fortified with
vitamin B12.

8) HEREDITARY ANAEMIAS
 25

• Sickle cell disease,

• thalassemia