Anemia and Malnutrition

Over the last 1 month, we have been facing the brunt of morbidity that anemia can cause in our patients. Today (19th September, 2011), I had to face the havoc it could play in our patient’s lives. We ultimately end up taking uncalled risks in the management of our patients.

Anemia in obstetric patients in this part of the country has always been a constant problem. Over the last 2 weeks, we had 6 bad wound infections after Cesarian section. Overall, our practices of sterile techniques and patient management protocols are quite robust to ward off any possibility of infection.

The constant feature we saw in each of the 6 wound infections was a pattern of low hemoglobin associated with a history of having been handled elsewhere. It is quite easy to find excuses and shift the blame to something else. Of course, I’ve already started a process of reviewing our processes and ensured that fumigations are done at the necessary places as well as tested the autoclaving processes.

In addition to the low hemoglobin, we’ve discovered something else too. And that is the low serum protein levels in such patients. Of course, before I come to a conclusion, we need to compare it with the other patients who do not develop wound infections.

Nevertheless, I just wanted to put in this post something which I’ve been thinking for quite a long time. I suspect that most of our patients are chronically malnourished. When I look at my anemic patients, many of them have told me of having taken their iron tablets. But, when I ask their dietary practices, I get very terrible replies. For most of them, their basic diet is rice with a little dal which becomes more watery as you become poorer.

Basically, none of these people have much of any protein in their diets. Well, if you know medical biochemistry, iron transport occurs in our body through protein substances called ferritin and transferrin. When people have such a protein deficient diet, how can you expect their bodies to make transferring and ferritin which are very much essential in the absorption, transfer and storage of iron?

One more facet of anemia which has been quite known to quite a number of clinicians but quite ignored in clinical teaching is the role played by Vitamin B12 and Folic Acid in the synthesis of red blood cells. After Angel joined work, I’ve been encouraging my colleagues to send peripheral blood smears of patients who have anemia as well as tingling/burning sensation or numbness of the limbs. Angel has been reporting macrocytosis, and hypersegmented neutrophils which is very much suggestive of Vitamin B12 deficiency.

I wish we could do an epidemiological study into this aspect of anemia. I understand that I could be wrong – but there is enough evidence to warrant a proper look into this by the scientific community. There are quite a lot of things which I suspect – there could be a Intrinsic Factor deficiency in the community, the diet could be poor in Vitamin B12 deficiency, there may be inhibitors of the absorption of Vitamin B12… However, there is a common denominator to all this – and that is the lack of a balanced diet in the community.

The lack of a balanced diet is very much linked to the issue of food security. The nutrition is quite skewed towards the carbohydrates and the fats. Proteins are a definite no-no in most of the diets which I’ve experienced in the communities here. And one more matter of concern is the lack use of vegetables in the diets here in spite of the local cultivation and availability of vegetables.

I’ve always felt that the lack of Public Distribution System has played havoc in the dietary patterns of our communities and patients like the one I described in my earlier post reinforce this. When I look back at my childhood in Kerala, the Public Distribution System played a very significant role in ensuring that no family went to bed without food. If it is true that the chronic malnutrition which is being purported as a cause of the various deficiencies which we commonly see in the rural communities, there is a strong case from the healthcare research community to strongly establish (in some places re-establish) the Public Distribution System in every nook and corner of the country.