Nutritional anemia

Nutritional Anemia- from a public health point of view

1. NUTRITIONAL ANEMIA Dr. Moumita Pal MBBS, DPH, MD Dept. of Community Medicine College of Medicine and Sagar Dutta Hospital 1

2. Iron Group Requirement (mg) / day RDA(mg) Male 0.84 17 Female 1.65 21 Pregnancy 2.80 35 Lactation 1.65 21 Micro element- mineral Adult body contains- 4 gm iron; >2/3 rd i.e. 2.4 gm present in haemoglobin 2

3. Iron- sources Haem -iron: Non vegetarian sources- meat, fish, poultry, liver. Help in absorption of Non haem iron. Milk is poor source but iron in breast milk is well utilized. Non haem iron : vegetarian sources like cereals, green leafy vegetables, pulses, nuts, dry fruits, jaggery . Bioavailability is poor. Decrease absorption - Phytic acid( cereals, fibre ), polyphenols ( in plants), tannins ( tea), phosphates ( milk, eggs), calcium Enhance non haem iron absorption - haem iron, ascorbic acid, low pH ( vit C ). 3

4. Absorption and Loss Mostly from duodenum and upper small intestine in ferrous state according to body need. Absorption from habitual Indian diet is <5% Transported as Plasma Ferritin Stored in liver, spleen, bone marrow and kidney. Lost by-1. hemorrhages- physiological(menstruation, childbirth) Pathological( hookworm, malaria, hemorrhoids, peptic ulcers) 2. Basal loss- through urine, sweat, bile and desquamation of surface cells. 4

5. Functions Formation of haemoglobin and Myoglobin . Constituents of enzymes like cytochromes , catalase , peroxidase , Oxygen transport and cellular respiration. Cellular immune response and functioning of phagocytes. Brain development and function Regulation of body temperature and muscle activity. 5

6. Iron deficiency 6

7. Evaluation of iron status Haemoglobin concentration- Serum iron concentration- 0.80-1.80 mg/L Serum ferritin - < 10mcg/L absence of store. Serum transferrin saturation-30% 7

8. Definition Disease syndrome by malnutrition A condition in which the hemoglobin content of blood is lower than normal as a result of a deficiency of one or more essential nutrients regardless of the cause of such deficiency. (WHO) Most common- IDA ( Microcytic ) Less common- Vit B 12 and Folic acid Deficiency ( Macro/, megaloblastic Anemia) 8

9. WHO CUT OFF CRITERIA OF HB% (IN VENOUS BLOOD) Age/gender group HB ( g/dl) Adult man 13 Adult woman (non pregnant) 12 Adult woman (pregnant) 11 Child above 6 yrs 12 Child below 6 yrs 11 9

10. The problem Statement World wide problem specially for developing countries. More prevalent in women of child baring age, young children, pregnancy, lactation. In India >50% of women, 70% of children are anemic. Adolescent girls- 72.6% anemic ( DLHS) Megaloblastic anemia masked by IDA. 30% in pregnant women 10

11. Causes -IDA Inadequate intake of iron Poor diet Poverty Ignorance Inadequate folate / vit C intake Poor absorption and bioavailability of iron Absorption-5% Poor absorption- Non heame iron Inhibitors- phosphates, phytates, oxalates, fibre , tea(tannin), calcium Excessive loss of iron Normal man (1mg/dl) Menstruation( 2 mg/dl) IUDs Intestinal worms Malaria Repeated pregnancies Increased demand of iron Pregnancy Growth 11

12. Increased risk of Iron deficiency women Growing children and adolescents Pregnancy and lactation Heavy menstruation Chronis bleed- hemorrhoids, peptic ulcers, acute gastritis Iron deficient diet Strict vegetarians Heavy tae coffee drinkers Reduced gastric acid secretion Atrophic gastritis Chronic antacid use Reduced transport due to deficiency of- Vit -A, Vit B6, Copper 12

13. Prevention and control ( Integrated approach) Breastfeeding and appropriate weaning. Dietary modification De-worming Control of infection Supplementation Iron fortification Nutrition education Home gardening Care of pregnant and lactating women. 13

14. Iron fortification By National Institute of Nutrition, Hyderabad Addition of ferric ortho -phosphate or ferrous sulphate with sodium bisulphate to fortify common salt Consumed over 12-18 months-reduced prevalence Advantages- universally consumed by all sections, no special delivery system needed. 14

15. National nutritional anemia prophylaxis program Launched in 1972 Beneficiaries : pregnant and lactating women, children 1-5 years and women acceptors of family planning. Currently operating as a part of RMNCH+A. Target group includes infants(6-12 months), School children 5-10 years and adolescents 10-19 years. 15

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18. New strategies under RMNCH+A 18

19. NATIONAL IRON + INITIATIVE Continuum of care- management of anemia across all life stages. Use of folic acid in planned pregnancies-3 months before and 3 months after conception to prevent Neural tube defect. For 6-60months- ASHA are key person to visit home to provide 1 dose under direct observation and educate mother about importance of IFA. IFA tablets for adolescent is colored blue- IRON KI NILI GOLI to distinguish it from red IFA for pregnant and lactating women. 19

20. The weekly Iron and Folic Acid supplementation (WIFS) Community based intervention address IDA amongst adolescents( boys and girls) for both Urban and Rural areas. Covers adolescent enrolled in class VI-XII of Govt., Govt. aided and Municipal schools. Includes out of school girls too through anganwadis. 20

21. Cont. Key features of WIFS Supervised administration of weekly IFA Screening of target groups for mod and severe anemia and referral to appropriate facility Bi annual de worming IEC for improve diet and prevention of worm infestation. 21

22. Causes of poor out come of the program Poor perception of the problem by population Poor compliance Medicine supply and stock inadequate and poor quality Knowledge of functionaries and beneficiaries poor Evaluation system not implimented 22

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