The Pale Girl Who Chews Clay
Anjali, 13, studies in Class IX in a village about 6 km from the nearest PHC. Her family of five eats rice with a thin dal and one seasonal vegetable at both main meals; tea with milk is drunk with every meal, and green leafy vegetables appear only in winter because her mother says they spoil within a day. Eggs or fish come about twice a week. Her father earns about Rs 400 on the days he gets work. Anjali complains of tiredness while climbing the school slope and breathlessness when she walks fast; her tongue and nail beds look pale, and her mother has noticed her chewing clay picked from the wall. At the Anganwadi camp her haemoglobin was recorded as 8.2 g/dL, her weight as 40 kg and her height as 152 cm. Her mother has bought iron tablets from the pharmacy on her own and gives them with the morning tea because, she says, 'the tablet smells'.
1. Which nutritional deficiency best explains Anjali's condition? Support your answer with three findings from the case and explain how the family's daily diet brought it about.
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Iron-deficiency anaemia is the best explanation, but it is not the only problem.
- Supporting findings: (i) haemoglobin 8.2 g/dL, well below the roughly 12 g/dL taken as the cut-off for a non-pregnant adolescent girl; (ii) pale tongue and nail beds with tiredness and breathlessness on climbing a slope - too little haemoglobin means too little oxygen reaching the muscles; (iii) pica (chewing clay) is strongly associated with iron deficiency. Her BMI of about 17.3 (40 kg at 1.52 m) also shows she is underweight, so undernutrition and anaemia are running together, but anaemia explains the pallor and breathlessness.
- Why the diet causes it: the meals are rice-heavy, so most of the iron is non-haem iron from dal and vegetables, which the body absorbs poorly. Tea with every meal adds tannins that bind iron in the gut. Green leafy vegetables, the cheapest iron source, are available only in winter; eggs and fish, which supply well-absorbed haem iron, come only twice a week. So intake is low and absorption is poorer still.
- Important caution: a haemoglobin figure and iron tablets should be confirmed by a doctor at the PHC, not self-prescribed from a pharmacy. She should be referred and rechecked after treatment.
2. Plan one day's meals for Anjali using foods available in her village, keeping her share under about Rs 60. Identify two practices that increase iron absorption and one that decreases it.
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One day's plan (about Rs 55–60 for her share):
- Morning: chira (rice flakes) with roasted Bengal gram and a piece of lemon or guava.
- Midday: rice, dal, a handful of amaranth or other greens if available, otherwise a little dried fish (about Rs 10) with tomato.
- Afternoon: roasted chana and a small piece of jaggery.
- Night: rice, pumpkin or other vegetable, and one boiled egg (about Rs 7) or small fish.
- Tea kept well away from meals.
Reasoning on cost: eggs, dried fish, chana, jaggery and seasonal greens are the cheapest iron-carrying foods in a village shop, so the plan changes the pattern of eating rather than buying an expensive supplement.
- Increase absorption: (i) eat iron foods with a vitamin C source - lemon, guava, amla, tomato; (ii) soak, sprout or ferment the dal to reduce phytates, or cook in an iron karahi.
- Decrease absorption: tea or coffee taken with or just after a meal; large amounts of milk with the iron-rich meal act the same way.
3. The mother gives the iron tablet with morning tea. Explain the problem and state exactly what she should be advised.
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The problem: tea contains tannins (polyphenols) that bind iron in the gut and can cut absorption by roughly half or more. Giving the tablet with tea partly defeats the treatment, and it also teaches the girl to link medicine with tea, so the habit continues.
Advice to the mother:
- Give the tablet with plain water or lemon water, either about an hour before food or two hours after a meal, and keep tea at least an hour away.
- If it causes nausea, give it with a small snack - but not with tea or milk.
- Explain that black stools are normal and not a reason to stop.
- Continue for the full period the doctor prescribes; anaemia returns if the tablets are stopped as soon as she 'feels better'.
- Keep the tablets out of reach of younger children - iron overdose is dangerous for them.
- Ask about deworming and a repeat haemoglobin check, since worms and continued blood loss will undo the tablets.