WHE2008
Anemia (When Iron Deficiency is the Cause)
By: Dr. ABDULLAH T. AL-MOHAMADI
DEMONESTRATOR
King Abdulaziz University Hospital
Jeddah, K. S. A.
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Today’s Agenda
● 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
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
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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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
Table 1
1988-1994
Sex/Age group (yrs)
No.
1999-2000
%
(95%CI+)
No.
%
(95% CI)
Both sexes
1-2
3-5
6-11
1,339
2,334
2,813
9
3
2
(6 - 11)
(2 - 4)
(1 - 3)
319
363
882
7
5
4
(3-11)
(2 - 7)
(1 – 7)
Males
12-15
16-69
> 70
691
6,635
1,437
1
1
4
(0.1 - 2)
(0.6 - 1)
( 2 - 3)
547
2,084
381
5
2
3
(2-8)
(1-3)
(2-7)
Females**
12-49
12-15
16-19
20-49
5,982
786
700
4,495
11
9
11
11
(10-12)
(6-12)
(7-14)
(10-13)
1,950
535
466
949
12
9
16
12
(10-14)
(5 - 12)
(10-22)
(10-16)
1,827
2,021
1.845
2,034
1,630
8
15
19
5
7
(7-9)
(13-17)
(17-21)
(4-7)
(5-8)
573
498
709
611
394
10
19
22
9
6
White, non-Hispanic
Black, non-Hispanic
Mexican American
50-69
>70
(7 - 13)
(14-24)
(17-27)
(5 - 12)
(4 - 9)
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World Health Organization (WHO)
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
2001.
Managers. Geneva.
Table -2- Updated Regional and Global Prevalence
(%) and Numbers Affected by Anemia(2001)
Population affected by anemia
Region
Populations
(millions)*
Number
% Prevalence
(millions)
Africa
535
244
46
Americas
751
141
19
Eastern
Mediterranean
408
184
45
European
860
84
10
South East Asia
1364
779
57
Western Pacific
1574
598
38
Total
5491
2030
37
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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.
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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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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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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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.
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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Fig (2)
Heme
Hemoglobin
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Fig (2) Normal Iron Cycle
Utilization
Duodenum
(average, 1 - 2 mg
per day)
Dietary iron
Utilization
Plasma
(TIBC)
transferrin
(3 mg)
Muscle
(myoglobin)
(300 mg)
Circulating
erythrocytes
(hemoglobin)
(1,800 mg)
Storage
iron
(Ferritin)
Liver
(1,000 mg)
Sloughed mucosal cells
Desquamation/Menstruation
Other blood loss
(average, 1 - 2 mg per day)
Iron loss
Bone
marrow
(300 mg)
Reticuloendothelial
macrophages
(600 mg)
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Causes of Iron Deficiency Anemia
 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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Daily iron losses and requirements (mg)
Daily Loss
Requirement
for Growth
Total Loss
(=Requirement)
Urine, skin,
Faeces, etc. menses
Infant (0-4 months)
(5-12months)
Child
Adolescent male
Adolescent female
Menstruating female
Adult male
Post menopausal female
0.5
0.5
0.5
0.9
0.9
0.9
0.9
0.9
1.0
1.9
0.5
0.5
0.9
0.5
0.5
1.0
1.0
1.8
2.4
2.8
0.9
0.9
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Causes of iron deficiency anemia: cont
 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
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.
● 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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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.
●
*
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.
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
Physical State (bioavailability)
heme>Fe2+>Fe3+
High Gastric pH
hemiastrectomy, vagotomy, pernicious
anemia
Histamine H2 receptor blockers, calciumbased antacids
Disruption of Intestinal Structure
Crohn’s disease, celiac disease (non-tropical
sprue)
Inhibitors
Phylates, tannins, soil clay, laundry starch,
iron overload
Competitors
cobalt, lead, strontium
Facilitators
ascorbate, citrate, amino acids, iron
deficiency
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● 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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■ 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. Al—Quaiz-Iron deficiency anemia, A Study of risk factors Saudi Med J. 2001
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Symptoms
■
■
Seldom appear before Hb <10g/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.
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
■
■
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.
■
■
■
■
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
● 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
very vague
■
symptoms such as fatigue and tiredness may be attributed
to overwork or disregarded completely.
● Complete blood count~Hb 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.
Fig (1) Iron Deficiency Anemia
Anemia
Normal blood
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Diagnosis of Iron Deficiency: cont.
● 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.

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
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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● 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
(1) Health infrastructure.
(2) Economy.
(3) Access to iron fortification.
(4) Food education.
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Treatment of Iron Deficiency
(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 children’s reach.
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Treatment of Iron Deficiency: cont.
Types of inorganic iron:
(1) Ferrous sulphate
(2) Ferrous gluconate
(3) Ferrous fumarate
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Treatment of Iron Deficiency: cont.
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.
Side effects  related to amount of iron
epigastric pain and nausea
diarrhea, constipation
rarely skin eruptions
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Parentral Therapy
- unnecessary
lack of compliance because of side effects
malabsorbtion
late pregnancy
when hemorrhage is likely to continue
Parentral Therapy:cont
Intravenous preparation , Iron dextran (Imferon)
Intramascular preparation , Iron sorbitol
(jectofer)
Sodium ferric gluconate (ferrlecit) sucrose (venofer)
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Parentral Therapy: cont.
Side effects
(1) systemic anaphylaxix (0.6-0.7%)
(2) local inflammation, phlebitis
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Poor Response to Therapy
(●) Non compliance
(●) On-going blood loss, infection or occult
malignancy.
(●) Incorrect diagnosis ~thalassemia trait.
Anemia of chronic disorder.
(●) Other nutritional deficiencies~B12 and or
folate.
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Recommendations: I
■ Educational programs to improve public awareness of
this problem and it’s 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
■
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
● 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.