All about anaemia and dietary requirements

1. ANAEMIA

2. CONTENTS
• WHAT IS ANAEMIA?
• WHO IS PRONE TO ANAEMIA?
• PREVALENCE OF ANAEMIA
• AETIOLOGY OF ANAEMIA
• SYMPTOMS OF ANAEMIA
• CLASSIFICATION OF ANAEMIA
• COMPLICATIONS OF ANAEMIA
• DIAGNOSIS AND TREATMENT OF ANAEMIA
• DIETARY CONSIDERATION
• PREVENTION AND CONTROL OF ANAEMIA

3. WHAT IS ANAEMIA?
• Anaemia is very common blood disorder in which there is a decrease in the size of
RBC or number of RBC or the amount of haemoglobin in RBC than the normal.
• Severe or long lasting anaemia can cause damage to heart, brain and other organs
in the body. Very severe anaemia may even cause death.
• To produce the red blood cells and haemoglobin the human body needs iron,
vitamin B12, folate along with vitamin C which is required for the absorption of
iron.
• Anemia can also occur when the body does not receive enough of the above
nutrients, though this is not the sole cause for this condition to occur.

5. Normal haemoglobin levels (g/dl)
Category Value
MALES
Age 12-18 years 13.0-16.0
Age >18 years 13.6-17.7
FEMALES
Age 12-18 years 12.0-16.0
Age >18 years 12.1-15.1
Pregnant woman 11.0-14.0
Category Value
CHILDREN
At birth 13.5-24.0
< 1month 10.0-20.0
1-2 months 10.0-18.0
2-6 months 9.5-14.0
6 months -2 years 10.5-13.5
2-6 years 11.5-13.5
6-12 years 11.5-15.5

6. GRADES OF ANAEMIA
GRADE SEVERITY
HAEMOGLOBIN
LEVELS (gm/dl)
Grade 0 Normal
>12 for women
>14 for men
Grade 1 Mild
10 - lower limit to
normal
Grade 2 Moderate 8 – 9.9
Grade 3 Severe 6.5 – 7.9
Grade 4 Life threatening <6.5
Grade 5 Death Death

7. WHO IS PRONE TO ANAEMIA?
Some people are more prone to anaemia than others. They include:
• Premature and low-birth-weight babies.
• Adolescent girls are at higher risk for iron-deficiency anemia because of
blood loss during their monthly periods.
• Pregnant women are at higher risk for the condition because they need
twice as much iron as usual.
• Adults who have internal bleeding, such as intestinal bleeding, can develop
iron-deficiency anemia due to blood loss.
• People who get kidney dialysis treatment may develop iron-deficiency
anemia due to blood loss during dialysis.
• People who have gastric bypass surgery also may develop iron-deficiency
anemia.

8. • A person who has a family history of an inherited anemia, such as sickle
cell anemia, may be at increased risk of the condition.
• People who have a medical history of certain types of illnesses, such as
blood diseases and autoimmune disorders are more prone to anemia.
• People who suffer from alcoholism.
• People who face exposure to toxic chemicals.
• People who use certain medications which can affect red blood cell
production and thus lead to anemia.
• People who are over the age of 65 years.
• People who consume a diet that is consistently low in iron, vitamin B12
and folate increases your risk of anemia.
• People of low-income group who eat poorly.

9. RISK FACTORS

10. PREVALENCE OF ANAEMIA
• India is one of the countries with high prevalence of anaemia in the world.
• Almost 50% of pregnant women in India are anaemic and it is estimated that
anaemia is the underlying cause for 20-40% of maternal deaths in India.
• Nutritional anaemia is a major public health problem in India and is primarily
due to iron deficiency.
• The (NFHS-3) National Family Health Survey-3 data suggest that anaemia is
widely prevalent among all age groups, and is particularly high among the
most vulnerable – nearly 58% among pregnant women, 50% among non-
pregnant non-lactating women, 56% among adolescent girls (15 to 19 years),
30% among adolescent boys and around 80% among children under 3 years of
age.
• 7 out of every 10 children aged 6 to 59 months in India are anaemic – 3% are
severely anaemic, 40% are moderately anaemic and 26% are mildly anaemic.

11. Prevalence of anaemia among different age groups

12. Prevalence of anaemia among adolescent girls (12-19 years)
and young women (20-29 years) in India

13. Prevalence of anaemia among pregnant women

14. AETIOLOGY OF ANAEMIA
a)Increased loss of blood
• Acute blood loss: haemorrhage from trauma or surgery, obstetric haemorrhage
• Chronic blood loss, usually from the gastrointestinal, urinary or reproductive tracts:
parasitic infestation, malignancy, inflammatory disorders, menorrhagia.
b)Decreased production of normal red blood cells
• Nutritional deficiencies: iron, B12, folate, malnutrition, malabsorption
• Viral infections: HIV
• Bone marrow failure: aplastic anaemia, malignant infiltration of bone marrow, leukemia.
• Reduced erythropoietin ( Growth factor responsible for erythropoiesis)production:
chronic renal failure
• Chronic illness
• Poisoning of the bone marrow: e.g. Lead, drugs (e.g. Chloramphenicol)

15. c)Increased destruction of red blood cells (haemolysis)
• Infections: bacterial, viral, parasitic
• Drugs: e.g. Dapsone
• Autoimmune disorders: warm and cold antibody
haemolytic disease
• Inherited disorders: sickle cell disease, thalassaemia, G6PD
deficiency, spherocytosis
• Haemolytic disease of the newborn (HDN)
• Other disorders: disseminated intravascular coagulation,
haemolytic uraemic syndrome, thrombotic
thrombocytopenic purpura.
d)Increased physiological demand for red blood cells and iron
• Pregnancy
• Lactation

16. SYMPTOMS OF ANAEMIA

17. CLASSIFICATION OF ANAEMIA
Classification of Anaemia
Morphological
classification(On the
basis of morphology
of RBC)
Aetiological
classification (On the
basis of cause of
anaemia)
• Normocytic Normochromic
• Microcytic hypochromic
• Macrocytic hypochromic
• Haemorrhagic anaemia
• Haemolytic anaemia
• Nutrition deficiency anaemia
• Aplastic anaemia
• Anaemia of chronic diseases

18. Morphological classification
• Based on size and colour of RBC there are three types of anaemia.
• Size of RBC is determined by Mean Corpuscular Volume (MCV).
• Colour of RBC is determined by Mean Corpuscular Haemoglobin Concentration (MCHC).
• The three types of anaemia based on morphology of RBC are:
a)Normocytic Normochromic Anaemia
b)Microcytic Hypochromic Anaemia
c) Macrocytic Hypochromic Anaemia
Type of Anaemia
Size of RBC
(MCV)
Colour of RBC
(MCHC)
Normocytic Normochromic Normal Normal
Microcytic Hypochromic Small Less
Macrocytic Hypochromic Large Less

21. Aetiological classification
• On the basis of cause, due to which anaemia occurred, it is
classified into 5 types. They are:
a) Haemorrhagic Anaemia
b) Haemolytic Anaemia
c) Nutrition deficiency Anaemia
d) Aplastic Anaemia
e) Anaemia due to chronic diseases

23. a) HAEMORRHAGIC ANAEMIA
• Hemorrhagic anaemia is caused due to loss of blood. It may be
either acute blood loss or chronic blood loss.
• Acute blood loss from internal bleeding (as from a bleeding ulcer)
or external bleeding (as from trauma, excessive menstrual flow)
can cause anaemia in a very short time.
• If there is a massive bleeding from a wound or other lesion, the
body may lose enough blood to cause severe and acute anaemia.
• Severe sudden blood loss anaemia may cause dizziness,
lightheadedness, fatigue, confusion, shortness of breath and loss
of consciousness.

24. Sudden loss of blood
RBC count decreased for 1-3 days
RBC are restored in 3-6 weeks
Acute blood loss
Chronic blood
loss
Body cannot absorb iron enough
to form haemoglobin
Have hypochromic, Microcytic
anaemia

25. b) HAEMOLYTIC ANAEMIA
•In haemolytic anaemia the low RBC is caused by the destruction rather than the underproduction of RBC.
•It occurs when RBC are destroyed faster than the bone marrow can make them.
•There are two types of haemolytic anaemia.They are:
i) Inherited Haemolytic Anaemia/Intrinsic Haemolytic Anaemia
ii) Acquired Haemolytic Anaemia/Extrinsic Haemolytic Anaemia
1. Inherited haemolytic anaemia:
It is caused by a defect in RBC themselves and result when one or more genes that control RBC production
do not function properly. With these conditions, RBC are destroyed earlier than normal. Sickle cell anaemia
and thalassaemia are types of intrinsic haemolytic anaemia.
2. Acquired haemolytic anaemia:
It is caused by factors outside the RBC, such as antibodies from an autoimmune disorder, burns or
medications. In these conditions, RBC are usually healthy when they are produced by the bone marrow, but
later they are destroyed directly in the bloodstream or get prematurely trapped and recycled in the spleen.

26. Haemolytic Anaemia
Inherited Haemolytic
Anaemia/Intrinsic
Haemolytic Anaemia
Acquired Haemolytic
Anaemia/Extrinsic
Haemolytic Anaemia
• Sickle cell anaemia
• Thalassemia
• Immune Haemolytic Anaemia
• Autoimmune Haemolytic Anaemia (AIHA)
• Alloimmune Haemolytic Anaemia
• Drug-induced Haemolytic Anaemia
• Mechanical Haemolytic Anaemia
• Paroxysmal Nocturnal Haemoglobinuria (PNH)
• Malaria, babesiosis and other infectious
anaemias

27. c) NUTRITION-DEFICIENCY ANAEMIA
• Nutrition deficiency anaemia is caused when the body does not absorb
enough of certain nutrients. It can also result from an imbalance diet intake
or certain health conditions or treatments.
• Nutritional deficiencies can lead to low RBC count, low levels of haemoglobin
in RBC cells, or improper functioning of RBC.
• Iron deficiency anaemia is the most common type, but low levels of folate
and vitamin B12 can also cause the condition and a low vitamin C intake can
contribute to it.
• Nutrition-deiciency anaemia is of three types.
1. Iron deficiency anaemia
2. Vitamin deficiency anaemia
3. Protein deficiency anaemia

28. Nutrition-deficiency anaemia
Iron deficiency
anaemia
Protein deficiency
anaemia
Vitamin deficiency
anaemia
Vitamin B12
deficiency
Folic acid
deficiency

29. Causes of Nutritional Anaemia

30. 1. Iron deficiency anaemia
• It is a condition where there are too few RBC in
the body due to shortage of iron.
• Iron deficiency is a consequence of
i) Decreased iron intake (poor diet)
ii) Increased iron loss from the body (blood loss)
iii) Increased iron requirement
iv) Decreased ability to absorb iron by body
i) Diet that lack iron is a leading cause of an iron
deficiency. Foods rich in iron such as eggs and meat
supply the body with much of the iron it needs to
produce haemoglobin. If a person does not eat
enough to maintain the iron supply, an iron
deficiency can develop.

31. ii) Loss of iron from body occur due to blood loss which may occur in a accidental haemorrhage in
chronic diseases such as tuberculosis, ulcers or intestinal disorders, or excessive blood donation
or due to hookworm infestation. Helminths such as hookworm and flukes cause chronic blood
loss and consequently iron loss from the body, resulting in anaemia. A hookworm burden of 40-
160 worms depending on the iron status of the host is associated with iron deficiency anaemia.
iii) During periods of accelerated demand like in infancy (rapidly expanding blood volume),
adolescence (rapid growth and onset of menses in girls) and pregnancy and lactation can result in
anaemia.
iv) Insufficient iron absorption due to poor availability of iron in phytate and fibre rich Indian diet
causes anaemia. Iron absorption also decreases due to the lack of vitamin C in body as vitamin C
plays a role in enhancing iron absorption in intestine. Vitamin C reduces ferric ion to ferrous
state, which is commonly absorbed. This is due to the reducing property of vitamin C. Vitamin C
helps in formation of ferritin (storage form of iron) and mobilization of iron from ferritin.

32. Three stages of iron deficiency
a) First stage is characterized by decreased storage of iron without any other detectable
abnormalities.
b) An intermediate stage of latent iron deficiency, that is, iron stores are exhausted, but
anaemia as not occurred as yet. Its recognition depends upon measurement of serum ferritin
levels. The percentage saturation of transferrin falls from a normal value of 30 per cent to less
than 50 per cent. This stage is the most widely prevalent stage in India.
c) The third stage is that of overt iron deficiency when there is a decrease in the concentration
of circulating hemoglobin due to impaired hemoglobin synthesis.

33. 2. Vitamin deficiency anaemia
• It is a lack of healthy RBC caused when you have lower than normal amounts of certain
vitamins needed to produce RBC.
• Vitamins linked to vitamin deficiency anaemia include Folate, Vitamin B12 or Vitamin C.
• It can occur if you don’t eat enough foods containing folate, Vitamin B12 and Vitamin C
or it can occur if your body has trouble absorbing or processing these vitamins.
• Anaemias caused by a lack of Vitamin B12 or a lack of Folate are two types of
“Megaloblastic Anaemia.”

34. i) Vitamin B12 deficiency
• Pernicious anaemia is a type of B12
deficiency.
• It causes due to vitamin B12
deficiency in some people or due to
malabsorption in some people.
• Malabsorption is due to absence of
Gastric intrinsic factor (GIH) which is
secreted by parietal cells in ileum.
• The red cell count is often less than
2.5 million and a large proportion of
the cells are macrocytic.
• This anaemia occurs chiefly in
middle-aged and elderly persons and
may be a genetic defect.

35. ii) Folic acid (vitamin B9) deficiency
• Folic acid is a B vitamin that helps our body make RBC. So the deficiency
of folate leads to anaemia.
• In tropical countries, most cases of megaloblastic anaemia are due to
folate deficiency associated with malnutrition infection and pregnancy.
• It is common in the age group 20 to 30 years.
• In this anaemia, RBC are larger than normal and there are fewer cells
and oval shaped.
• Folate deficiency is due to poor dietary intake of Folic acid , low
absorption, alcoholism, infestation and infection, intake of certain drugs
and increased requirements.
• Chronic infections and parasitic infestation, oral contraceptives (in some
women) may impair absorption of folic acid.

36. 3. Protein deficiency anaemia
• Decreased dietary intake of protein may
lead to mild to moderate anaemia.
• This type of anaemia is seen in vegans,
vegetarians, elderly and endurance
athletes, anorexia nervosa and people
with diminished intake of protein for any
cause.
• The protein deficiency anaemia is also
called hypoproliferative anaemia.
• It may even develop in people with
chronic liver disease, chronic kidney
disease, and low function thyroid.
• The mechanism involved in protein
deficiency anaemia is simple as shown
in the picture.

37. d) APLASTIC ANAEMIA
• Aplastic anaemia is a rare condition in
which the body stops producing enough
new blood cells.
• It develops as a result of bone marrow
damage.
• Damage may be present at birth or occur
after exposure to radiation,
chemotherapy, toxic chemicals, some
drugs or infection.
• In this anaemia, symptoms may develop
slowly or suddenly. Fatigue, Frequent
infections, rapid heart rate and bleeding
may occur.

38. e) ANAEMIA DUE TO CHRONIC DISEASES
• Certain chronic diseases such as Cancer, HIV or AIDS, Rheumatoid arthritis, Crohn’s
disease and other chronic inflammatory diseases, can interfere with the production
of Red blood cells resulting in chronic anaemia. Kidney failure can also cause
anaemia. This condition is also called Anaemia of inflammation (AI) or Anaemia of
inflammation and chronic disease (ACD).
• It is the second most common type of anaemia after anaemia due to iron
deficiency.

39. COMPLICATIONS OF ANAEMIA
• Impaired cognitive performance at all stages of life.
• Significant reduction of physical work capacity and productivity.
• Increased morbidity from infectious diseases.
• Greater risk of death of pregnant women during the perinatal period.
• Negative foetal outcome intrauterine growth retardation, low birth weight,
prematurity.

40. DIAGNOSIS AND TREATMENT OF ANAEMIA

41. • TREATMENT OF ANEMIA:
1) Treatment of the causative diseases
2) Vitamin and mineral supplements
3) Change in diet
4) Medication
5) Blood transfusion
6) Bone marrow transplant
7) Surgery
8) Antibiotic therapy

42. DIETARY CONSIDERATION
High Calorie + High Protein + High Iron + High Vit B12 + High Vit C + High Folic acid
• Diet taken should meet the above diet principle and the RDA.
• Anaemia can be prevented by taking proper diet. By regular consumption of green
leafy vegetables, cereals such as wheat, ragi, jowar and bajra, pulses, jaggery and
foods of animal origin anaemia can be prevented. Fruits rich in vitamin C help in
the absorption of erythropoietic nutrients.
• Some suggestions for Anaemia:
- Take animal foods that provide iron, protein and high doses of vitamin B12.
- Try to combine cereals, bread and vegetables with milk or egg.
- Finish meals with a fruit rich in vitamin C that increases iron absorption.
- Take dried fruit and nuts between meals to provide iron all day.
- Green vegetables every day: they are the best source of dietary folic acid.

43. • Haeme iron from animal foods is better absorbed than non-haeme iron present in plant sources. Liver is
the best source of iron. Iron is also absorbed well from red meat like beef and lamb.
• Non-haeme iron is present in cereals, millets, pulses and green leafy vegetables. Of the cereal grains,
wheat and millets like bajra and ragi are very good sources of iron. Inclusion of green leafy vegetables
which are rich in iron can meet a fair proportion of Iron needs.
• 1gm of protein per kg body weight should be taken daily.
Foods rich in iron and protein

44. • Foods rich in folic acid like pulses, green leafy vegetables, cluster beans, ladies finger,
gingelly seeds, liver and eggs should be included in the diet.

45. • Vitamin B12 is synthesized by bacteria and is present only in animal foods. Fermented
foods like curd, and liver, fish, eggs, red meat are good source of vitamin B12.

46. • Ascorbic acid occurs widely in plant foods particularly in fresh fruits and vegetables
especially green leafy vegetables. Amla is the richest source of vitamin C. Guava, Orange
and lime are good sources of Vitamin C. Green leafy vegetables like drumstick leaves and
Agathi are good sources of Vitamin C.

47. PREVENTION AND CONTROL OF ANAEMIA
Anaemia can be prevented by dietary improvement, supplementation, fortification and education.
1. DIETARY IMPROVEMENT:
• Proper diet can definitely prevent anaemia. Balanced diet rich in protein, vitamins and minerals should
be consumed. Dietary improvement is done through education to increase the selection of iron rich
foods to improve iron content and bioavailability.
2. SUPPLEMENTATION:
• Under National Nutritional Anaemia Prophylaxis Programme (NNAPP), Iron and Folic acid tablets are
distributed to pregnant women during last trimester and for preschool children, to prevent anaemia.
Expectant and nursing mothers are given 60 mg of elemental iron and 0.5 mg of Folic acid. Children in
the age group 1 to 5 years are given 20 mg of elemental iron and 0.1 mg of Folic acid. The elemental iron
was increased from 60 mg to 100 mg under the National Nutritional Anaemia Control Programme
(NNACP).
• Under Reproductive and Child Health Programme, young children and adolescent girls are given Iron
and Folic acid. Children under the age of 6-24 months (in syrup form) and below 5 years
(Supplementation should be given for 100 days in a year) are given 20 mg elemental iron and 100 ug of
folic acid.

48. • The National Weekly Iron and Folic acid Supplementation (WIFS) programme is a unique initiative to
protect the adolescent population in the age group of 10 to 19 years from iron deficiency anaemia.
Adolscent girls on attaining menarche should consume weekly dosage of 1 IFA tablet containing 100 mg
elemental iron and 500 ug folic acid.

49. 3. FORTIFICATION:
• Fortification of a commonly consumed food item with iron has been considered as one
of the practical approaches for the prevention and control of iron deficiency anaemia.
• Salt is considered as an eminently suitable food for iron fortification in India as it is
consumed in India by all segments of population rich as well as poor. Salt consumption
lies within a narrow range of 12 to 20 grams per day with an average intake of 15 grams
per day per person. Salt is fortified with ferrous sulphate and one gets 1 milligram of
iron per gram of fortified salt.
• Foods like wheat flour, rice, sugar, milk, fish sauce and curry powder have been
successfully fortified with iron. Fortified wheat (12mg iron and 300ug/200ug folic acid)
is now available in the market.
• Fortified rice and Ultra rice Improves iron stores, reduces the morbidities among school
children participating in the mid-day meal programme which can be considered as a
strategy to prevent iron deficiency anaemia among children.

50. Salt fortified with iron and iodine
Wheat flour fortified with iron,
folic acid and vitamin B12
Rice fortified with iron,folate, zinc
and vitamins A, B1, B3, B6, B12.

51. 4. EDUCATION:
Nutrition education related to iron and anaemia should be given to the community. All Medical, Health
and Social workers, Horticulture department and Voluntary organisations have roles to play in promoting the
consumption of iron rich foods. Following points need to be considered for promotion of the strategy:
• Promotion of consumption of pulses, green leafy vegetables, and other vegetables (which are rich in Iron
and Folic acid) and meat products rich in bioavailable iron, particularly by pregnant and lactating mothers.
• Creation of awareness in mothers attending antenatal clinics, immunization sessions, anganwadi centres
and creches about the prevalence of anaemia, ill effects of anaemia and its preventable nature.
• Regular consumption of foods rich in vitamin C such as oranges, guava, amla etc., need to be encouraged
to promote iron absorption.
• Addition of iron-rich foods to the weaning foods of infants.
• Promotion of home gardening to increase the availability of common iron rich foods such as green leafy
vegetables.
• Periodical administration of antihelminthic drugs to control parasitic worms. Malariashould be controlled.
• Discouraging the consumption of foods and beverages like tea and tamarind that inhibit iron absorption
especially by the vulnerable groups like pregnant women and children.
• Encouraging the use of iron pans and consumption of foods like rice flakes and fortified salt.

52. THANK YOU
Presented by
- P. CHATURYA
- B. ANJANA DEVI