The Anaemic Fourteen-Year-Old and the Family That Wants a Tonic
Sunita, 14, is a Class IX student in a semi-urban block of Bihar. Her father is a daily-wage mason earning about ₹9,000 a month for a family of six. Her height is 148 cm and her weight 38 kg. She reports feeling tired by mid-morning, cannot concentrate in the last two periods, and her teacher notes pallor of the tongue and nails. A private clinic reports haemoglobin 8.2 g/dL; no other test was done. The household is strictly vegetarian, eats rice and dal twice daily, and drinks tea with both meals. Green leafy vegetables appear about twice a week; fruit almost never. Her mother says the girl eats very little because "she is always full of tea". The family wants a tonic from the medical shop rather than a change of diet, and has about ₹60 a day to spend on her food.
1. Assess Sunita's nutritional status from the data given and identify the most probable deficiencies, giving the dietary reason for each.
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Reading the numbers
- BMI = 38 ÷ (1.48)² = 38 ÷ 2.19 = 17.3. For a girl of 14 this is below the expected BMI-for-age range; she is thin for her age. The BMI does not diagnose anything by itself, but combined with the diet history it points to chronic low intake.
- Hb 8.2 g/dL falls in the 8.0–10.9 g/dL band, i.e. moderate anaemia, not a borderline value. The clinic did no ferritin, no folate/B12 and no stool examination, so the cause is presumed, not proved - that gap should be stated.
Probable deficiencies and why
- Iron. A rice–dal plate supplies mainly non-haem iron, which is absorbed at only a few per cent. Tea with both meals adds tannins that bind iron in the gut. Reference intake for adolescent girls is roughly 25–30 mg iron a day; this plate gives about 8–12 mg.
- Vitamin C. Almost no fruit, and vegetables are usually overboiled and drained. Vitamin C is the main enhancer that converts non-haem iron to its absorbable ferrous form; without it, even the little iron eaten is poorly used.
- Folate and B12. Green leafy vegetables only twice a week, and a strictly vegetarian diet puts B12 at risk.
- Energy and protein. "Always full of tea" means tea is displacing food; anaemia here is secondary to overall undernutrition, so iron alone will not correct it. The correct judgement is that this is a diet-and-infection problem with a medical component, not a tonic deficiency.
2. Plan a one-day diet for her within ₹60 using locally available Bihar foods, and state the principle behind each choice.
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Principles: keep the food familiar and cheap; move tea out of meal times; pair an iron source with a vitamin C source at every main meal; add one green leafy vegetable daily; use jaggery, sattu and Bengal gram, which are cheap, local and iron-carrying.
| Time | Food | Approx. cost |
|---|---|---|
| Morning | 2 sattu parathas (60 g sattu, 60 g atta) + nimbu pani | ₹11 |
| Mid-morning | 1 guava | ₹5 |
| Lunch | 120 g rice, 50 g dal, 150 g saag, 5 g mustard oil | ₹17 |
| Afternoon | 30 g murmura + 15 g jaggery | ₹4 |
| Evening | 30 g boiled chana with onion and lemon | ₹6 |
| Night | 2 rotis, leftover saag, 100 g curd | ₹14 |
| Total | ₹57 |
Reasoning, not just a menu: the guava, nimbu pani and lemon on the chana are placed with the iron foods to supply vitamin C at the same meal. Jaggery and sattu add iron without cost. Tea is shifted to at least one hour after meals, because the tannin effect operates inside the gut at the time of the meal.
An honest calculation: this diet supplies only about 10–13 mg iron a day against a need of about 26 mg, so it cannot close the gap alone. The diet plan must therefore be paired with medical iron–folic acid supplementation and deworming; saying so is part of the answer, not a failure of it.
3. Write three counselling points for the mother and explain why a shop 'tonic' alone will not solve the problem.
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- Change when tea is given, not just how much. Move tea to at least an hour after meals and give nimbu pani or plain water with meals instead. Reason: tannins act in the gut at the moment of eating, so timing changes the absorption of iron from the same food.
- One green leafy vegetable and one vitamin C food every day. Reason: this is the cheapest change available at ₹60 a day and it works on the enhancer side of iron absorption, which the family controls fully.
- Take the Hb report back to the doctor for iron–folic acid tablets, deworming and a repeat test. Reason: diet supplies about 12 mg against a 26 mg need; tablets close a gap that food cannot. Deworming matters because hookworm causes blood loss in the gut.
Why the tonic alone fails: most 'tonics' are sugar-based syrups with little or unlisted iron, so they add calories and cost while leaving the three real causes - low total intake, tea tannins, and possible worms or B12/folate deficiency - untouched. The Hb may drift up briefly and then fall again, and the family concludes that the girl is 'weak by nature'. Also flag that if Hb does not rise on treatment, thalassaemia trait and B12 deficiency must be tested, since these are common reasons for non-response in this region.