European Journal of Cardiovascular Medicine

Anaemia is characterised by a reduced haemoglobin concentration relative to that of age-matched controls. The World Health Organisation defines anaemia as a haemoglobin level below 13 g/dl in adult males, below 12 g/dl in adult females, and below 11 g/dl in pregnant females.

WHO's Hemoglobin thresholds used to define anemia (1 g/dL = 0.6206 mmol/L)

A complete blood count (CBC) is utilised in the laboratory to identify anaemia. Anaemia can be divided as microcytic, normocytic, and macrocytic types based on the Mean Corpuscular Volume (MCV). Microcytic anaemia may result from iron deficiency, thalassaemia, and hemoglobinopathies. Anemia's aetiology is complicated and contingent upon the physiological and biological attributes related to the individual's living conditions. The World Health Organisation thinks that iron deficiency anaemia is the predominant cause of nutritional anaemia. Fifty percent of all anaemia cases in both pregnant and non-pregnant women are attributable to iron insufficiency, while 42% of anaemia cases in children under five years of age globally are likewise ascribed to iron deficiency alone.According to World Health Organization figures, 5% of the world populations are carriers of a potentially pathological hemoglobin (Hb) gene. The Indian Council of Medical Research conducted a multicenter investigation across six states, revealing an overall incidence of beta thalassaemia trait (BTT) of 2.78%. Other studies from different parts of India have shown an incidence of beta thalassemia to be 3-15% Anaemia in adults is often overlooked, as symptoms like weariness, weakness, or dyspnoea may be ascribed to the natural ageing process. While the incidence of anaemia rises with age, good ageing is typically not correlated with anaemia. Anaemia should not be regarded as an unavoidable outcome of ageing, as a cause—often multifactorial—can be found in approximately 80% of senior people. Consequently, neglecting to assess anaemia in the elderly may result in a postponed identification of possibly manageable illnesses. Establishing suitable haemoglobin levels to characterise anaemia is crucial for accurate identification and prevention of its adverse effects. Understanding the diverse and intricate aetiology of anaemia is essential for formulating suitable therapies that target context-specific causes and for evaluating the effectiveness of anaemia control programs. In 2019, anaemia resulted in the loss of 50 million years of healthy life globally due to its associated disabilities. Given the heightened frequency and associated handicap, it is essential to comprehend the contemporary trends of anaemia within our community; therefore, we conducted this study to ascertain the clinical and etiological characteristics of anaemia in adults.

AIM

To assess and describe the clinical presentation and underlying etiological factors of anaemia among adult patients.

This hospital-based observational study was conducted in the Department of Family Medicine and General Medicine at Mahatma Gandhi Medical College and Hospital from March 2023 to August 2024. Participants were adult patients (>18 years) visiting the outpatient departments who fulfilled the symptomatology criteria. Prior to the commencement of the study, approval was obtained from the Institute Ethics Committee, and written informed consent was secured from all participants. Eligible subjects included adults with hemoglobin levels below 12.9 g/dl in men and 11.9 g/dl in women according to WHO guidelines. Patients with a prior diagnosis of chronic renal disease, known hematological disorders, hemodynamic instability, critical illness, pregnancy or lactation, post-traumatic conditions, or those unwilling to provide consent were excluded. No biological or hazardous materials were used during the study.

Sample Size:

Approximately 400 patients were taken.

The sample size was calculated using the following formula: N =z2 x p(1-p)/d2 N=minimum sample size required

z=confidence interval at 95% (standard value of 1.96)

p=estimated prevalence of anemia as per National Family Health Survey 5(2019-2021) is approximately 41%9 d=margin of error (0.05)

N= (1.96) 2 x 0.41(1-0.41/(0.05)2=368

TABLE 1: Socio-demographic characteristics of participants

Males were 44% and females were 56%. 19-30 year age group cases were 37%, 30-40 year age group cases were 21%, 40-50 year age group cases were 25.3%, 50-60 year age group cases were 13.3% and > 60 year age group cases were 3.5%. Mean age was 37.4 years. Urban residents (58.5%) were more represented than rural (41.5%). Most anaemic patients were from lower middle (28.2%), upper middle (27.5%) classes, upper lower (22.8%) and 21.5% cases were from the lower class.

Table 2: Distribution of Participants by Dietary Habits and Substance Use

Vegetarian (85.5%) cases were higher than non-vegetarian (14.5%) cases. Tobacco use was used by 203 (50.7%) cases. Alcohol consumption was by 51 (12.8%) anaemic patients.

Table 3:Co- morbidity among participants

HTN (5.3%) cases were higher than COPD (2.5%), type 2 DM (1.8%) and CAD (1.3%).

Table 4:Distribution of Participants According to Presenting Symptoms

Generalized weakness (54%) and fatigue (52.7%) were the most common symptoms. SOB (6%), paraesthesia (6%), giddiness (4%), cough (4.75%) and weight loss were also found.

Table 5:Sign wise distribution of the study

Pallor (93.25%) was overwhelmingly common. Tachycardia (18.5%), haemorrhoids (3.2%), crepts (2.5%) and knuckle hyperpigmentation (2.7%) were also found.

Table 6:PBF wise distribution of the study

Most of the higher cases were microcytic anemia (63.6%) followed by Normocytic (28.1%) and macrocytic (8.5%).

Table 7:Anemia wise distribution of the study (based on MCV)

Most patients have microcytic anemia (54.8%), followed by normocytic (30.9%), with macrocytic (14.5%).

Table 8:Severity wise distribution of the study

Moderate anemia (69.5%) is predominant than mild anemia (15.8%)  and severe anemia (14.8%)

Table 9:Etiology wise distribution of the study

Nutritional anemia (84.5%) was overwhelmingly the main cause.Other causes include pulmonary TB (5%), CKD (3.3%), dengue (2.5%), and multiple myeloma (2%), each contributing marginally.

The present study provides a comprehensive profile of anemia in a cohort of 400 patients, evaluating hematological parameters, symptomatology, demographics, and etiological factors. Anemia remains a critical public health issue, particularly in developing countries like India, where nutritional deficiencies are prevalent.

The descriptive statistics revealed a mean hemoglobin level of 8.93 ± 1.56 g/dL, indicating that most participants were moderately anemic. Mean corpuscular volume (MCV), red cell distribution width (RDW), and serum ferritin values pointed towards iron deficiency as the predominant cause. This finding is in concordance with WHO reports that emphasize iron deficiency anemia (IDA) as the most common form globally, especially in women of reproductive age and individuals with poor nutritional intake.

The age distribution showed the highest concentration of anemic individuals in the 19–30 year group (37%), again reinforcing the vulnerability of young women in their reproductive years.But in a study done by Kumar S et al, the most common affected age group was 0-20years.The WHO statistics indicate that the prevalence of iron deficiency anaemia, the predominant cause of anaemia among females aged 15-49 years, is 52%.

In terms of gender distribution, females constituted 56% of the study population, consistent with prior research showing that anemia disproportionately affects women due to menstruation, pregnancies, and gendered disparities in dietary access. , Such female dominance was also shown in studies conducted by Alvarez-Uria G et al, and Talwelkar SR et al. In the study conducted by Joshi P et al., also repor reported that anaemia was more prevalent among females across all age categories. In the study conducted by Ather Akhtar Pasha et al, 38% of the study population were male and 62% were female.

Urban residents (58.5%) slightly outnumbered rural residents. This could reflect greater healthcare access and diagnosis rates in urban settings rather than actual prevalence differences, as anemia is typically more common in rural populations due to limited nutritional options and healthcare availability.

Socioeconomic status further supports this pattern, with most cases falling into the lower middle (28.2%) and upper middle (27.5%) categories. Financial constraints likely limit access to iron-rich foods and supplements, affecting anemia risk. Anaemia is more common in lower socioeconomic groups due to factors such as a higher incidence of nutritional deficiencies, delays in accessing healthcare services, increased prevalence of parasitic infections, insufficient knowledge regarding nutrition and hygiene, and general ignorance about available resources. Tobacco use was observed in 50.7% of participants. Smoking may influence anemia through chronic inflammation and altered erythropoiesis. Alcohol consumption (12.8%) also contributes to bone marrow suppression and gastrointestinal losses, exacerbating anemia. ,Kaliya M et al. demonstrated that 22% of males were Bidi smokers, 14% were alcoholics, and 45% were tobacco chewers. This study indicates that anaemia was more prevalent among lower socioeconomic guys (67%) compared to medium and upper socioeconomic males (33%).

Clinically, generalized weakness (54%) and fatigue (52.7%) were the most frequently reported symptoms—both classic manifestations of decreased oxygen-carrying capacity. Pallor was the most prominent clinical sign (93.25%), followed by tachycardia and minor findings such as koilonychia and knuckle hyperpigmentation, all of which align with features of iron and vitamin deficiencies. Unnikrishnan V et al. observed that the predominant symptom was generalised weakness, succeeded by pallor in 83.5%, fever in 53.5%, and splenomegaly in 18% of the cases. Gayathri BN et al. reported findings that closely align with the current study, including 89% exhibiting generalised weakness, 92% presenting with pallor, 46% experiencing fever, and 30% showing splenomegaly. Common symptoms were weakness, fatigability, diminished work performance, and dyspnoea on exertion, attributable to cardiovascular impairment. job capacity is evaluated through aerobic capacity, endurance, energetic efficiency, voluntary activity, and job productivity.

The study found a large proportion of vegetarians (85.5%), a factor significantly associated with vitamin B12 and iron deficiency in Indian diets due to limited intake of heme iron and animal-derived nutrients. Kakkar R has also found nearly similar result (57% Hindu adolescents were anemic) due to the consumption of vegetarian diet with low bioavailability of iron.

Peripheral blood film (PBF) examination supported the predominance of microcytic anemia (63.6%), followed by normocytic (28.1%) and macrocytic (8.5%) variants. A similar trend was observed in the classification based on RBC indices, with microcytic anemia accounting for 54.8% of cases. These findings underscore nutritional causes, particularly iron deficiency and, to a lesser extent, vitamin B12 and folate deficiencies, as major

contributors. , Microcytic (50.3%) and normocytic (42%) anemias were the two most common types observed in Aryal D et al study. Other less frequent peripheral smear findings were macrocytic (4.7%) and dimorphic (3.1%). These results are in agreement with findings obtained from previous studies. ,

The assessment of anaemia severity indicated that moderate anaemia was the most prevalent, accounting for 69.5%, which implies a significant burden of chronic but managed cases. Timely detection and suitable dietary therapy may avert the advancement to severe anaemia (14.8%). Patil A was found that severe anemia (87.17%) was most common than moderate anemia (12.82%). Out of 230 patients, 74.3% had microcytic anemia. 17.4% had macrocytic and 8.3% had normocytic anemia. Raina A et al, observed that within the study population, 21.4% exhibited severe anaemia, 72.6% moderate anaemia, and 6% light anaemia, indicating lower severity compared to the current study; this discrepancy may be attributed to differing study conditions. Gupta N et al, reported that 22.8% experienced severe anaemia, 50% had moderate anaemia, and 27.1% exhibited light anaemia. Ratre BK et al, revealed that 57% of the study population exhibited moderate anaemia, while 41% presented

with severe anaemia. Fatima SH et al found that 58.6% had moderate anaemia, 36.6% had mild anaemia, and 4.7% had severe anaemia. In contrast, maximum number of severe anemia was noted in study done by Karunakar R et al (severe 54.8%, moderate 36.5%, mild 8.7%) and Patel S (severe 85%, moderate 15%). Mild anemia was predominant in study done by Drissa S et al (mild 60.41%, moderate 31.47%, and severe 8.12%). The variations in severity may stem from differences in study environments (primary care versus referral centres, rural versus metropolitan settings), healthcare accessibility, patient awareness regarding anaemia, and their health-seeking behaviours.

The etiological distribution confirmed that nutritional anemia (84.5%) was overwhelmingly the dominant cause, followed by pulmonary tuberculosis (5%), chronic kidney disease (3.3%), and multiple myeloma (2%). Dasharatham P and Reddy VS were found severe anemia nutritional anemia was the most common cause found in 42% of the cases. This aligns with national data that report nutritional deficiencies—particularly of iron, folate, and B12—as the leading causes of anemia in India. Nutritional anemia emerged as the leading cause, affecting 338 participants. This high prevalence is consistent with national and global reports, especially among populations with inadequate dietary iron, folate, and vitamin B12 intake. The World Health Organization (WHO) underscores iron deficiency as the most common and widespread nutritional disorder in the world, disproportionately affecting women and children in resource-limited settings. Additionally, cultural dietary practices, frequent pregnancies, and menstrual losses may contribute to this burden in Indian women. The second most common etiology in this cohort was pulmonary tuberculosis (5.0%). Anemia in tuberculosis is multifactorial and may result from chronic inflammation, malnutrition, or bone marrow suppression. Anemia of chronic disease is well-documented among patients with tuberculosis and often correlates with disease severity. Chronic kidney disease (CKD) (3

course of CKD and worsens with declining glomerular filtration rate. Less prevalent but clinically relevant causes include multiple myeloma (2.0%), dengue (2.5%), and aplastic anemia (0.8%). In multiple myeloma, bone marrow infiltration disrupts normal hematopoiesis, leading to anemia. Dengue-related anemia may occur due to hemorrhagic manifestations or hemolysis. Aplastic anemia, though rare, represents a serious hematological emergency requiring specialist care.Other contributors such as hemorrhoids (1.3%) and chronic liver disease (CLD) (0.8%) indicate that occult blood loss or impaired hematopoiesis could play minor but notable roles. It is important to consider that hemorrhoids and CLD may lead to chronic, unnoticed blood loss and undernutrition, further aggravating anemia.

Limitations

This is a hospital-based study. So, findings may not accurately reflect anemia in community. Being a single center study, the results cannot be generalized to all the hospitals in Jaipur. Response to treatment was not studied. Future research can solve these limitations.

CONCLUSION

The most common cause of severe anemia was nutritional anemia. Females were found more affected than males. The findings emphasize the critical role of nutrition and public health awareness in anemia management. Routine screening, dietary counselling, and targeted supplementation could significantly reduce the anemia burden in similar populations. Further studies incorporating longitudinal follow-up and interventional strategies are recommended.

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