Iron-deficiency anaemia in a vegetarian adolescent on a tight budget
A 15-year-old girl, Selvi, is brought to the anganwadi by her mother because she 'looks pale and tired'. She is 148 cm tall, weighs 38 kg (BMI about 17.4), and her haemoglobin is 7.6 g/dL. Her menstrual periods are regular with normal flow. She is a vegetarian from a landless labour family in a village in Tamil Nadu. The family's food budget is about ₹120 a day for five people. She drinks tea with every meal and eats rice with sambar twice a day, but no green leafy vegetables because 'they are costly this season'. She walks 3 km to school and back and often skips breakfast. The medical officer prescribes oral iron and folic acid tablets and asks the nurse to give dietary advice that the family can actually follow.
1. Identify the nutritional problems and explain, with mechanisms, why her diet has produced a haemoglobin of 7.6 g/dL.
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Problems identified
- Iron-deficiency anaemia (Hb 7.6 g/dL is moderate to severe for a 15-year-old girl).
- Low dietary iron and very low bioavailability - her iron comes from rice and dal, which contain non-haem iron absorbed at only about 1–5%, unlike 15–35% from meat.
- Tea with every meal - tannins and polyphenols bind iron in the gut and block absorption. This single habit can halve the iron absorbed from a meal.
- No vitamin C source at meals - ascorbic acid converts ferric to ferrous iron and can double or triple non-haem absorption; without it, even the little iron she eats is poorly taken up.
- No green leafy vegetables - drumstick leaves, amaranth and spinach are the cheapest local iron sources and are missing.
- Energy deficit and skipped breakfast - BMI 17.4 with a 3 km walk each way means intake is below need; iron cannot correct anaemia in an energy-deficient diet.
Reasoning: menstrual loss is normal, so the cause is dietary, not blood loss. The prescription will fail unless the tea habit, the missing vitamin C and the total food intake are addressed together - tablets cannot compensate for a diet that blocks absorption.
2. Plan one day's diet using foods available in her village, costing about ₹35 for her share, and show where the iron and vitamin C come from.
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One-day plan (about ₹30–35)
| Meal | Food | Iron source | Vitamin C source |
|---|---|---|---|
| Breakfast | Ragi porridge, 40 g ragi, with 100 mL milk | Ragi ≈ 3.5–4 mg | - |
| Mid-morning | One guava (cheap and seasonal) | - | Guava ≈ 200 mg |
| Lunch | Rice, 60 g dal, 50 g drumstick leaves poriyal, lemon squeezed on top | Dal ≈ 1.5 mg, greens ≈ 1.5 mg | Lemon |
| Evening | 30 g chana sundal with onion and lemon | Chana ≈ 1.5 mg | Lemon |
| Dinner | Rice with sambar and 50 g amaranth or spinach | Greens ≈ 1.5 mg | Tomato in sambar |
Total iron ≈ 9–10 mg with good absorption.
Counselling points
- No tea for one hour before or after a meal; give it between meals instead.
- Lemon or guava with every iron-containing meal - this is free and doubles absorption.
- Cook in an iron kadai where available; it adds iron to the food.
- Drumstick leaves and amaranth are cheaper than the vegetables she avoids; they grow locally and can be picked.
- Do not skip breakfast - the ragi porridge is the cheapest way to add both energy and iron.
Reasoning: the plan uses only foods already sold in her village and stays inside the family's budget, because advice a family cannot afford is advice that will not be followed.
3. What will you advise about the iron and folic acid tablets, and how will you check that the advice is working?
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Advice on the tablets
- Take one tablet after food with lemon water or water - not with tea, milk or calcium supplements, which block absorption.
- Warn her that stools will turn black; this is harmless and is the commonest reason girls stop the tablets.
- Nausea and constipation are common in the first week; taking the tablet after the evening meal reduces this.
- Continue for at least three months after the haemoglobin returns to normal, because the tablets refill stores, not just the blood level.
- Deworming with albendazole, if not already given, is needed - hookworm causes ongoing blood loss.
Monitoring
- Repeat haemoglobin at 4 weeks (expect a rise of about 1 g/dL) and at 3 months.
- Weigh her monthly and plot on the growth chart; ask about appetite, fatigue and school attendance.
- Ask her to bring the strip at each visit and count the remaining tablets - this is a simple, non-accusatory check of adherence.
- Ask specifically about tea and about lemon or guava with meals at each visit.
Reasoning: anaemia in an adolescent girl recurs unless diet and adherence are both monitored. Counting tablets and repeating Hb turns vague advice into a measurable plan, and treating her as a partner rather than a suspect keeps her coming back.