Anemia, interpreted as a low blood hemoglobin values, has been considered as a major health complication with critical outcomes in the developed and developing countries and additionally unfavorable effects on social and financial conditions (Stevens et al., 2013). Three mechanisms mainly lead to anemia: blood loss, when body is unable to produce enough red blood cells (erythropoiesis), and when red blood cells die (hemolysis). Genetic disorders and deficiency of certain nutrients are other contributors of anemia (Kassebaum, 2016). The most widely recognized reason of anemia is Iron deficiency, which is estimated to cause half of all instances of anemia. Because of their certain roles in synthesis of red blood cells and hemoglobin, deficiencies of vitamins A, riboflavin (B2), pyridoxine (B6), cobalamin (B12), C, D, E, folate, and copper can also lead to anemia (Balarajan et al., 2011).
People more susceptible to anemia include infants, children under five years, adolescents, females of reproductive age (both pregnant and non-pregnant), and elderly. For various reasons women are at a higher risk of having anemia: blood wastage every month with menstruation causes high iron losses and hence iron demand, during adolescence (high development and growth phase), and pregnancy incur additional requirements for iron (for their own growth and the growing fetus) (Torheim et al., 2010). It was estimated that about 1.3 billion people all over the world suffer from anemia, making it a standout amongst the most critical health problems globally. Many investigations showed the relationship of anemia with maternal diseases and death. Worldwide anemia adds to 20% of all maternal deaths, leading to premature deliveries, low birth weight, infant mortality, and mental impairment (Obai et al., 2016).
Anemia was also found prevalent (49%) among women in Pakistan according to the National Nutrition Survey (NNS) of 2011 (Bhutta et al., 2011). High prevalence of anemia was also reported among married women in urban (26%) and rural (47%) areas of Pakistan (Baig-Ansari et al., 2008). The prevalence of anemia among pregnant women living in urban areas is similar, ranging from 29% to 50% among pregnant women attending antenatal clinics in a large private, tertiary hospital in Karachi (Aziz-Karim et al., 1990). In the new born children, anemia was found to cause cognitive and behavioral dysfunction, low iron stores, and iron deficiency anemia (Lozoff et al., 2006). Lone FW revealed that infants of anemic mothers had 1.8 times higher chance of having low Appearance, Pulse, Grimace, Activity and Respiration (APGAR) score at the time of birth (Lone et al., 2004).
Rich dietary sources of iron include meat especially offal (organ meat), fish, eggs, poultry, and meat extracts. However, bread and flour, breakfast cereals, dark green vegetables, pulses, nuts, dried fruits like prunes, figs, and apricots are good sources of iron (Webster-Gandy et al., 2020). Dietary factors such as inadequate amount of iron rich foods, vitamin C rich foods (iron absorption enhancers), high amounts of iron inhibitors (e.g. tea, coffee, calcium rich foods) in the diet particularly at the time of meals lead to low bio-availability of dietary iron (Rasheed et al., 2008).
During pregnancy, an expanded danger of maternal and perinatal mortality and low size or weight at birth can be related with low hemoglobin values. Maternal and neonatal passing are a noteworthy reason for mortality in creating nations and cause deaths around the world (Abdelhafez and El-Soadaa, 2012, Zhang et al., 2009). In pregnancy, maternal anemia is viewed as a hazard factor for unfavorable outcomes. In developing countries, anemia is in charge of 40-60% of maternal passing. Directly or indirectly, anemia contributes to premature delivery, pre-eclampsia, infection, cardiac failure, and hemorrhage  (Padmanabhan and Chandrakar, 2018).
The research was aimed to find out the nutrient intake causing anemia among pregnant females. Given the low level of knowledge regarding dietary practices, awareness should be increased through health education and regarding behaviors modification. In the case that these practices
and behaviors are not addressed on time, consequences of anemia on babies will increase, such as low body weight, malnutrition, delayed development, and still births. The purpose of this study was to compare the nutrient intake among pregnant females with and without anemia in order to highlight the effect of inappropriate dietary pattern and insufficient nutrients intake among pregnant anemic females.
Materials and Methods
Study design and participants: A comparative cross-sectional study design was used. Data were collected from females visiting the indoor and outdoor units of Gynae and Obstetrics department and vaccination center of Preventive Pediatrics department at Sir Ganga Ram Hospital, Lahore for a duration of 4 months in December 2018- March 2019. As a result, 150 pregnant women were enrolled in the study using non-probability convenient sampling technique. Pregnant females visiting the respective departments were selected for the follow-up routine checkup having biochemical profile. Later, the participants were categorized as anemic and non-anemic if they had Hb 8 g/dl or less and Hb above 8 g/dl, respectively.
Measurements: Data were collected via self-structured questionnaire regarding their demographics, medical history, food frequency questionnaire (FFQ) (Willett, 1998), and 24-hour recall.  After receiving the written informed consent forms, data were collected by interview.
Ethical considerations: Ethical approval was taken from the Institutional Review Board (IRB) of the University of Lahore. All the rules and standards set by the committee were respected. Patients were pre-informed regarding the benefits of study, they were allowed to leave the study any time during interview. Their identities were kept anonyms. Prior written informed consents were taken from all the participating females.
Data analysis: The quantitative variables were assessed using mean ± SD and the qualitative variables were reported using frequencies and percentages. To analyze the data, SPSS version 21.0 was used. Nutrients from 24-hr dietary recall were derived with reference to the standard serving sizes using MS excel.
Results
The comparison of demographic profile showed insignificant association of patient’s age (P = 0.88) and significant association of age at the time of marriage (P = 0.02) between anemic and non-anemic females. Education (P = 0.001) and socio economic status (P = 0.001) also showed significant association with anemia. However, employment status showed insignificant association with anemia (P = 0.16) as shown in Table 1.

Nutrient intakes of the pregnant women were estimated through 24-hour recall data. Mean value of energy intake in a day was 1429.7 ± 734 kcal for the anemic women and 1504.27 ± 736.4 kcal for non-anemic women; whereas, RDA of energy during pregnancy was 2200 Kcal. Mean value of daily carbohydrate intake of anemic women during 24 hours was 141.1 ± 80.4 g and non-anemic women intake was 135.4 ± 69.4 g; whereas, 175 g is considered as the RDA. The major reasons behind anemia among pregnant females included lower intake of protein (36.1 ± 20.0 g/day), which is approximately half of the RDA since protein is the building block of the cells and Hb; inadequate iron intake (8.9 ± 4.1 mg), which is highly lower than the RDA (as iron is the basic oxygen carrying unit of blood) and RDA (371.2 ± 173.8 mg); and intake of calcium, which helps oxygen carrying and iron absorption in blood.
Intake of other micronutrients was also not adequate, mean of vitamin A intake among anemic women was 605.1± 88.8 µg, while its RDA during pregnancy is 750-770 µg. Mean of Vitamin C intake was 20.0 ± 18.8 mg, whereas RDA is 80-85 mg.  B₁ and B₂ intake means were 0.7 ± 0.3 mg and 0.5 ± 0.2 mg, respectively and their RDA during pregnancy is 1.4 mg. Mean intake of Niacin (B₃) was 6.5 ± 5.2 mg and
its RDA was 18 mg during the pregnancy
(Table 2).
Dietary intake of the participants was recorded through FFQ. Findings showed that among the anemic group, only 23 females had the knowledge regarding balanced diet during pregnancy and 48 of them were taking iron supplements. However, among the basic reasons towards anemia, 64 anemic females were taking tea or coffee on daily basis, 59 were taking tea after meal, and 46 were having craving for pica (Figure 1).