Iron Deficiency Anemia

The magnitude of anemia as a public health issue is significant, affecting:

• Global prevalence: Anemia affects approximately 1.62 billion people worldwide, representing 24.8% of the population.
• Vulnerable groups: Women of reproductive age and children are particularly affected, with higher rates in developing countries.
• Consequences: Anemia can lead to fatigue, decreased productivity, and increased morbidity and mortality, especially in vulnerable populations.

Anemia is a condition characterized by not having enough healthy red blood cells or hemoglobin to effectively carry oxygen to the body's tissues. Hemoglobin is a protein in red blood cells that transports oxygen from the lungs to other organs.

Common symptoms of anemia include fatigue and dyspnea on exertion (shortness of breath during physical activity).

Iron deficiency anemia is common in developing countries.

Higher prevalence is observed among toddlers and females of childbearing age.

The prevalence is 2-5% among adult men and post-menopausal women in the developed world.

Approximately 25% of people worldwide have anemia.

Iron deficiency is the most common cause of anemia, responsible for 50% of all anemias.

The prevalence of iron-deficiency anemia in men under 50 in the United States is 1%, while the rate of iron deficiency is higher in developing countries.

In women of childbearing age in the United States, the rate of iron-deficiency anemia is 10% due to losses from menstruation.

9% of children ages 12 to 36 months are iron-deficient, and one-third of these children develop anemia.

Low-income families are particularly at risk for iron-deficiency anemia in the United States, despite the overall low rates.

The estimated prevalence of iron deficiency anemia in Egypt is around 25-30% among the general population.

Iron deficiency anemia has a particularly severe impact on women and children in Egypt.

Previous studies indicate that anemia affects 30-40% (average 35%) of school children in Egypt.

IDA affects 43% of Egyptian infants aged 6 to 24 months from low socioeconomic backgrounds.

The prevalence of IDA among preschool children in Egypt is 39.6%.

The rise in IDA rates occurred alongside changes in food consumption patterns and increases in childhood diarrhea.

The aim of the national flour fortification project is to fortify wheat flour used for subsidised baladi bread with iron and folic acid to reduce the prevalence of anemia and increase the iron and folate status of the Egyptian population.

The objective was to assess iron deficiency anaemia status, and dietary iron and bread consumption among the Egyptian population, including mothers, preschool children, school children, and adolescents.

18.5% of all 12,023 participants surveyed were identified with iron deficiency anaemia (low haemoglobin and low ferritin).

26.2% of participants were classified as having iron deficiency (low iron stores with normal haemoglobin).

Menorrhagia is one of the most frequent causes of iron deficiency anemia in women during reproductive life.

Blood loss, particularly due to menorrhagia, should always be suspected as a cause of iron deficiency anemia in women of reproductive age.

Specific points to query include the presence of menorrhagia and the use of intra-uterine devices (IUCD).

Causes that can increase iron loss include:

1. Colorectal cancer
2. Polyps
3. Diverticular disease
4. Excessive use of certain medications
5. Hookworm infestation
6. Frequent blood donation

The most common cause of iron deficiency anemia in adult men and post-menopausal women is blood loss from the gastrointestinal (GI) tract.

A common cause of referral to a gastroenterologist is blood loss from the gastrointestinal (GI) tract, which is a significant factor in iron deficiency anemia.

High physiological requirements include:

1. Infancy
2. Early childhood
3. Puberty
4. Pregnancy

These stages require increased iron due to growth and development needs.

Most women start pregnancy without sufficient iron stores due to:

• Increased blood volume: Blood in the body expands until it is about 50% or more during pregnancy.
• Increased demand for iron: Particularly in the second and third trimesters, the demand for iron rises significantly.

• 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.

• Vitamin C can increase the absorption of iron.
• Tea, coffee, and cocoa can reduce the absorption of dietary iron, especially when consumed with food.

Vegetarians may be more likely to develop iron deficiency anemia because their diets may lack sufficient sources of iron, which are more readily available in animal products.

Calcium intake can inhibit iron absorption. A study among girls and young women in six European countries found a consistent inverse association between dietary calcium intake and iron stores.

• Hypo- or achlorohydria: Reduced stomach acid can impair iron absorption.
• H. Pylori colonization: Infection can affect the stomach lining and absorption.
• Coeliac disease: An autoimmune disorder that damages the intestine and affects nutrient absorption.
• Gastrectomy: Surgical removal of part or all of the stomach can reduce iron absorption.
• Gut resection and gastric bypass surgeries: These procedures can alter the digestive tract and impair iron uptake.

Low serum ferritin (SF) is diagnostic of iron deficiency as it indicates depleted iron stores in the body.

Iron deficiency after gastric bypass develops due to several factors:

1. Intolerance for red meat - Patients may find it difficult to consume red meat, which is a primary source of iron.
2. Diminished gastric acid secretion - Reduced acid production can impair iron absorption.
3. Exclusion of the duodenum - The duodenum is crucial for iron absorption, and its exclusion from the alimentary tract can lead to deficiencies.

Common symptoms include:

• Tiredness
• Palpitations
• Lack of stamina
• Shortness of breath
• Dizziness
• Headache
• Irritability
• Depression
• Excessive hair loss
• Soreness and burning of the tongue
• Swollen sensation of the tongue
• Vertigo
• Tinnitus
• Tendency to faint
• Anginal pain
• Gastrointestinal discomfort
• Loss of appetite or perversion of appetite (pica)

Pica is a condition where patients consume unusual items such as laundry starch, ice, soil, or clay. It occurs variably in patients with iron deficiency, and while the precise pathophysiology is unknown, the consumption of clay and starch can bind iron in the gastrointestinal tract, exacerbating the deficiency.

• Pallor
• Dryness or roughness of the skin, which may appear more transparent and thinner than normal.
• Koilonychia: Brittle, soft, and flattened or spoon-shaped nails.
• Lips: Often dry and cracked, with an uneven surface.
• Angular cheilitis: Painful, moist cracks at the angles of the mouth occur in about 15%.

Common symptoms include:

1. Glossitis: 50% of patients may experience a smooth, glossy, reddening of the tongue, with possible vesicles or erosions.
2. Hair Changes: Hair may become brittle, splitting at the ends, and show marked thinning.
3. Cold Intolerance: Approximately 20% of patients may develop cold intolerance.
4. Dysphagia: 5-20% of patients with long-standing iron deficiency anemia may develop difficulty swallowing (dysphagia).

Prelatent iron deficiency occurs when iron stores are depleted without any change in hematocrit or serum iron levels. This stage is rarely detected due to the lack of noticeable symptoms or changes in standard blood tests.

Latent iron deficiency is characterized by a drop in serum iron levels and an increase in Total Iron Binding Capacity (TIBC) without a change in hematocrit. It can occasionally be detected through routine checks of transferrin saturation.

Frank iron deficiency anemia is characterized by erythrocyte microcytosis and hypochromia. This stage typically attracts medical attention as it presents more noticeable symptoms and changes in blood tests.

Symptoms such as fatigue and tiredness may be attributed to overwork or disregarded completely.

A complete blood count documents the severity of microcytic hypochromic indices including Hb level, MCV, MCH, MCHC, and red cell distribution width.

The WBC count is usually within the reference range in patients with iron deficiency anemia.

Platelet counts may be normal, but can be increased or reduced in rare cases.

In iron deficiency anemia, red blood cells are typically pale and abnormally shaped. A notable feature is the presence of small red blood cells with a large area of central pallor.

In a normal blood smear, red blood cells have a normal biconcave shape and color, indicating adequate hemoglobin levels, unlike the pale and abnormally shaped cells seen in iron deficiency anemia.

The serum transferrin receptor assay measures iron status at the cellular level, providing insight into the body's iron availability and utilization.

The Serum Transferrin levels are similar in both Normal and Iron Deficient patients, with the light blue bar being very tall in both cases.

The Serum Iron levels are lower in Iron Deficient patients compared to Normal patients, as indicated by the shorter red bar on the Iron Def side.

Total Iron Binding Capacity is significantly lower in Iron Deficient patients, as shown by the dark blue bar being much shorter than that of Normal patients, indicating a reduced capacity to bind iron.

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.

Positive celiac disease serology should be confirmed by small bowel biopsy.

There is accumulating evidence suggesting a strong relationship between iron deficiency and brain development. Specifically, it has been observed that iron deficiency can negatively impact the IQ of school children and is associated with attention deficit disorder.

No, functional defects affecting learning and behavior caused by iron deficiency cannot be reversed by administering iron later on. Early intervention is crucial for preventing these defects.

The WHO strategies include:

1. Food education - Promoting knowledge about nutrition and healthy eating habits.
2. Iron supplementation - Providing iron tablets to specific target groups, such as pregnant women and pre-school children.
3. Iron fortification - Adding iron to certain foods to enhance their nutritional value.

The factors include:

1. Health infrastructure - The availability and quality of healthcare services.
2. Economy - Economic stability and resources available for health initiatives.
3. Access to iron fortification - Availability of iron-fortified foods and supplements.
4. Food education - Knowledge and awareness about nutrition and dietary needs.

1. Blood transfusion should be reserved for patients with or at risk of cardiovascular instability.

2. Food education to promote dietary changes.

3. Treatment of the underlying cause of iron deficiency.

4. Correction of the deficiency through therapy with inorganic iron.

Note: Keep iron supplements highly capped and away from children's reach.

The types of inorganic iron include:

1. Ferrous sulphate
2. Ferrous gluconate
3. Ferrous fumarate

200 mg of ferrous sulphate provides 63 mg of iron.

Simultaneous intake of ascorbic acid enhances iron absorption.

Treatment typically lasts for 3-6 months, taken 2-3 times per day.

Common side effects include:

• Epigastric pain and nausea
• Diarrhea or constipation
• Rarely, skin eruptions

• Lack of compliance due to side effects
• Malabsorption issues
• Late pregnancy complications
• Situations where hemorrhage is likely to continue

1. Intravenous preparation: Iron dextran (Imferon)
2. Intramuscular preparation: Iron sorbitol (jectofer)
3. Other intravenous preparations: Sodium ferric gluconate (Ferrlecit) and sucrose (Venofer)

The side effects of parenteral therapy include:

1. Systemic anaphylaxis (occurs in 0.6-0.7% of cases)
2. Local inflammation and phlebitis

Reasons for poor response to therapy include:

1. Non-compliance with treatment regimens.
2. Ongoing blood loss, infection, or occult malignancy.
3. Incorrect diagnosis, such as thalassemia trait or anemia of chronic disorder.
4. Presence of other nutritional deficiencies, such as B12 and/or folate deficiency.

• Implement educational programs to enhance public understanding of iron deficiency and its causes.
• Emphasize that greater food availability does not guarantee better nutrition and health status.
• Educate physicians to increase awareness of iron deficiency and the necessary testing for diagnosis and underlying causes.
• Conduct screening for iron deficiency in high-risk groups within the community.
• Promote healthy dietary habits.

A preventive dose of iron tablets is recommended for women presenting with heavy periods.

Mothers are encouraged to breastfeed their infants and to include iron-enriched foods in the diet of infants and young children.

Prescription of NSIAD or antacids should be carried out with caution due to potential interactions affecting iron absorption.

Future research is needed to evaluate dietary iron adequacy in the Egyptian diet.

One in five women and about half of all pregnant women are iron deficient.

It is widespread, underdiagnosed, and undertreated, despite being a simple and easily treatable health issue.

They should advocate for a fight against this longstanding public health issue.

B. The blood does not have enough red blood cells

C. Too little iron in the blood

D. Older adults

Anemia affects the body by preventing the blood from delivering enough oxygen to tissues and organs, leading to fatigue and weakness.

A lack of Vitamin B-12 and folic acid results in abnormally large red blood cells, leading to a condition called megaloblastic anemia.

Signs of anemia include:

1. Pale gums
2. Dark circles under the eyes
3. Bleeding
4. Numbness in hands and feet

Iron-deficiency anemia can lead to:

1. More fatigue
2. Increased irritability
3. Aggravation of hyperactivity

The correct answer is D. A and B.

Pica is a rare condition where a person craves eating nonfood items. Individuals with pica might crave:

• Ice
• Soil
• Clay

The correct answer is D. Any of the above.

Anemia can contribute to several complications among older adults, including:

1. More falls
2. High blood pressure
3. Diminished eyesight
4. Diabetes

The correct answer is A. More falls.

Anemia is a condition characterized by a decrease in circulating red blood cells, leading to insufficient oxygen supply to the body. This can result in symptoms such as fatigue and weakness.

The most common cause of anemia worldwide is iron deficiency, which leads to the production of microcytic and hypochromic red blood cells as observed in a peripheral smear.

Treatment for iron deficiency anemia includes:

1. Reversal of the underlying condition
2. Iron supplementation