Download Prevalence of Anemia

M 272
HLS Module
Hemato-Lymph System
Community Medicine
1

Anemia is ignored in most developing countries even though it is
one of the most prevalent public health problems and has
serious consequences for national development.
What is Anemia?

A state of tissue hypo-oxygenation, attributed to
lower levels of healthy RBCs or Hb.
3
Anemia Etiology : Outline
Impaired Erythropoiesis (Production):
* nutritional inadequacies and deficiencies ( > 95 % of ALL cases)
* bone marrow injury, whether idiopathic (e.g., inheritance) or acquired.
Blood loss:
* acute haemorrhage (placental, cord, visceral, wound etc)
* chronic haemorrhage (hookworm, amoebiasis, GI disease)
Shortend Life Span of RBCs : (destruction)
* intra-corpuscular cause: e.g., familial spherocytosis , hemoglobinopathies
* extracorpuscular cause:
 infection / inflamation: e.g., malaria, sepsis (e.g., AIDS)
 drug susceptibility : due G6PD.
4
The -INACG-
8 Major Causes in Developing Communities
5
All Anemias @ Community Level
Developing
vs
World
Developed
World
Prevalence of Anemia
(100 % of Cases)
Nutritional
Non-nutritional
6
Nutritional Anemia
A Basic Concept
Total amount of a body micronutrient =
circulating + reserve (store or pool)
In “–ve” balance, reserve is mobilized to circulation
Stages of development of deficiency anemia :
1.
normal status ► store depletion ► deficiency state
2.
deficiency state ► anemia (mild ►moderate ► advanced)
7
IDA (Iron Deficiency Anemia)
The Most Common Nutritional Anemia
8



Iron deficiency causes at least 50% of all anemia, and almost a million
deaths a year; three-quarters of the deaths occur in Africa and South-East
Asia.
Iron deficiency anemia (IDA) is in the "top ten" risk factors contributing
to the global burden of disease.
Worldwide, $50 billion is lost annually in low-Estimates of Economic
Losses from Iron Deficiency Anemia (Cognitive & Productive)


Iron is present in greatest concentration in meat and dark green
vegetables.
The U.S. Recommended Daily Allowance for adults is 10 mg for
males, 18 mg for menstruating females. The average daily
American diet contains about 10 mg iron, of which only about 1
mg is absorbed.
IDA @ Community Level
Developing
vs
Iron deficiency
Developed
Iron deficiency
IDA
IDA
Anemia
Anemia
11
IDA : Diagnosis

Morphologically, it is
 microcytic , and
 hypochromic

Hb level &
 serum ferritin (Normal blood levels are
30-300 ng/mL for males and 15-200
ng/mL for females.
12
ID
(Iron Deficiency)
Etiology ?
Inadequate absorption



low intake,
poor bioavailability,
Malabsorption
Increased requirements,
–
due to high loss (e.g., disease or bleeding)
13
ID
(Iron Deficiency) - continued
Iron Sources:
 animal origin
(mainly heme forms)
 plant origin
(organic salts)
14
Iron Deficiency, ID : Selected Outcomes
Microcytic, hypochromic anemia
Lack of energy (easy fatigue)
Decreased mental performance
Decreased immunity
15
Iron Bioavailability : Determinants
Individual’s iron status
(deficient individuals show higher absorbability)
Nature of foods in diet
(absorption from plant foods = 1 % ; from animal foods = 20 %).
% of food from animal sources
(absorption from balanced diet is about 10 %) .
Fe Oxidation state
(only Fe+2 is absorbed)
Enhancers
(reducing agents : ascorbate, reducing sugars, gastric acidity)
Depressors
(high dietary fiber, PO4, phytates, calicium)
Note: Iron from milk and egg has Low Bioavailability (% reaches
the circulation)
16
Iron : Determinants of Requirements
-
RBC iron recycles ( 90- 95 %)
Requirements = obligatory loss + growth need+other losses.
Obligatory loss :



-
feces, skin, and urine
Variability : (5-10% )
for man and woman ≈ 1mg/day.
Average menstruation loss ≈ 0.5 mg/d).
In some cases menstruation loss may mount upto 2 mg/d
Total maternity requirement (loss) averages 3 mg/d
17
Iron Requirement in Infancy
-
Growth requirement: 0.5 mg per kg gain;
Loss is negligible in infancy
Predisposition to IDA: depends on
1. Birth endowment
(depends on prematurity + maternal nutrition)
-
2. Infant’s growth rate
Prolonged excessive milk feeding  milk Anemia
18
Reference Man's
Maximum Body Content of Iron*
Hemoglobin
Store
In tissues
 myoglobin
 enzymes
Transported (in blood)
2000 mg
1000 mg
130 mg
8 mg
3 mg
* Values for a reference woman are generally lower
19
Vulnerability to IDA
increased significantly during:



age period 6-24 months;
pregnancy & lactation, &
girls-late adolescence .
serum ferritin drops rapidly starting from mid
pregnancy below 12 ng/ml; at 28 gestation weeks,
median ferritin averages 6 ng/ml. (Normal value=15200 ng/ml)
20
Iron Deficiency, ID
 First, iron stores start dropping down, as assessed only
by biochemical tests
 If dropping down reached a significantly low and
critical level, then the reduction in Hb concentration
starts to be apparent
 ID is NOT detectable by Hb / Hct tests alone
21
IDA : the Hematological Tests and Indices
Morphologic
RBC
Hb,
Examination
count
Hemoglobin ,
PCV,
Hematocrit,
MCV,
Mean Corpuscular Volume
MCHC,
Mean Corpuscular Hemoglobin Concentration
23
Anemia, Hb and Ferritin





Low Hb means Anemia.
Low Hb is not necessarily an IDA.
Low Hb assesses only non specific anemia .
Hb alone does not assess for iron deficiency, ID.
Both low serum ferritin and Hb may diagnose IDA.
24
Folate Deficiency anemia


anemia is a decrease in red blood cells (anemia) due to a lack of
folate.
The red cells are abnormally large (megaloblastic anemia).
25
Causes of this anemia are:
a. Certain medications (e.g. phenytoin)
b. Diseases such as celiac disease (sprue), which reduce absorption of folic
acid from the diet
c. Poor dietary intake of folic acid (FA is available in green leafy vegetables,
citrus fruits, beans, whole grains, and liver)
Because folate is not stored in the body in large amounts, a continual dietary
supply of this vitamin is needed to maintain normal levels.

26

Folate deficiency in a pregnant mother can lead to problems for the
infant during the first four weeks of formation of the neural tube
and this can lead to problems in higher mental function later in life.
27




Prevention
Good dietary intake of folate (better steamed food than normal cook)
for the at risk population groups, and folic acid supplementation during
pregnancy may help prevent this anemia.
Prevention of neural tube defect can be fairly easily corrected by
supplementation with a folic acid supplement.
The annual number and prevalence of NTDs (i.e., spina bifida and
anencephaly) in Puerto Rico declined significantly (p<0.05) from 93
(14.7 per 10,000 live births) in 1996 to 27 (5.3 per 10,000) in 2003
28





The folic acid campaign in Puerto Rico continues. Campaign staff
members attend health fairs throughout the year; and each
October on Folic Acid Awareness Day, they distribute educational
materials to students at 30 university campuses.
In 2006, promotional activities were extended to all public primary
and secondary schools.
During National Birth Defects Prevention Month in January,
articles are placed in newspapers, television interviews are
conducted, and partner organizations help to disseminate
educational materials.
The campaign has developed educational materials on birth defects
prevention for health professionals and teachers.

However, despite these measures, only approximately one
fourth of women of childbearing age in Puerto Rico consume a
vitamin containing folic acid daily, suggesting that other factors
might affect behavior.





Treatment
The goal is to identify and treat the cause of the folate deficiency.
Folic acid supplements may be given orally or intravenous on a
short-term basis until the anemia has been corrected.
In the case of poor absorption by the intestine -- replacement
therapy may be lifelong.
Dietary treatment consists of increasing the intake of green, leafy
vegetables and citrus fruits.
31
B12 deficiency anemia

1.
The etiology of B12 deficiency is more complicated than that of
folate deficiency. One can develop deficiency through either of
the following mechanisms
Dietary deficiency
B12 is only found in animal products, but it is plentiful.
Therefore, nutritional deficiency is seen almost exclusively in
vegans.
Unlike the situation with folate, B12 body reserves can last for
years.
2.
Malabsorption states
By far, this is the most common mechanism of disease development.
The absorption of B12 is much more complicated than that of folate and
iron. B12 is absorbed only in the terminal ileum.
3.
4.
Intrinsic factor not produced
Infestation with the fish tapeworm, Diphyllobothrium latum,
Other Nutrients in Erythropoiesis
1.
Retinol : It has a special implication with IDA.
2.
Tocopherol (E): maintains integrity of RBC’S membrane; supplementation
prevents haemolytic anaemia in infants fed PUFA-rich formulas.
(polyunsaturated fatty acids).
3.
Riboflavin (B2) : its coenzyme helps in :
- synthesis of glutathione (GSH), needed for maintenance of cell stability
- activation and release of Fe from ferritin.
4.
Ascorbic acid: it protects the active form of folic acid , & assists in iron transfer
from transferrin to ferritin
34
Other Nutrients in Erythropoiesis
4.
Pyridoxine (B6) : works at the initiation level of heme synthesis.
5.
Copper : it is bound to ceruloplasmin; it serves in transfer of Fe++ from ferritin
to transferrin ; copper deficiency impairs iron absorption, and increases iron
accumulation in storage tissues.
6.
Zinc,
6.
Other B-vitamins.
35
Retinol Correlates with Erythropoiesis
Modern Research: serum retinol strongly correlates with
-
blood Hb, &
-
serum ferritin.
Literature: Vitamin A Deficiency, VAD, can cause IDA.
Jordan :
VAD is a common finding in some poor areas
36
VAD - IDA - Interaction
In VAD - Affected Populations
Anemia may not respond to iron supplements
unless linked with Vit A supplementation.
VAD suppresses child growth and immunity.
In illness conditions, VA supplementation
promotes recovery rather than prevention.
During illness the body utilizes vitA to combat infection, so that WHO guidelines call for
replacement in cases of infection (diarrhea, ARI) in children under one year.
37
Jordan Map
Most Underpriviliged Areas
shown in pink
38
Grounds for Deficiencies in Community
1.
2.
3.
Deficient maternal education
Lack of physicians’ awareness
Poverty
39
Nutritional Anemia Prevalence in Jordan 1996
1


year old infants : more than 60 % (in rural areas)
In other children : 20 % affected (in poor areas)
In pregnants : 27 % affected
40
Anemia in U5y-Children, 2002
(6-59 months)
34% are anemic:
mild
moderate
severe
*
21 %
13 %
0.2 %
2002 Jordan Population and Family Health Survey> Department of Statistics, ORC Macro
41
JPFHS 2002 - Conclusion
Anemia in Jordanian children is…
 higher in rural (40%) compared to urban (32%).
 lower in first birth order (29%) compared with
any higher birth order (35%).
* 2002 Jordan Population and Family Health Survey> Department of Statistics, ORC Macro, 2002
42
Prevalence of Vitamin A Deficiency (VAD)
Jordanian U5y- Children
VAD Prevalence = 15.2 %
VAD is a Public Health Problem in Jordan
43
Findings on Vitamin A Intake





VAD is caused by :
i) inadequate intake , and/or
ii) infection (causes depletion of body – Vit A stores).
Retinol from traditional Vitamin A /sources as the orange and
yellow or red fleshed vegetables and fruits shown less bio-available
than previously thought.
It is very difficult / almost impossible for young children to meet
needs through consumption of vegetables alone .
Fortified foods are designed for the general population, but
These do not meet the needs of infants and young children.
44
Breast Feeding Prevents IDA
Breast
milk, not only provides adequate iron but also vitamin A.
Breast milk is the only reliable source of vit A for the U2y child.
Vitamin A levels in breast milk is related to maternal stores
In VAD areas breast milk may be unreliable.
Supplementation for women after delivery guarantees the supply
for sucklers for the first 6 months.
It is important to continue BF for 2 years as U2y cannot
consume enough vegetable sources to meet Vit A needs.

IVACG, WHO
45
Intervention
1.
Supplementation
2.
Fortification
3.
Programming (other apropriate tactics)
46
What is Food Fortification ?
Fortification of food is deployment of
biological weapons of mass protection
47
Fortification in Jordan
 Modified Wheat Flour Fortification Program
has been going on since March 2006.
 The fortificants are 9 micronutrients
48
Prevalence of Anemia in Children*
Age-months
6 to 9
10 or 11
12 to 23
24-35
36-47
48-59
Sex
Male
Female
Anemia
23
24
0.4
22
0.6
8
0.2
6
51%
22%
14
18%
13
23
14
13
29
31%
20
11
0
0.2
43
65%
21
0
0.1
47%
18
Mild
Moderate
Severe
37%
31%
* 2002 Jordan Population
and Family Health Survey> Department of Statistics, ORC Macro, 2002
0.3
49
Anemia & VAD (1)



Children aged 24-59 months with VAD are often anemic, stunted,
and occasionally wasted.
To address severe VAD in these children, vitamin A capsule
distribution is the most practical immediate response.
If the magnitude and pervasiveness of VAD among preschool-aged
children is considerable, there is a likelihood that this problem
extends to older children and adults; then, a comprehensive, longterm program is indicated.
CDC-Morbidity and Mortality Weekly Report .Vitamin A Deficiency Among Children -Federated States of Micronesia,
2000. MMWR Morb Mortal Wkly RepJune 22, 2001/ 50(24);509-512
50
Anemia & VAD (2)


The adequacy of observed intakes for vitamin A is
compromised by the low lipid content of many complementary
food of young children.
This indicates that dietary quality rather than quantity is the
key aspect of complementary food diets that needs to be
improved.
Lutter CK, Rivera JA.Nutritional status of infants and young children and characteristics of their
diets. J Nutr. 2003 Sep; 133(9):2941S-9S.
51
Anemia & VAD (3)

Women with low serum vitamin A levels had 1.8 times
greater risk of being anemic than did the women with
normal vitamin A status.
Ahmed F, Mahmuda I, Sattar A, Akhtaruzzaman M. Anaemia and vitamin A deficiency in poor urban
pregnant women of Bangladesh. Asia Pac J Clin Nutr. 2003;12(4):460-6..
52
Anemia & VAD (4)

Vitamin A fortification of foods had a favorable effect on iron
metabolism and nutritional status.
Mejia LA, Arroyave G.The effect of vitamin A fortification of sugar on iron metabolism in preschool
children in Guatemala. Am J Clin Nutr. 1982 Jul;36(1):87-93.
53
Anemia & VAD (6)

Anemia prevention programs among young children
should focus on feasible strategies to improve intakes
of bioavailable Fe and vitamin A, and reduce infection.
Osorio MM, Lira PI, Ashworth A. Factors associated with Hb concentration in children
aged 6-59 months in the State of Pernambuco, Brazil. Br J Nutr. 2004 Feb;91(2):307-15
54
Anemia & VAD (7)
 The
importance of iron deficiency anemia (IDA) is adequately
recognized; yet, it is far from being under control.
 Literature reviews continue to report that direct combat against
IDA has attained only partial success [1]
 This may be explained by the roles of other factors, such as VAD.
 VAD, through different mechanisms [1-3], can adversely affect
the utilization of available-iron and consequently the process of
blood formation.
1.
2.
3.
Underwood BA. Perspectives from micronutrient malnutrition elimination/ eradication
programes. Bull World Health Organ 1998;76 Suppl 2:34Underwood BA and Arthur P. The contribution of vitamin A to public health. FASEB
J 1996 Jul;10(9):1040-8 .
Sommer A, Davidson FR; Annecy Accords. Assessment and control of vitamin A
deficiency: the Annecy Accords. J Nutr 2002 Sep;132(9 Suppl):2845S-2850S
55