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Dr. Sakshi Sharma
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MD Pharmacology, MBBS
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Iron deficiency anemia

Iron deficiency anemia

Also known as Greensickness and Chlorosis

Overview

Iron deficiency anemia, as the name suggests, is a type of anemia in which there is not enough iron present in the blood. It is the most common cause of anemia worldwide. As iron is needed for the production of hemoglobin, the molecule in your blood that carries oxygen, lack of this mineral is related to decreased oxygen delivery to the entire body. This can lead to symptoms such as pale or yellow skin, shortness of breath, chest pain, rapid heartbeat, unexplained weakness, and brittle nails or hair loss. 

Iron deficiency anemia is very common, especially among women, which include menstruating women, pregnant women and breastfeeding women. It is also quite common in people who have undergone major surgery or physical trauma, people with peptic ulcer disease, vegetarians and not eating a diet rich in iron.

The condition is diagnosed by blood tests that include complete blood tests (CBC), low hemoglobin (Hg) and hematocrit (Hct), low ferritin, low serum iron, and low iron saturation. Iron deficiency can be treated by taking medicinal iron in the form of multivitamins until the deficiency is corrected. 

In severe cases of iron deficiency anemia, red blood cell transfusions may be given that are actively bleeding or have symptoms such as chest pain, shortness of breath, or weakness. Transfusions are only a temporary cure to replace deficient red blood cells and will not completely correct the iron deficiency.

Key Facts

Usually seen in
  • Adults between 20 to 35 years of age
  • Pregnant women
  • Lactating women
Gender affected
  • Both men and women but more common in women
Body part(s) involved
  • Red blood cells
  • Blood
Mimicking Conditions
  • Chronic fatigue syndrome
  • Thrombotic thrombocytopenic purpura
  • Plummer vinson syndrome
  • Lead poisoning
  • Hookworm infestation
  • Thalassemia minor
  • Sideroblastic anemia
  • Anemia of chronic disease
Necessary health tests/imaging
Treatment
Specialists to consult
  • General physician 
  • Hematologist

Symptoms Of Iron Deficiency Anemia 

 

Iron deficiency anemia can range from mild to severe. People with mild or moderate iron-deficiency anemia may not show any signs or symptoms. But, as the anemia generally worsens the condition becomes more severe.

A few symptoms of iron-deficiency anemia are: 

  • Unexplained fatigue or lack of energy 

  • Pale yellow skin 

  • Shortness of breath or chest pain 

  • Rapid heartbeat 

  • Generalized weakness 

  • Brittle nails 

  • Hair loss 

  • Sore or swollen tongue 

  • Tingling or crawling feeling in the legs

  • Dysphagia (difficulty in swallowing) due to formation of esophageal webs (Plummer–Vinson syndrome)

  • Brittle nails

  • Irritability

  • Pica (desire to eat peculiar substances such as dirt or ice)

  • Headache

  • Enlarged spleen

Did you know?
Anemia is the most common nutritional disorder across the world. It is known to affect an estimated 2.36 billion individuals worldwide with a high prevalence in women and children. Read more about symptoms of anemia that you might be ignoring.
Did you know?

Causes Of Iron Deficiency Anemia 


The main causes of iron deficiency anemia include:


Diet low in iron 

Iron is obtained from foods in our diet; however, only 1 mg of iron is absorbed for every 10 to 20 mg of iron ingested. Examples of iron-rich foods include meat, eggs, leafy green vegetables, and iron-fortified foods. If a person is unable to obtain a balanced iron-rich diet, he/she may suffer from some degree of iron-deficiency anemia.


Loss of blood

Blood contains iron within red blood cells. So if a person loses blood, he or she will lose some iron. Iron deficiency is very common, especially among women having heavy periods as blood is lost during menstruation. Slowly, chronic blood loss within the body such as from a peptic ulcer, a hiatus hernia, a colon polyp, or colorectal cancer can also cause iron-deficiency anemia. It can also be due to conditions like hemorrhoids, gastritis (inflammation of the stomach), and cancer.


Inability to absorb iron

Iron from food is absorbed into the bloodstream in the small intestine. An intestinal disorder such as celiac disease, which affects the intestine's ability to absorb nutrients from digested food, can lead to iron-deficiency anemia, if a part of the small intestine has been bypassed or removed surgically. In other cases, children drink more than 16 to 24 ounces a day of cow's milk (the milk contains little iron, but it can also decrease absorption of iron and irritate the intestinal lining causing chronic blood loss). 


Pregnancy 

An increased iron requirement and increased red blood cell production are required when the body is going through changes, during pregnancy iron deficiency anemia occurs in many pregnant women because iron stores need to serve their increased blood volume as well as be a source of hemoglobin for the developing fetus.


Endometriosis

If you have endometriosis, you may have heavy blood loss during menstrual periods. You may not even know you have endometriosis because it occurs hidden in the abdominal or pelvic area outside of the uterus.


Parasitic disease

The leading cause of iron-deficiency anemia worldwide is a parasitic disease known as helminthiasis caused by infestation with parasitic worms (helminths); specifically, hookworms.

Destruction of red blood cells (haemolysis)

Inherited conditions such as sickle cell anemia and thalassemia; stressors such as infections, drugs, snake or spider venom; or certain foods can cause destruction of RBCs. Intravascular hemolysis is a condition in which red blood cells break down in the bloodstream, releasing iron that is then lost in the urine. This sometimes occurs in people who engage in vigorous exercise, particularly jogging. This condition can also be seen in other conditions including damaged heart valves or rare disorders such as thrombotic thrombocytopenic purpura (TTP) or diffuse intravascular hemolysis (DIC).

Gastrointestinal tract abnormalities

Blood loss from the gastrointestinal tract due to gastritis (inflammation of the stomach), esophagitis (inflammation of the esophagus), ulcers in the stomach or bowel, hemorrhoids, angiodysplasia, infections such as diverticulitis, or tumors in the esophagus, stomach, small bowel, or colon. 

 

Increased demand by the body

Chronic kidney disease (CKD) patients receiving I/V erythropoietin therapy have increased iron demand. Similarly, iron demand is increased during rapid growth in infancy and adolescence.

Genetics

Some conditions — like celiac disease — that can make it difficult to absorb enough iron are passed down through families. There are also genetic conditions or mutations that can add to the problem. One of these is the TMRPSS6 mutation. This mutation causes your body to make too much hepcidin. Hepcidin is a hormone that can block your intestine from absorbing iron.

Other genetic conditions such as Von Willebrand disease and hemophilia may contribute to anemia by causing abnormal bleeding.

Anemia is a common health problem in children. Here's more about iron deficiency anemia in children.

Risk Factors For Iron Deficiency Anemia 


Iron deficiency is very common, especially among women and in people who have a diet that is low in iron.

  • Menstruating women, particularly if menstrual periods are heavy

  • People who have undergone major surgery 

  • Vegetarians, vegans, and other people whose diets do not include iron-rich foods

  • Pregnant or breastfeeding women or those who have recently given birth

  • Athletes, especially young females, are at risk for iron deficiency

  • Frequent blood donation

  • Kidney transplant recipients

  • Bariatric surgery (procedure of the digestive system to promote weight-loss in people with severe obesity) patients

Did you know?
According to the National Family Health Survey (NFHS-4) for the years 2015-16, iron deficiency in India is rampant. It was reported that around 55.9% of children in the age group of six months to less than a year are anemic. Most cases of low hemoglobin count can be treated with simple lifestyle changes like eating a healthy and balanced diet and regular exercise. Read about tips to increase hemoglobin count.
Did you know?

Diagnosis Of Iron Deficiency Anemia

 

1. Physical examination and medical history

Iron-deficiency anemia may be suspected from general findings on a complete medical history and physical examination, such as complaints of getting tired easily, abnormal paleness or yellow-colored skin, or a fast heartbeat (tachycardia). Checking the medical and genetic background of the suspected person.

A thorough medical history is important to the diagnosis of iron deficiency anemia. The history can help to differentiate common causes of the condition such as menstruation in women or the presence of blood in the stool. Travel history to areas in which hookworms and whipworms are endemic may also be helpful in guiding certain stool tests for parasites or their eggs.


2. Lab tests

  • Complete blood count (CBC): A CBC test measures many blood-related issues. It measures the red blood cells (RBC) count, white blood cells (WBC), hemoglobin, hematocrit, and platelets. A low RBC count may be a sign of iron deficiency anemia.

  • Hemoglobin count: Iron-deficiency anemia is usually discovered during a medical examination through a blood test that measures the amount of hemoglobin (number of red blood cells) present. 

  • Serum iron (Fe): It is a laboratory test that measures the amount of circulating iron that is bound majorly to transferrin and serum ferritin. The main aim of the iron-serum test is to examine the iron present in the blood. Low levels of serum iron may indicate iron deficiency. 

  • Total iron-binding capacity (TIBC): A TIBC test measures the blood's ability to attach itself to iron and transport it around the body. If TIBC levels are high, it may indicate low iron in the blood due to iron deficiency anemia. 

  • Peripheral smear: Examination of blood smear under a microscope can help detect iron deficiency anemia. While examining, the RBCs may appear smaller and paler than usual.

  • Ferritin test: Ferritin is an iron-containing protein in the blood. Measuring the amount of ferritin in the blood helps in understanding the iron reserve in the blood. Low levels of ferritin in the blood can be indicative of iron deficiency.

  • Red cell protoporphyrin levels: Protoporphyrin is an intermediate in the pathway in the production of hemoglobin. Under conditions in which production of hemoglobin is impaired, protoporphyrin (an organic compound that plays an important role in living organisms as a precursor to heme) accumulates within the red cell. Normal values are <30 µg/dL and in iron deficiency >100 µg/dL.

Hemoglobin electrophoresis and measurement of hemoglobin A 2 and fetal hemoglobin - to rule out thalassemia. 

Sometimes, it is difficult to diagnose the cause of iron deficiency, or your doctor may be concerned that there is a problem other than iron deficiency causing the anemia. In patients such as men, postmenopausal women, or younger women with severe anemia, the doctor may recommend additional testing. These tests may include the following:

  • Upper and lower endoscopy: This test is done to look for abnormalities in the gastrointestinal tract which looks to the stomach, esophagus, and colon. These tests may help rule out a source of blood loss. 

  • Fecal occult blood test (FOBT): This test may be useful in identifying patients with iron deficiency anemia who may have gastrointestinal lesions. Occult gastrointestinal bleeding usually is discovered when fecal occult blood test results are positive. 

  • Urine routine: Urine-containing blood can be due to some internal bleeding and can be a cause of anemia. 

  • Bone marrow aspiration and biopsy: This test is done in very few cases, this test helps diagnose a few types of cancers like leukemia, myeloma, and the diagnosis of anemia. The procedure involves taking a small amount of bone marrow fluid or solid bone marrow tissue (called a core biopsy), to be examined for the number, size, and maturity of blood cells or some abnormal cells.

Here’s more about the hemoglobin test & what the results mean.

 

Celebs affected

Selena Gomez
In 2011, Selena Gomez was taken to the hospital where she was found to be malnourished, exhausted, and had an iron deficiency anemia. She is doing well now.
Angelina Jolie
American actress, filmmaker, and humanitarian. Angelina Jolie became very sick in 2010 when she adopted a Vegan lifestyle. Though green leafy vegetables are known for their iron, they are not enough to provide the nourishment her body needs.

Prevention Of Iron Deficiency Anemia 


When caused by inadequate iron intake and blood loss due to menstruation, iron-deficiency anemia can be prevented by eating a diet high in iron-rich foods. For infants, breast milk or iron-fortified infant formula can be given. Some of the foods rich in iron include:

  • Greens leafy vegetables such as spinach 

  • Non-vegetarian food such as lamb, pork, chicken, and beef

  • Iron-fortified dry and instant cereals

  • Seafood such as clams, sardines, shrimp, and oysters

  • Raisins and other dried fruits

Did you know?
There is a link between iron and Vitamin C. Iron absorption is significantly increased by the presence of Vitamin C, also known as ascorbic acid. Both iron and Vitamin C work together within the body and a major role is played by them in the synthesis of red blood cells. Iron is an important component of hemoglobin, it is found in red blood cells. Read more about Vitamin C rich foods that are easily available and are cost effective.
Did you know?

Specialist To Visit


Sometimes, it is difficult to diagnose the cause of iron deficiency, a general practitioner may be concerned that there is a problem other than iron deficiency causing the anemia. These may include genetic blood disorders including thalassemias in which red blood cells appear small and pale, hemoglobinopathies such as sickle cell disease, and other blood disorders. When the cause of the anemia is not clear, your doctor may refer you to a hematologist, for consultation and further evaluation.

  • General physician

  • Hematologist

Hematologist specializes in blood disorders including iron deficiency anemia and helps in managing your iron deficiency as well as any underlying causes. 

If you or anyone in your family are facing such issues, seek medical help immediately. 

Treatment Of Iron Deficiency Anemia 


Treatment guidelines from the American College of Physicians (ACP) for adult patients with anemia and iron deficiency include the following:

  1. Patients hospitalized with coronary heart disease, with the hemoglobin levels as low as lowered to 7-8 g/dL , red blood cell transfusion strategy is recommended.

  2. Agents that stimulate red cell production are not recommended for patients with mild to moderate anemia and either congestive heart failure or coronary heart disease. 


Specific treatment for iron-deficiency anemia will be determined by your doctor based on the following:

  • Medical history, genetic history, and age

  • Cause of the anemia 

  • Extent of anemia 

The treatments consist of the following:


1. Iron-rich diet

Eating a diet with iron-rich foods can help treat iron-deficiency anemia. Good sources of iron include the following:

  • Meat such as beef, pork, or lamb, and organ meats such as liver

  • Leafy green members of the cabbage family including broccoli, kale, and turnip

  • Iron-enriched pasta, grains, rice, and cereals

  • Legumes including beans, peas, pinto beans, and black-eyed peas

  • Poultry such as chicken, duck, and turkey

2. Iron supplements 

These can be taken over several months to increase iron levels in the blood. The amount of iron needed to treat patients with iron deficiency is higher than the amount found in multivitamin supplements. Most people with iron deficiency need 150-200 mg per day of elemental iron (2 to 5 mg of iron per kilogram of body weight per day).

The purpose of oral iron supplementation is to treat your symptoms by increasing the levels of iron and hemoglobin in the body. Examples include folic acid, methylcobalamin, carbonyl iron, ferrous fumarate, ferrous sulfate, and gluconate. It is recommended by some doctors to take Vitamin C (ascorbic acid) including ferrous ascorbate with folic acid, with iron supplements as it improves iron absorption. 

The oral iron preparations available are ferrous sulfate, ferrous fumarate, ferrous gluconate, and polysaccharide iron. 

Note: You should avoid taking oral iron supplements with milk, tea, coffee, antacids or calcium supplements as these may reduce the absorption of iron.


3. Intravenous iron infusion 

In some cases, the doctor may recommend intravenous (IV) iron. It may be necessary to treat iron deficiency in patients who do not absorb iron well in the gastrointestinal tract. In the case of patients with severe iron deficiency or chronic blood loss, patients can receive supplemental erythropoietin, a hormone that stimulates blood production, or patients who cannot take oral iron supplements. A few examples of IV infusions are iron sucrose, iron dextran, ferric gluconate, low molecular weight iron dextran, and ferric carboxymaltose.

Feraheme (ferumoxytol injection), a hematinic, was initially approved by the FDA in 2009 to treat iron deficiency anemia in adults with chronic kidney diseases (CKD). In 2018, the FDA expanded the indication for ferumoxytol injection to include all eligible adults with iron deficiency anemia who have an intolerance or unsatisfactory response to oral iron.

Ferric derisomaltose (monoferric) was approved by the FDA in January 2020 for iron deficiency anemia in adults who have an intolerance to oral iron or have had an unsatisfactory response to oral iron.

Note: Large doses of iron can be given at one time using iron dextran. Iron sucrose and ferric gluconate require more frequent doses spread over several weeks. 


4. Blood transfusions 

Red blood cell transfusions may be given to patients with severe iron-deficiency anemia who are actively bleeding or have significant symptoms such as chest pain, shortness of breath, or weakness. Red blood cell transfusions will only provide temporary improvement, it is important to find and treat the cause of anemia. 

Watch this video to know more about the symptoms and treatment of iron deficiency anemia.

 

Home-care For Iron Deficiency Anemia 


Home remedies 


1. Drumstick 

Drumsticks are loaded with vitamins A and C, iron, calcium, and magnesium that can help cure anemia. Chop the leaves, blend them, and drink this juice for about a month. 

2. Raisins (kismish) and dates (khajur)

These dried fruits offer a combination of iron and Vitamin C. This enables the body to quickly and effectively absorb the iron from them.

3. Green vegetables 

Green veggies like kale, spinach, radish greens, mustard greens, and broccoli. The vegetables contain high amounts of chlorophyll and are a good source of iron and help in treating anemia. 

4. Vitamin C rich foods 

Anemia tends to weaken your immune system and thus, you may be more prone to infections and inflammatory diseases. Fruits like orange, apple, lime, lemon, grapefruit, tangerine, gooseberries, apple, and berries are loaded with Vitamin C and other essential vitamins and minerals that help in the production of RBCs and hemoglobin. 

5. Figs (anjeer)

Figs are a great source of iron. They are loaded with Vitamin A, folate, and magnesium.

6. Beetroot (Chukandar)
It is one of the healthiest and richest sources of iron. Consuming it regularly can help treat and prevent iron deficiency.

7. Shilajit 

It is an herbal remedy that is useful in gradually increasing iron levels. The use of these herbal remedies for anemia would also ensure proper oxygen supply to all organs and improve their health. 

Iron deficiency negatively affects the growth and development of both the mind and body of a child. Here’s an article highlighting the significance, detection, and prevention of iron deficiency in children. 

Alternate Treatment For Iron Deficiency Anemia 

 


1. Yoga and exercise 

Doing yoga and exercises three times a week can help improve blood circulation and help the body to feel fresh and prevent from feeling fatigued all the time. However, to reduce stress or pressure on the body, exercise when your condition has improved a bit and you feel stronger.


2. Water therapy

Hydrotherapy (that takes advantage of water at different temperatures and pressures) could be an adjuvant treatment for iron deficiency anemia. Specifically, it’s believed that the water could stimulate circulation and, as a result, the production of red blood cells (RBCs).

3. Lifestyle changes 

Changing the lifestyle can help in curing iron deficiency anemia. Cooking in iron pots is a fine remedy to treat anemia and sitting in sun (sunbathing) for some time ensures an increase of red blood cells in the body because of the increase in blood circulation.

Living With Iron Deficiency Anemia 

Self management can help in taking care of yourself. It includes:

  • Understanding your condition: Sometimes, iron deficiency anemia can affect the mental health of a person and it can lead to anxiety and depression. Talking to your near and dear ones can eliminate cases of emotional drainage and thus an effective treatment plan. 

  • Exercising daily: It increases the blood circulation of the body and frees the mind from tension and stress. 

  • Taking your medicine on time: Self helps give a sense of satisfaction to the person that he/she is aware of the condition. 

  • Talking with a doctor openly in case of any questions related to the disease: The person having iron deficiency anemia should ask as many questions that come to his mind. 

  • Lowering the stress levels: Practicing meditation and yoga helps in eliminating stress and keeps the person happy,

  • Getting adequate sleep: Sleep activates and calms the body and mind. This makes the person feel less fatigued.

In this video, Dr. Akta Bajaj clearly mentions about the anemia issues during pregnancy and multiple ways to handle the situation carefully without having side effects in infants.

 

Frequently Asked Questions

References

  1. Stoltzfus RJ. Iron deficiency: global prevalence and consequences. Food Nutr Bull. 2003 Dec;24External Link
  2. Busti F, Campostrini N, Martinelli N, Girelli D. Iron deficiency in the elderly population, revisited in the hepcidin era. Front Pharmacol. 2014 Apr 23External Link
  3. Samal J. Ayurvedic preparations for the management of Iron Deficiency Anemia: A systematic review. Ayu. 2016 Jul-DecExternal Link
  4. Bansal, Deepak. (2016). Iron Deficiency in India. The Indian Journal of Pediatrics. External Link
  5. Warner MJ, Kamran MT. Iron Deficiency Anemia. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 JanExternal Link
  6. Iron Deficiency Anemia. Johns Hopkins Medicine. External Link
  7. Patients. Iron Deficiency Anemia. American Society of Hematology.External Link
  8. Introduction. Iron Deficiency Anemia. National Health Portal. February 2016.External Link
  9. Iron Deficiency Anemia. National heart, lung, and blood institute. External Link
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