On Call is a series where I present some interesting cases I saw in the course of my practice. 

Case #1: A Young Woman with Fatigue and Shortness of breath

Mrs. S, is a very pleasant 35 yo young woman. She is married with two young children and is a school teacher by profession. She was referred to the hospital by her doctor for evaluation of new onset shortness of breath and concern of a serious heart condition. 

When I interviewed her she told me the shortness of breath has been now ongoing for about a month and steadily getting worse. In the beginning she noticed she was unusually exhausted when she reached home from school and didn’t find the energy to prepare dinner and play with her kids (something she really loved to do). She also notes headaches, irritability of mood, difficulty concentrating which has been affecting her work as well as dizziness. She is also very concerned that she is losing hair. She denies that she is under much stress and says her family has just returned from a two week holiday. Unfortunately, she couldn’t enjoy herself very much because of how exhausted she felt. 

Her symptoms have progressed to the extent that now she is out of breath when she walks up a short flight of stairs; she also notes a feeling of tightness across her chest. She also feels her heart racing and puffiness in her arms and legs. She is worried she has a serious heart condition especially since her father died of a heart attack in his 60s. 

When I examined her I was struck by the pallor of her skin. I also noticed her tongue was swollen and her nails were thin and brittle and there was definite swelling around her ankles.

Her heart rate was regular but fast– 90-100 beats/minute, she had a normal blood pressure and oxygen level. 

I heard a loud murmur (a sound made by the turbulent flow of blood in or near the heart) over her heart and fine crackles at the base of her lungs. 

I make a presumptive diagnosis of heart failure and order further tests including blood work and a cardiac echocardiogram.

Her blood work confirmed my suspicion of heart failure and at the same time also demonstrated severe anemia (low red blood cell count as well as low hemoglobin levels). Further tests showed very low iron levels. 

Above: Blood smear of iron deficiency anemia (Left) compared to normal blood smear on the right. 

 

Her echocardiogram showed her heart was hyperdynamic i.e. it was working too hard as it could not meet the demands of the body. 

I made the diagnosis of severe iron deficiency anemia leading to heart failure. 

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The above case is an extreme presentation of iron deficiency anemia. It demonstrates how severe untreated iron deficiency anemia can get. 

Therefore, it is essential to recognize this very common condition and treat it in a timely fashion. 

Anemia occurs when there is low level of hemoglobin in your RBCs (Red Blood cells). Hemoglobin is the protein which is responsible for transporting oxygen to the tissues. 

Iron Deficiency Anemia is the most common type of anemia. Iron is required to make hemoglobin. Low iron levels mean low hemoglobin levels means inadequate delivery of oxygen to the body tissues. 

Prevalence: according to Lancet (a leading medical journal) anemia affects roughly a third of the world’s population; half the cases are due to iron deficiency. It is a major and global public health problem that affects maternal and child mortality, physical performance, and referral to health-care professionals. Children aged 0–5 years, women of childbearing age, and pregnant women are particularly at risk.

Global Nutrition report 2017, states that India has the maximum number of women impacted with anemia 51%,  followed by China, Pakistan, and Nigeria.  

Causes: 

• Loss of iron- in women of child bearing age such as during heavy menstruation and during pregnancy. 

 

Also it can occur from bleeding from any cause; especially in the GI (gastrointestinal) tract- an important concern in people over the age of fifty. 

Parasitic infestation of the intestines such as schistosomiasis, hookworm and whipworm. 

• Deficiency of iron in the diet. 
• Poor absorption of iron due to certain intestinal diseases. 
• Chronic kidney disease, chronic heart disease, cancer, inflammatory bowel disease

Symptoms: as described in the above case such as:

• Fatigue (lack of energy, feeling tired all the time)
• Weakness
• Pale skin
• Brittle nails
• Dizziness
• Difficulty breathing
• Rapid heart beat
• Headache
• Cold hands and feet
• Pica: cravings to eat things that are not food such as ice, clay, chalk, dirt, paper

Diagnosis: A CBC (complete blood count) will reveal low hemoglobin and hematocrit (percentage of blood volume made of red blood cells or RBCs) and smaller than normal size and paler RBCs. 

Iron studies will show low iron levels and low ferritin levels (protein which helps with iron storage). Other tests include a TIBC (amount of transferrin that is carrying iron in the blood) and Transferrin saturation. Transferrin is the protein that transports iron in the blood. 

Treatment: Oral iron in the form of iron tablets is usually the first line of therapy and is usually continued for several months. Iron tablets should be taken on an empty stomach for better absorption otherwise they can be taken with meals. Iron tablets can cause constipation and or black stools. 

Important! Iron supplements should always be taken under the supervision of your doctor so the response can be tracked and because excess iron or iron overload can cause liver and heart damage! 

Diet: Iron deficiency can be prevented by consuming a diet high in iron rich food and vitamin C (helps in better absorption of non heme iron). 

Dietary iron recommendations are based on age, sex, race, socioeconomic factors and whether you consume a primarily vegetarian or plant based diet which contains non heme iron which the body does not absorb as well as heme (animal or meat) based iron. 

Our resident nutritionist Palak Nagpal provides a Nutrition plan to prevent iron and treat iron deficiency anemia. Since our case is about a young woman of child bearing age her nutrition plan is focused on young women. Thank you Palak!

 

NUTRITION PLAN:

If you are anemic, you’ll have to make certain dietary changes in your nutrition plan. These changes include an increase in the intake of vitamins and minerals particularly iron, folate (vitamin B9), and cobalamin (vitamin  B12), which promote the production of red blood cells and hemoglobin.

Recommended dietary allowance (RDA) for an adult woman is 18-21mg/day.

In a study the mean reported iron density in Indian diets was found to be less than 25% of the RDA. 

Iron is of two types- Heme and Non-Heme

Heme iron is found in animal sources like eggs, chicken, fish whereas non-heme iron is found in plant sources. Heme iron is easily absorbable but Non-heme iron is not easily absorbed. Let’s understand the ways by which we can make this absorption in the body possible.

• Combine iron-rich foods with Vitamin C: It helps to boost iron absorption.

For example: Beans with tomatoes, almonds with orange/ strawberries, poha (flattened rice) with lemon juice.

• Soak & strain your lentils/legumes/grains before cooking – They contain phytic acid/phytates. These are anti-nutrients, which lock the iron and make it hard for it to get absorbed in the body. Soaking and sprouting both help.

How to soak? Overnight in water- strain and cook in freshwater.

• Avoid coffee and tea with meals: They contain compounds like tannins, caffeine, and polyphenols, that hamper iron absorption from the food.

Factoid! In a study it was found that 1 cup of black tea with a meal reduced iron absorption by 60%

• Avoid calcium and iron-rich meals together: as both of them compete to get absorbed in the body and in this process calcium always wins. Thus, calcium doesn’t let the iron get absorbed.

Did you know? Palak Paneer is a bad idea 🙁 Spinach contains iron and paneer contains calcium. 

• Avoid Antacids (unless prescribed by your doctor): It reduces stomach acid, which is important to digest food and absorb iron.

 

• Use cast iron cookware- Iron seeps into wet dishes which are cooked for long like sauces.

Note: For people who have normal iron levels, on consuming too much food made in cast iron cookware can lead to iron intoxication- BE CAREFUL!

• Consume unprocessed foods/minimally processed foods: as they contain more iron than processed foods.

 

SOURCES:

1. Green Leafy Vegetables: spinach, celery, green peas, cauliflower greens, garden cress, mint leaves, parsley

#PROtip: Spinach –lightly steam- as uncooked spinach is high in oxalates which block absorption of iron in our body

#PROtip: Beetroot – cooked or raw? BEST WAY is to juice it and add lemon (lemon in rich in Vitamin C which helps to enhance absorption of iron in the body). This juice is a blood purifier as well.

1. Fruit- pomegranate, sitaphal (sugar apple), pineapple
2. Lemon – lemon water is rich in vitamin C – you can drink it 30 mins before your meal.
3. Copper vessel water- copper helps to increase iron and hemoglobin levels in the body but limit the consumption to 2 glasses/day
4. Black sesame seeds & mustard seeds
5. Dates and raisins- are a great source of iron but remember moderation is the key.
6. Turmeric powder with yogurt- increases iron level & it’s absorption. It’s an ayurvedic practice.
7. Nuts & seeds – almonds, walnuts, pumpkin seeds & pistachios
8. Dark chocolate – good quality 75% + cocoa, contains iron
9. Moringa – Drumstick tree leaves. It’s cheap and inexpensive.

#PROtip: How to use? Add moringa leaf powder in kichadi, curries, have it with a cup of water, in smoothies- it’s packed with iron.

1. Legumes & Lentils- Cow Pea, Bengal gram, moth beans, soya bean, chickpea
2. Whole grains- Amaranth, Bajra (pearl millet).

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I hope the above case presentation and nutrition suggestions have helped you to gain a better understanding of iron deficiency anemia and what you can do to prevent and treat it. Please feel free to share this with friends and loved ones.

Thanks for reading!

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