Anemia

Our blood is a circulating fluid in the body which provides different nutrients to and carries waste material out of the cells. One of the important components of blood is red blood cells (RBCs), which contain a protein called haemoglobin. The haemoglobin carries oxygen to each part of the body, which is essential to carry out important functions. Upon reduction of either red blood cells or haemoglobin level, our body suffers from a lack of oxygen, and hence the functions of the body are also affected. This condition in which there is a decrease in the RBC count or haemoglobin level is called as anaemia. According to the 2006 data by the Indian National Family Health Survey (NFHS), around 55% of females and 29% of males in the age group of 15-49 years suffer from anaemia. It is one of the major health issues in Indian females as most of those who are in the reproductive age are anaemic. Therefore, you should always visit your doctor for regular health check-up including laboratory tests to keep a check on red blood cell count and haemoglobin level. Also, as a preventive measure, you should have a nutritious diet containing iron, vitamin C and zinc among others.

What Is Anaemia?

Anaemia is a condition in which there is a decrease in the oxygen carrying capacity of the blood due to a low red blood cell count or low haemoglobin concentration.

There are various types of anaemia as mentioned below. A few of these are commonly seen in the Indian population. These include:

• Iron deficiency anaemia
  This is the most common type of anaemia and occurs due to a deficiency of iron. As iron is responsible for the production of haemoglobin, a decrease in its level due to poor nutrition can lead to this type of anaemia.
• Megaloblastic anaemia
  It is also a type of nutritional anaemia caused by a deficiency of vitamin B12 and folic acid.
• Gestational anaemia
  Due to physiological changes during pregnancy, there is an increase in volume and dilution of the blood, which leads to anaemia. Also, there is an increased demand for haemoglobin as the foetus grows in the womb of the mother.
• Sickle cell disease
  It is an inherited condition found in children, in which the normal shape of red blood cells is changed and there is a production of pathological haemoglobin. This makes the red cells rigid, and hence they get destroyed while passing through small blood vessels thus causing anaemia.
• Thalassemia
  It is an inherited condition which leads to the production of different types of haemoglobin due to a defect in genes, and hence the normal functional variant of haemoglobin reduces in the body, leading to anaemia.
• Aplastic anaemia
  It is the condition in which the bone marrow of long bones (responsible for the production of new red blood cells) fails to produce the required amount of RBCs, thereby causing anaemia.
• Miscellaneous
  This includes the other types of anaemia such as:
  • Hemorrhagic anaemia
    It occurs due to chronic blood loss caused by worm infestation, piles, and stomach or intestinal ulcers. Anaemia may also occur due to acute blood loss in case of accidents and heavy menstrual bleeding.
  • Anaemia in Chronic Kidney Disease
    Chronic kidney disease in which there is a decrease in the production of a factor called erythropoietin, which is necessary for the production of red blood cells. Hence, there is less number of red blood cells, which leads to anaemia.
  • Unexplained anaemia
    This type of anaemia usually occurs in the elderly. The anaemia is mild with a haemoglobin level not less than 1 g/dL below the normal range. It is known as unexplained anaemia because the condition cannot be attributed to a single cause, and there are multiple factors which are responsible for its development.

Depending upon the haemoglobin concentration denoted in g/dL unit, anaemia can be categorized in three main stages, which are:

In adults

• Mild: Haemoglobin concentration of 11-11.9 g/dL
• Moderate: Haemoglobin concentration of 8-10.9 g/dL
• Severe: Haemoglobin concentration of less than 8 g/dL

In pregnant women

• Mild: Haemoglobin concentration of 9-11 g/dL.
• Moderate: Haemoglobin concentration of 7-9 g/dL.
• Severe: Haemoglobin concentration <7 g/dL.

Treatment option is decided on the basis of the stage of anaemia and overall health of the person.

As mentioned above, in anaemia, the oxygen-carrying capacity of the blood is reduced. Therefore, the symptoms are also related to this change and include:

• Weakness
  A feeling of weakness is the most common symptom of anaemia and can be noticed as tiredness without doing any significantly heavy activity.
• Difficulty in breathing
  One of the most noticeable symptoms of anaemia is having difficulty in taking breaths or taking efforts to catch a breath.
• Uneasy feeling
  Sometimes you may feel a lack of sense of well-being or an unexplained uneasy feeling which may due to anaemia.
• Dizziness
  Dizziness should never be ignored as it can lead to complications like injury due to a fall. This can be due to a reduced oxygen supply to your brain.
• Decrease in performance
  You may not be able to exercise or work or study, which you could easily do before. It may include a persistent lack of concentration or focus in work.
• Headache
  A headache a rare symptom of anaemia with a mild to moderate degree of pain.
• Pica
  Longing to eat or eating things which are generally not edible like chalk, ice and clay, is known as pica. This feeling is mostly associated with anaemia but is rarely seen.

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Some important and common causes of anaemia are listed below:

• An iron deficient diet
  Children are recommended to take iron daily in a dose of 10 mg/day. For males, the recommended dose is 12 mg/day and for females of reproductive age, it is 15 mg/day. It implies that you should include a sufficient quantity of iron-rich food in your diet, otherwise you may suffer from iron-deficiency anaemia. Vegetarian foods in India are mostly not fortified with iron, and hence strict vegetarians are more prone to developing iron deficiency anaemia.
• Vitamin B12 and folate deficiency
  If your diet is lacking foods rich in vitamin B12 such as meat, egg, fish, or if you are purely a vegetarian then you may suffer from this type of anaemia.
• Celiac Disease
  It is an autoimmune disorder, a condition in which your immune system attacks your body instead of protecting it. In celiac disease, the immune system starts attacking the tissues of the small intestine. As a result, there is malabsorption and diarrhoea. Hence, there is a deficiency of nutrients in the body, which can lead to anaemia.
• Low vitamin C intake
  Vitamin C is required for proper absorption of iron from your intestine. Hence, a deficiency of this vitamin can lead to anaemia.
• Worm infection
  Worm infection is more common in children and it leads to blood loss through stool, leading to anaemia.
• Pregnancy and lactation
  There is an increase in the iron requirement during pregnancy and lactation as the blood volume increases due to the dilution of blood. Hence, there is a physiological anaemia that occurs in pregnancy.
• Drugs
  Some drugs used for the treatment of HIV (like zidovudine and nevirapine) and cancer can cause anaemia as a side effect.

Risk factors

There are certain factors, which increase the risk of developing anaemia. They are:

• Strict vegetarian diet
  People eating only vegetarian food are at high risk of developing nutritional anaemia.
• Pregnancy
  In pregnancy, there is an increased demand for iron and thus all pregnant females are at a higher risk of developing anaemia.
• Poor economic condition
  It is found that people who belong to low economic class suffer from this condition due to a lack of nutritious food.
• Alcohol consumption
  People who consume alcohol are at a higher risk because alcohol interferes with the absorption of iron. They may also suffer from peptic ulcers, which on chronic bleeding, cause anaemia.
• Tobacco consumption
  Chewing tobacco can interfere with the metabolism of iron, which may lead to anaemia.
• Having tea with food
  If you consume tea with or after food, it affects the absorption of iron from the diet, and hence increases the risk of developing anaemia.
• Genetic factor
  If your maternal or paternal family member is suffering from a condition like sickle cell anaemia or thalassemia, you may inherit the condition too.

Anaemia of nutritional origin is completely preventable by following some important tips such as:

• Eating beans
  Beans are a good source of iron. Including various types of beans like soybean and French bean in your diet can help prevent iron-deficiency.
• Consumption of meat, fish, chicken, or eggs
  They contain vitamin B12 and folic acid which can prevent megaloblastic anaemia.
• Education and awareness
  Most people are not aware of the fact that nutrition plays an important role to prevent anaemia. Also, in Indian society, females of childbearing age tend to ignore their overall health and do not take an iron-rich diet, and hence suffer from anaemia in the early stage of pregnancy. Increasing awareness of this fact is important to reduce the cases of anaemia.
• Avoiding tea with meals
  As tea affects the absorption of iron when taken with food, avoiding tea will help in proper absorption of iron from the intestine.
• Preventing worm infection
  By taking one tablet of Albendazole annually or half-yearly with proper guidance and check-up by your doctor, worm infection can be prevented.

For diagnosing the exact cause of anaemia, following diagnostic tools are used:

• Complete medical history
  Your doctor will take down a complete medical history including your personal history to rule out anaemia due to poor nutrition, and family history to rule out an inherited cause of anaemia like sickle cell anaemia or thalassemia.
• Clinical examination
  It helps in diagnosing the common type of anaemia by looking for discolouration (pallor) of the eyelids, tongue, nail beds and palms. Also, your feeble pulse can give a clue to the doctor along with an increased heart rate. For further confirmation, your doctor may prescribe diagnostic tests.
• Complete blood count
  It includes an estimation of haemoglobin concentration, red blood cell count, red cell distribution width, packed cell volume, mean corpuscular volume, and mean corpuscular haemoglobin concentration.
• Test for checking iron concentration in blood
  Test such as total iron binding capacity, serum iron, and serum ferritin may be advised to find out the concentration of iron stores in the blood.
• Serum B12
  To rule out the deficiency of vitamin B12.
• Serum Folic acid
  To test for any existing folic acid deficiency.
• Bone marrow examination
  It is done to find out the cause in case of an unexplained anaemia or in suspected cases of aplastic anaemia.
• Stool examination
  To rule out worm infection like hookworm, which can cause blood loss and anaemia.

Treatment of anaemia generally depends upon the underlying cause, grade of anaemia and overall health of the person.

General points for the treatment of anaemia:

• Maintaining proper nutrition by taking iron, vitamin B12 and folic acid supplements under the guidance of your doctor.
• Taking a diet rich in iron like green leafy vegetables, fresh fruits, egg, meat and fish.
• Eating sufficient amount of vitamin-rich foods like citrus fruits including lemons, oranges, mango, and more. Also, vitamin C supplements are available over-the-counter. However, check with your doctor to know the correct dosage as per your age and body weight.
• Albendazole tablet once every six months for deworming children.
• A compulsory iron and folic acid supplementation in adolescent boys and girls and pregnant women irrespective of their anaemia status.

Treatment depending upon grades of anaemia:

• For mild anaemia, your doctor will advise you to take a diet rich in iron and folic acid.
• In case of moderate level of anaemia, your doctor may advise iron and folic acid supplements. It works especially if you are asymptomatic and can tolerate oral iron therapy without any side effects like gastric intolerance, which can cause diarrhoea. In case of oral iron intolerance, your doctor may start with injectable therapy, which generally does not require admission to the hospital, and you can go home after taking the dose and come back again for next one.
• In case of severe anaemia, depending upon your overall health, your doctor may choose to give injectable iron or may advise hospitalization to check for your vitals like pulse, blood pressure, breathing. Also, sometimes artificial oxygen might be required.
• Blood transfusion
  In case of severe anaemia and conditions like sickle cell anaemia and thalassemia, blood transfusion is the treatment of choice.
• Bone marrow transplant
  Bone marrow is the blood cell-producing tissue present in the long bones. In conditions like aplastic anaemia, there is a destruction or malfunction of the bone marrow, and it is not able to produce blood cells. Therefore, bone marrow from a healthy donor may be transplanted to the person by surgery.
• Erythropoietin
  It is a hormone present in the kidneys, which is necessary for the production of blood cells. It can be used for treating anaemia in people with kidney disease who are not able to produce erythropoietin due to kidney damage.
• Splenectomy
  The spleen is a small organ near the stomach, which is important for new red blood cell production along with the destruction of old red blood cells. Red blood cells have a lifespan of 120 days. In people with anaemia, sometimes there is a tendency of excessive breakdown of red blood cells in the spleen. In such cases, surgical removal of the spleen is the treatment of choice (splenectomy).

Treatment of anaemia in pregnancy:

• For mild anaemia with haemoglobin levels of 9-11 g/dL, your doctor may advise you oral iron and folic acid tablets on a daily basis and may ask to repeat laboratory test after a month to check for any improvement.
• For moderate anaemia with haemoglobin levels of 7-9 g/dL, your doctor may first try to find out the cause and then start the treatment by giving oral iron and folic acid tablet. A monthly reassessment is done to check whether the haemoglobin levels have reached between 8-9 g/dL. Your doctor may also start injectable iron supplements to make your haemoglobin levels reach up to 9 g/dL and then again put you on oral supplements.
• For severe anaemia with haemoglobin levels of <7 g/dL, your doctor needs to look for the cause for such low levels and may start injectable iron supplements immediately. The doctor may also hospitalise you for a blood transfusion if the delivery is near or the levels are too low.

Lifestyle management

Anaemia can be managed effectively by making some simple lifestyle changes. These include:

• Avoiding Tobacco use
  Use of tobacco can affect the iron absorption and metabolism, which reduces the level of iron in the body thus causing its deficiency. Hence, avoiding tobacco use can help prevent anaemia.
• Avoiding tea with food
  Tea can impair iron absorption, hence avoiding tea with meals can help to improve the absorption of iron.
• Taking a diet rich in iron
  To maintain adequate iron stores in the body, have a diet rich in green leafy vegetables, fresh fruits, beans, egg, fish and meat.

Prognosis

The outcome of anaemia depends upon the underlying cause and overall health of the person. Mostly prognosis is very good as most of the causes are diagnosable and treatable.

Complications

Anaemia should not be ignored as its complication may be life-threatening:

• Organ damage
  In case severe anaemia is not treated, a lack of oxygen to the organs may lead to organ damage and sometimes the damage may be permanent causing a lifelong disability.
• Hypertension and convulsions in pregnancy
  Pregnant anaemic females have an increased risk of developing pregnancy-induced hypertension (high blood pressure), which further can lead to a pre-convulsion and convulsion (sudden involuntary shaky movements of the body caused due to a disorder in the brain) stage with life-threatening complications.
• Early delivery
  In pregnancy, anaemia can lead to severe complications like premature delivery of the baby.
• Low birth weight
  One more common complication of anaemia in pregnancy is a low birth weight of the baby (less than 2 kg). Sometimes the weight is extremely low (up to 1 kg) due to which the infant survival rate becomes low.