Anemia=When Iron Deficiency is the Cause

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welcome

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Anemia (When Iron Deficiency is the Cause)
WHE2008

• By Dr. ABDULLAH T. AL-MOHAMADI
• DEMONESTRATOR
• King Abdulaziz University Hospital
• Jeddah, K. S. A.

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Todays Agenda
WHE2008

• ? 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
WHE2008

• 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
WHE2008

• 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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WHE2008
Magnitude of the Problem

• 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.

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

WHE2008
Table 1 1988-1994 1999-2000 Sex/Age group (yrs) No. (95CI) No. (95 CI) Table 1 1988-1994 1999-2000 Sex/Age group (yrs) No. (95CI) No. (95 CI) Table 1 1988-1994 1999-2000 Sex/Age group (yrs) No. (95CI) No. (95 CI) Table 1 1988-1994 1999-2000 Sex/Age group (yrs) No. (95CI) No. (95 CI) Table 1 1988-1994 1999-2000 Sex/Age group (yrs) No. (95CI) No. (95 CI) Table 1 1988-1994 1999-2000 Sex/Age group (yrs) No. (95CI) No. (95 CI) Table 1 1988-1994 1999-2000 Sex/Age group (yrs) No. (95CI) No. (95 CI)
(3-11) (2 - 7) (1 7) 7 5 4 319 363 882 (6 - 11) (2 - 4) (1 - 3) 9 3 2 1,339 2,334 2,813 Both sexes 1-2 3-5 6-11
(2-8) (1-3) (2-7) 5 2 3 547 2,084 381 (0.1 - 2) (0.6 - 1) ( 2 - 3) 1 1 4 691 6,635 1,437 Males 12-15 16-69 gt 70
(10-14) (5 - 12) (10-22) (10-16) 12 9 16 12 1,950 535 466 949 (10-12) (6-12) (7-14) (10-13) 11 9 11 11 5,982 786 700 4,495 Females 12-49 12-15 16-19 20-49
(7 - 13) (14-24) (17-27) (5 - 12) (4 - 9) 10 19 22 9 6 573 498 709 611 394 (7-9) (13-17) (17-21) (4-7) (5-8) 8 15 19 5 7 1,827 2,021 1.845 2,034 1,630 White, non-Hispanic Black, non-Hispanic Mexican American 50-69 gt70


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World Health Organization (WHO)
WHE2008

• 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)
Population affected by anemia Number Prevalence (millions) Population affected by anemia Number Prevalence (millions) Populations (millions) Region
46 244 535 Africa
19 141 751 Americas
45 184 408 Eastern Mediterranean
10 84 860 European
57 779 1364 South East Asia
38 598 1574 Western Pacific
37 2030 5491 Total
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WHE2008
Magnitude of the Problem cont.

• 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.
WHE2008

• 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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WHE 2008

• 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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WHE2008

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

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WHE2008
Iron and Functions

• 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 cont.
WHE2008

• 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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WHE2008
Fig (2)


Hemoglobin
Heme
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WHE2008
Fig (2) Normal Iron Cycle
Duodenum
Dietary iron
(average, 1 - 2 mg
Utilization
Utilization
per day)
Plasma
(TIBC)

transferrin
(3 mg)
Bone
Muscle
marrow
(myoglobin)
(300 mg)
Circulating
(300 mg)
erythrocytes
Storage


(hemoglobin)
iron
(Ferritin)
(1,800 mg)
Sloughed mucosal cells
Desquamation/Menstruation
Other blood loss
(average, 1 - 2 mg per day)
Reticuloendothelial
Liver
macrophages
(1,000 mg)
Iron loss
(600 mg)
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Causes of Iron Deficiency Anemia
WHE2008

• 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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WHE2008

• 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

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Causes of iron deficiency anemia cont
WHE2008

• 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
WHE2008

• 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.
WHE2008

• ? 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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WHE2008
Causes of Iron Deficiency Anemia cont

• 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.

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Causes of Iron Deficiency Anemia cont.
WHE2008

• ? 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.
WHE2008

• 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
WHE2008
hemegtFe2gtFe3 Physical State (bioavailability)
hemiastrectomy, vagotomy, pernicious anemia Histamine H2 receptor blockers, calcium-based antacids High Gastric pH
Crohns disease, celiac disease (non-tropical sprue) Disruption of Intestinal Structure
Phylates, tannins, soil clay, laundry starch, iron overload Inhibitors
cobalt, lead, strontium Competitors
ascorbate, citrate, amino acids, iron deficiency Facilitators
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WHE2008

• ? 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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WHE2008

• 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. AlQuaiz-Iron deficiency anemia, A Study of
  risk factors Saudi Med J. 2001

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Symptoms
WHE2008

• Seldom appear before Hb lt10g/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.
WHE2008

• 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
WHE2008

• 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.
WHE2008

• 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
WHE2008

• ? 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
WHE2008

• very vague
• symptoms such as fatigue and tiredness may
  be attributed
• to overwork or disregarded
  completely.
• ? Complete blood countHb 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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Iron Deficiency Anemia
Fig (1)
Anemia
Normal blood
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Diagnosis of Iron Deficiency cont.
WHE2008

• ? 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.
WHE2008

• 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
WHE2008

• 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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WHE2008

• ? 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.

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Several Factors Determine the Feasibility and
Effectiveness of Different Strategies
WHE2008

• (1) Health infrastructure.
• (2) Economy.
• (3) Access to iron fortification.
• (4) Food education.

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Treatment of Iron Deficiency
WHE2008

• (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 childrens reach.

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Treatment of Iron Deficiency cont.
WHE2008

• Types of inorganic iron
• (1) Ferrous sulphate
• (2) Ferrous gluconate
• (3) Ferrous fumarate

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Treatment of Iron Deficiency cont.
WHE2008

• 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.
WHE2008

• Side effects ? related to amount of iron
• epigastric pain and nausea
• diarrhea, constipation
• rarely skin eruptions

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Parentral Therapy
WHE2008

• - unnecessary
• lack of compliance because of side effects
• malabsorbtion
• late pregnancy
• when hemorrhage is likely to continue

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Parentral Therapycont

• Intravenous preparation , Iron dextran (Imferon)
• Intramascular preparation , Iron sorbitol
• (jectofer)
• Sodium ferric gluconate (ferrlecit) sucrose
  (venofer)

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Parentral Therapy cont.
WHE2008

• Side effects
• (1) systemic anaphylaxix (0.6-0.7)
• (2) local inflammation, phlebitis

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Poor Response to Therapy
WHE2008

• (?) Non compliance
• (?) On-going blood loss, infection or occult
• malignancy.
• (?) Incorrect diagnosis thalassemia trait.
• Anemia of chronic disorder.
• (?) Other nutritional deficienciesB12 and or
• folate.

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Recommendations I
WHE2008

• Educational programs to improve public
  awareness of
• this problem and its 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
WHE2008

• 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
WHE2008

• ? Iron deficiency anemia has remained a
  widespread public health problem.
• ? One in five women and about half of all
  pregnant women are iron deficient according
• to 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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THANK YOU