Iron-deficiency risk in a vegetarian adolescent
Rina, 16, is in Class XI in a government high school in a semi-urban block of Odisha. She complains of tiredness, breathlessness while climbing two floors, and poor concentration in class. Her conjunctiva looks pale. A nearby health camp records her haemoglobin as 9.8 g/dL and advises follow-up. Rina's family is vegetarian by custom. A typical day is: two chapatis and tea at 7 a.m.; rice, dal, and a potato-vegetable curry at 1 p.m.; puffed rice with tea at 5 p.m.; rice, dal, and fried vegetable at 9 p.m. She drinks about 100 mL milk, eats no green leafy vegetables, citrus fruit, or groundnuts, and takes no supplements. Her menstrual periods are regular but described as heavy for three days. Her mother says tea is given because it 'gives energy' and that pulses are expensive. The family can afford one extra low-cost food item per day, but not commercial supplements.
1. Identify the dietary and physiological factors that raise Rina's iron-deficiency risk. Explain why tea with meals matters, and state what the haemoglobin value does and does not tell you.
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Rina has several risks acting together. Her diet is plant-based and low in iron-rich foods: no green leafy vegetables, no groundnuts, and only small amounts of dal. Non-haeme iron from dal and vegetables is poorly absorbed unless paired with vitamin C; her diet has no citrus, amla, guava or other enhancer. Tea at breakfast and in the evening is likely taken close to meals; tannins in tea bind non-haeme iron and reduce absorption. Her heavy three-day periods increase iron loss, and adolescent growth raises iron needs. The haemoglobin of 9.8 g/dL is a screening result that suggests anaemia, but it does not by itself prove iron deficiency or identify the cause. She needs clinical assessment, not a diet-only conclusion. The reasoning is additive: low intake + low bioavailability + high loss = high risk.
2. Plan changes that use existing foods and at most one extra low-cost item per day. Explain the mechanism of each change and name one practice the family should avoid.
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Use the one extra item for an iron-rich local food rather than a commercial supplement: for example, a bunch of amaranth or drumstick leaves (kosala saga) to add to dal, or 50 g groundnuts. Keep the rest of the diet but change timing and pairing. (1) Move tea to between meals, at least an hour away from meals; give water with meals. This reduces tannin interference at no cost. (2) Add the leafy vegetable to dal or rice at lunch; cover and cook briefly to preserve nutrients. (3) Pair dal/rice with lemon, amla or guava if already available; vitamin C improves non-haeme iron absorption. (4) Soak and pressure-cook pulses; this reduces phytate and improves digestibility. Avoid giving more tea as an 'energy' drink, and avoid self-prescribing high-dose iron tablets. Continue milk but do not use it as the main iron source. The plan is realistic because it changes use of existing foods before adding expense.
3. What should the school or anganwadi worker advise the family about the health-camp report, and why is self-medication risky?
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Advise follow-up at the health centre with the medical officer or ANM. The worker should explain that 9.8 g/dL is below the expected range for an adolescent girl and needs confirmation and a cause, but the worker must not label her as definitely iron-deficient. The medical officer may prescribe iron-folic acid under the national adolescent programme and investigate the heavy periods. Self-medication with high-dose iron is risky because it can cause side effects, mask other causes of anaemia, and delay diagnosis; more is not better. The family should continue the food changes, keep a follow-up date, and return sooner if she has breathlessness at rest, fainting or worsening weakness. This links screening, diet and referral rather than replacing one with another.