IRON DEFICIENCY ANAEMIA AMONG INDIAN POPULATION AND ITS AYURVEDIC MANAGEMENT

Dr. Sushant Kumar 1 , Dr.(Mrs) Prabha Kumari 2 , Dr. Amarendra Kumar Singh 3 , Dr. Prabhat Kumar Dwivedi 4 and Dr. Ajay Kumar Singh 5 . 1. Asst. Prof., Dept of RS & BK, Sri Sai Ayurvedic P.G. Medical College & Hospital, Aligarh (UP). 2. Reader, Dept of Prasuti Tantra & Stri Roga,Govt. Ayurvedic College & Hospital, Chaukaghat, Varanasi (UP). 3. Reader, Dept of Roga Nidan &Vikriti Vigyan, Govt. Ayurvedic College & Hospital, Patna. 4. Reader, P. G. Dept of Rasa Shastra & Bhaishjya Kalpana, Govt. Ayurvedic College & Hospital, Patna. 5. Prof., P. G. Dept of Rasa Shastra &Bhaishjya Kalpana, Govt. Ayurvedic College & Hospital, Patna. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History

Iron-deficiency also has important consequences for the future generations, as iron-deficiency anaemia increases the risk for preterm labour, low birth weight, infant mortality and predicts iron deficiency in infants after 4 months of age vvi . Anaemia, of which iron-deficiency is the major contributor, accounts for 3.7% and 12.8% of maternal deaths during pregnancy and childbirth in Africa and Asia, respectively vii . It also leads to cognitive deficits and reduced intellectual performance among school children viii . IDA impairs the mental development of over 40% of the developing world's infants. It decreases the health and energy of approximately 500 million women globally and leads to approximately 50000 deaths in child birth each year. In communities where iron-deficiency is highly prevalent, successful iron supplementation results in the disappearance of anaemia as a public health problem except where malaria and HIV or hookworm infection rates are high ix .
The World Health Organization defines iron-deficiency anaemia as a condition whereby either individual haemoglobin levels are two standard deviations below the distribution mean, or more than 5% of a given population has haemoglobin levels that are two standard deviations below the distribution mean, in an otherwise normal population of individuals from the same gender and age, living at the same altitude x . Significant public health implications are more commonly associated with moderate to severe anaemia, defined as haemoglobin level below 10 g/dL.
Despite increased national and international awareness and recent governmental intervention programs, the prevalence of anaemia among Indian women has remained higher than 45% since 1990, and anaemia trends remain strongly correlated with iron-deficiency xixii . A 2007 Indian government -12 by 12 initiative‖, aimed at ensuring that all Indian adolescents have 12 g/dL haemoglobin by 2012, listed the main causes of anaemia in India as low dietary intake, poor availability of iron, chronic blood loss due to hookworm infestation, and malaria xiii .
Vegetarianism, defined as the exclusive consumption of plant-based diets, is a common dietary pattern in India, dating back to at least 2500 years. In India, vegetarianism is influenced in part by adherence to the ethical teachings of ahimsa or -nonviolence‖ inherent in Hinduism, Buddhism, and Jainism. Vegetarian-style diets constitute a common dietary pattern in India, dating back to at least 2500 years, with Indians constituting about 70% of the world's population who adhere to vegetarian-style diets. About 75% of Indian vegetarians are lactovegetarians (i.e., do not consume meat or eggs, with no prohibition for milk or other dairy products), with up to 25% being lactovovegetarians (who do not eat meat, with no prohibition on eggs and dairy products). Less than 1% of Indians are vegans, who do not eat any animal products at all xiv . Vegetarianism has important implications for maternal irondeficiency in India, in terms of the availability and chemical form of iron in plant-based foods. Although a vegetarian diet is likely to contain iron in amounts equivalent to that in omnivorous diets, animal-based haemoglobin iron is better absorbed (15-40% absorption) compared with plant-based non haemoglobin iron (1-15% absorption), despite variations in body iron stores xv . Nutritionists recommend that vegetarians need to increase dietary iron by 80% to compensate for a lower iron availability of 10% from a vegetarian diet compared with 18% from an omnivorous diet xvi . This recommendation constitutes a major challenge in India where the majority of vegetarians subsist on inadequate quantities of iron-poor staples such as lentils, wheat bread, green peppers, and rice.
A modified food guide pyramid for vegetarians entails obtaining 32-36 mg of iron daily in a 2000 calorie diet containing 8 servings of grains, 3 of vegetables, 2.5 of green leafy vegetables, 1.5 of fruit, 2.5 of beans and protein foods, 3 of dairy or nonfortified dairy, 1.5 of nuts and seed, and 2.5 of oils xvii . The vast majority of Indian vegetarians are unable to afford to eat such varied vegetarian meals in the quantities suggested. In addition, affordable foodstuffs such as wheat bread contain high levels of phytates, while tea, a popular beverage in India, is high in tannic acid content. Phytates and tannins inhibit iron absorption xviii .
Most of the Indian staple foods are produced or grown locally, and most commonly consumed foods are not fortified with iron. A popular food item in India is beans. Beans have relatively high iron content, but only 2% is absorbed 629 from the most commonly consumed variety of beans in India, Phaseolus vulgaris. Other varieties of beans, such as soyabean, are more easily absorbed-iron absorption from soyabeans is about 30% in iron deficient women, which is similar to that from meat or iron sulphate tablets, because 90% of the iron in soybeans is in the form of ferritinsoyabean is not a popular food item in India xixxx .
Iron deficiency anaemia has been defined as iron store depletion refers to an imbalance between normal physiological demands and the level of dietary iron intake. Iron deficiency causes defective haemoglobinisation which leads to Microcytic Hypochromic Anaemia. 1 In the Indian context it is particularly a major cause of concern among masses. Inadequate dietary intake, blood loss due to various reasons and decreased iron absorption are major cause of anaemia or Panduroga. Acharya Caraka has said in the context of Panduroga-Ksharamlalavanayushna……………………………………………..sa panduroga etyuktah xxiii . Swarnamakshika (CuFeS 2 ) has been described for the treatment of Panduroga i.e. Iron Deficiency Anaemia in various classics of Ayurveda. e.g. Rasa Tarangini, Ayurveda Prakasha, Rasendra Chudamani etc. Swarnamakshika vrishyam………………………………………….....yogvahi param matam. xxiv It contains extrinsic factor such as copper and iron, required for the formation of haemoglobin. Being a Saumyakalpa xxv of iron, it is easily digestible and hence widely used in infants, pregnant, lactating women and frail old people. Easy availability and cheaper price makes it a drug of choice for the treatment of anaemia.

Criteria of Assessment-
For the purpose of assessment of improvement, a scoring system in sign and symptoms of IDA i.e. Panduroga was adopted. Further it was assessed by evaluating already mentioned laboratory findings, which were carried out at the time of inclusion and initiation of trial in the patient and during treatment on every fifteen days up to completion of trial. Untoward effect of the drug if any, were also noted on each and every visit. All the patients treated were also followed up for 15 days after completion of trial to assess the any effect which developed later on.
The data related to the clinical features and laboratory investigations was collected and then statistically analyzed. The status of IDA was assessed on the basis of grades of various variables compared between pre and post trial values in terms of percentage. Values between two variables were compared with student (t) test for dependent samples by using the degree of freedom, p value (two tailed) xxx . The results were expressed in terms of mean, standard deviation (SD±) and standard error (SE±)  The above data depicts that the initial mean score of Haemoglobin (in gm/dl) in Gr. A was 9.47 which increased to 11.57 after treatment showing change of 22.16%. In Gr. B, initial mean score was 9.41 which increased to 11.45 after treatment showing change of 21.68%. In Gr. C (control group), the initial mean score was 9.68 which increased to 11.16 after treatment showing change of 15.24%. The result was statistically highly significant in all the three groups.

Discussion:-
It was observed from the present study that the majority of the patients suffering from IDA were women (78.33%) while only 21.66% male were suffering from it (Table no-1). 80% registered patients were of rural background 633 whereas only 20% were from urban background (Table no- 2). The people of nearby rural area visited the hospital for various ailments frequently. Some of them incidentally diagnosed of IDA. It also shows more prevalence of IDA among rural population.
Occupation plays an important role in manifestation of various diseases. In registered patients (Table no-3), maximum were housewives (58.33%) followed by 18.33% students, 11.66% labourer and employee each. This shows that incidence of IDA is maximum in housewives as they do not care of their health due to ignorance and incidentally came to know regarding it.
Most of the patients (23.33%) were educated up to higher secondary followed by matriculation (21.66%), primary education (20%), graduate (13.33%), higher study 8.33% and illiterate 6.66% (Table no- 4). The possibility of IDA was maximum in less educated people as they have lack of knowledge about the importance of micronutrients in the body.
It was observed as per Table no-5, that 61.66% patients had addiction of either tea or coffee. It has already been proved through various researches that tannins formed by tea, phosphates of egg yolks and phytates of bran causes poor bioavailability and finally leads to reduction in the absorption of iron. This could have been the cause of more prevalence of IDA in tea addicted people in the present study.
In this study, it was also observed that incidence of IDA was maximum in patients having poor hygienic condition (65%) followed by 35% patients had good hygiene. Further 60% were taking mixed diet and only 40% were vegetarian. In this study Panduroga has been selected for the clinical trial of Swarnamakshika Bhasma for evaluating therapeutic effectiveness because Lauha preparation are considered as the best remedy of Panduroga. Here Panduroga is co-related with iron deficiency for their etiological, symptomatic and management similarities. Etiological similarities-Excessive intake of kshara and lavana reduces absorption of iron by neutralising gastric acidity. Excessive exercise may cause excessive demand or iron. Affliction of mind with shoka, chinta, bhaya, may cause defective intake of iron due to anorexia.

Conclusion:-
It can be concluded from the present study that clinically, Swarnamakshika Bhasma used in Gr. A was better as compared to Gr. B. The Bhasma used in Gr. A showed better haematinic effect than Gr. B. It could be a drug of choice for the treatment of anaemia due to easy availability and cheaper price. It was noticed that all the patients tolerated the treatment quite well and no adverse reaction to the drugs were observed during the course of treatment. The above mentioned results should be further analyzed by conducting such study in large number of patients with a longer period of follow up to observe any untoward effect of drugs. It is further suggested to evaluate haematological effect of these drugs by conducting Serum Ferritin and TIBC investigations.