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Open Access Full Text Article Review Article

Su’al-Qinya: Unani Perspective on Iron Deficiency Anemia, its Pathogenesis, and Therapeutic Interventions

Asba Sameen ¹, Md Salman ²*, Sadique Ali ³, Shaikh Talat Nasreen ⁴

¹ PG Scholar, Dept. of Mahiyatul Amraz, National Institute of Unani Medicine, Bengaluru

² PG Scholar, Dept. of Ilaj-bit-Tadbeer, National Institute of Unani Medicine, Bengaluru

³ Associate Professor, Dept. of Mahiyatul Amraz, National Institute of Unani Medicine, Bengaluru

⁴ PG Scholar Department of Amraz Jild Wa Tazeeniyat, National Institute of Unani Medicine, Bengaluru

 

 

Introduction

The term "anemia" (derived from the ancient Greek άvαιμία, anaimia, meaning "lack of blood") refers to a group of conditions caused by erythropoietin tissues' inability to maintain a normal haemoglobin concentration due to an inadequate supply of one or more nutrients, which lowers the total amount of circulating haemoglobin. Iron and vitamins, such as folic acid, vitamin C, vitamin E, and vitamin B12, are necessary for the production and proper development of red blood cells.¹ The World Health Organization defines anemia as "a condition in which the number of red blood cells or their oxygen-carrying capacity is insufficient to meet physiologic needs." It's the most prevalent illness in the world and one of the conditions that general practitioners see the most often. Anemia is typically a symptom of an acquired or hereditary condition rather than an isolated illness. The World Health Organization states that haemoglobin (Hb) levels below 13.0 gm/dl in adult males, 12.0 gm/dl in adult non-pregnant women, and 11.0 gm/dl in pregnant women should be regarded as indicators of anemia.²

Anemia can be classified on the basis of specific causes. And it can be defect in red blood cell production may result from deficiencies in iron, vitamin B12, or folate. On the other hand, excessive destruction of red blood cells can arise from chronic conditions with nutritional, infectious, metabolic, or genetic origins. Among these, iron deficiency anemia (IDA) is the most common type.²

Iron deficiency is identified by abnormal levels of serum ferritin, transferrin saturation, and/or erythrocyte protoporphyrin. Iron is stored as ferritin and transported by transferrin, which delivers it to cells via transferrin receptors (CD71) for incorporation into haemoglobin in the bone marrow. Unbound iron is toxic, so it must remain bound to transferrin. Transferrin levels increase during iron deficiency.³

In Unani medicine, anemia is referred to as Su’al-Qinya which means "lack of vital treasure—blood" in Arabic. It is a disorder that affects the blood's capacity to carry out physiological processes by causing both qualitative and quantitative fluctuations. It is also known as Faqru-dam, Qillatu-dam, or Fasadu-dam and the term "faqr'al dam" (anemia) is commonly used. Unani scholars, Ibn Sina (980-1037 AD), Ismail Jurjani (1041-1136 AD), Ibn Hubal Baghdadi (1117-1213 AD), and Hakim Azam Khan (1813-1902 AD) saw blood as a vital fluid produced in the liver. Nuqstaghzia occurs when the liver's functions and faculties are impaired or owing to related disorders, resulting in abnormal blood production and anemia.   And Hakeem Mohammad Kabiruddin(1894-1976AD) also mention in his book that it is an alteration in blood composition, a decrease in Kuriyat-e-Dam (red particles, or RBCs), and a fall in blood volume, all of which result in compromised oxygen supply.^4,5,6,7

Stages of IDA (Iron Deficiency Anemia):

First Stage: Iron Depletion

Reduced serum ferritin and iron stores in the marrow and liver occur due to insufficient iron absorption. Despite this, haemoglobin, serum iron, and erythropoiesis remain normal, and symptoms are absent.³

Second Stage: Latent Iron Deficiency

Substantially depleted iron stores begin to affect haemoglobin production, although levels remain normal. Markers include decreased serum ferritin, serum iron, and transferrin saturation (<15%), with increased total iron-binding capacity (TIBC) and free erythrocyte protoporphyrin.³

Final Stage: IDA

Microcytic, hypochromic anemia develops as haemoglobin-deficient cells replace normal erythrocytes. Symptoms include low haemoglobin, decreased serum iron, increased TIBC, and reduced transferrin saturation. Haemoglobin levels fall below normal thresholds for age and sex.³

Causes:

1. Temperamental Imbalance (Su-e-Mizaj): Dysregulation of digestive processes and temperament can impede nutrient absorption, thereby contributing to iron deficiency anemia.

2. Excessive Metabolism (Kasrat-e-Hazm): Conditions characterised by accelerated metabolism can deplete iron stores, exacerbating iron deficiency anemia.

3. Excessive Blood Loss (Kasrat-e-Istehlak-e-Dam): Prolonged or excessive blood loss due to various factors, including menstruation, trauma, or disease, can lead to iron deficiency anemia.

4. Impaired Nutrient Assimilation (Ihtibas-e-Mawad): Inefficient nutrient absorption and utilization can contribute to iron deficiency anemia.

5. Blood Impurities (Fasad-e-Khoon): The presence of toxins or impurities in the blood can disrupt normal hematopoiesis, contributing to iron deficiency anemia.

6. Gastric Weakness (Zof-e-Meda): Impaired gastric function can compromise nutrient digestion and absorption, leading to iron deficiency anemia.

7. Loss of Vital Fluids (Usool-e-Raeeq): Excessive loss of vital fluids through sweating, diarrhea, or bleeding can result in the depletion of essential nutrients, including iron.

8. Inadequate Nutrition (Ghiza-e-Naqis): A diet lacking essential nutrients, particularly iron, can precipitate iron deficiency anemia.^7,8,9,10 

In Unani medicine, the term Faqr al-Dam is closely associated with anemia. Numerous symptoms of anemia are described in classical Unani texts, including Su al-Qinya (abnormal blood), Qilla-i-Dam (reduced blood), and Kami Khun (low blood levels), which are attributed to Su-e-Mizaj (abnormal temperament). 

Unani scholars have provided various explanations for the development of Faqr al-Dam. Some attribute it to Duf-al-Jigar (liver weakness). Rabban Tabari noted that Su Mizaj Barid wa Ratb (cold and moist abnormal temperament) could lead to symptoms of anemia. Jurjani, in his classical work Zakheera Kharzam Shahi, linked anemia to imbalances in dietary habits. Avicenna, in his treatise Al-Qanoon, suggested that excess Sawda (black bile) contributes to the condition, while Al-Majoosi, in Kamil us Sana, attributed anemia to the liver’s inability to perform hemopoiesis due to Su Mizaj.^7,8,9

Azam Khan further elaborated that alteration in the blood caused by liver dysfunction lead to Su al-Qinya. He identified various causes of anemia, including liver diseases (Amrad-i-Kabid), gastrointestinal disorders (Amrad-i-Mi’da wa Am’a), renal conditions (Amrad-i-Kulya), acute and infectious illnesses (Haad/Ufunati Amradi), and genital system disorders (Amrad-i-A’da-i-Tanasuliyya).¹⁰

Pathophysiology of Anemia:

In Unani medicine, anemia (Sū’al-Qinya) arises from either a change in the body’s temperament (Mijaz) or an abnormal humoral imbalance.^7,11 Proper blood production depends on the vitality and functionality of key organs involved in digestion and elimination, such as the liver, stomach, kidneys, and spleen. Disruption in liver function, often due to altered temperament, impacts the production, quality, and quantity of humors.¹² It is also impairs the immunity and the body's innate healing power (Ṭabī‘at Mudabbira’-i-Badan).⁷

Unani medicine classifies diseases as Amrāḍ Mufrada (simple diseases) or Amrāḍ Murakkaba (complex diseases). Simple diseases include Sū’-i-Mizāj (temperamental disorders, especially cold and wet liver temperament), structural derangements (Sū’tarkeeb), and connectivity disorders (Tafarruqe Ittesāl) in organs like the stomach, kidneys, and gallbladder. Complex diseases involve combinations of these conditions.

Sū’-i-Mizāj is further divided into Sādā (pure temperamental alteration) and Māddῑ (humoral imbalance).^11,13 The liver, naturally hot and moist, metabolizes food into blood, making it central to nourishment.^14,15 Any disruption in its temperament affects blood quality and quantity, resulting in Sū’al-Qinya. Some scholars link this to liver weakness (Ḍu‘f al-Kabid), while others attribute it to temperamental disturbances.¹⁶

Kabiruddin (1950) described Khizra (chlorosis), a form of Sū’al-Qinya in women, as involving altered blood composition. He noted microcytosis (small RBCs), hypochromia (reduced red pigment), and increased fibrous material in the blood.¹⁷

Clinical and Diagnostic Manifestations (Istedlal wa Alȧmȧt) of Anemia in Unani Medicine:

• Pale and white discolouration of the skin.¹⁸
• Dyspnea. .¹⁸
• Puffiness of face and eyelids especially on the extremities. Sometimes it may be on the whole body Pitting edema on the feet.^5,10
• Brittle nails.⁴
• Irritability.¹⁸
• Prominent peripheral veins.
• Cold extremities.
• Indigestion.
• Loss of appetite, or sometimes increased appetite.¹⁸
• Feeling of air with fullness in the stomach.
• Alternate diarrhoea and constipation.⁵
• Heaviness and fatigue.¹⁸
• Sleep disturbances.
• Vertigo and giddiness.
• Spasms and tremors.
• Oliguria (reduced urine output, as noted by Sheikh).
• Excessive sweating.
• Delayed healing of wounds or ulcers.
• Gum itching and wounds.¹¹
• Stomatitis (inflammation of the mouth).
• Palpitations.¹⁸
• Occasional syncope (fainting).
• Splenomegaly (enlarged spleen).¹⁹
• Hepatomegaly (enlarged liver).
• Jaundice and ascites.¹⁵

Diagnosis (Tashkhees) in Unani Medicine:

Unani physicians employ traditional diagnostic techniques to identify anemia, including:

Comprehensive Patient History: A thorough inquiry into the patient's diet, menstrual patterns, lifestyle, and digestive issues provides valuable insights into the underlying causes of anemia.⁴

 Pulse Examination (Naabz): An irregular, weak, and slow pulse indicates anemia.^4,7

Visual Inspection: Observation of the skin, eyes, and nails reveals characteristic signs, such as pallor (Zard rang) of the skin and eyes.^{4, 9}

Usool-e-Ilaj (Principles of Treatment): 

•   Avoid foods that disrupt the liver's temperament (Jigar), leading to Baroodat (coldness) and reduced Hararate Ghareeziya (innate heat) of the liver.
• Refrain from consuming Ratab (moist), Ghaleez (heavy), and Dushwar Hazm (hard-to-digest) foods.
• Avoid drinking freezing or cold water.
• Perform daily Riyazat (exercise) on an empty stomach.
• Take baths using water infused with Gandhak (sulfur), Suhaga (borax), and Shib (alum).
• Use Dalk (massage) with a rough cloth and Garam Roghan (warm oil).
• Avoid bathing (Hammam) or engaging in sexual activity (Jimah) immediately after meals.
• Engage in Harkat fil Raml (rolling over warm sand or soil).
• Employ mild istefragh (evacuation) using Ayarij (Aloe barbadensis) and Habbul Neel, which help eliminate Ghaleez (thick), Lezdar (sticky), and Balghami Fuzla (vitiated phlegmatic fluids) from the body.^4,5,20

Prevention (Tahaffuzi Tadabeer):

Unani medicine emphasises the impact of environmental factors on health, advocating for a balanced ecosystem along with clean water, air, and food. It highlights the importance of adhering to Asbab Sitta Zaruriyya (six essential factors) as fundamental for maintaining and preserving health.¹⁴

Soo-ul-Qiniya Management:

1. Ilaj-bil-Ghiza (Dietary Therapy):

Nutritional Interventions for Iron Deficiency Anemia

A well-structured diet plays a vital role in managing iron deficiency anemia. The following foods, rich in iron, essential minerals, and vitamins, are highly recommended:

1. Fruits: Dates, figs, and pomegranates are excellent sources of iron and other essential nutrients.

2. Nuts and Seeds: Almonds and sesame seeds are rich in iron and can be incorporated into the diet.

3. Herbal Infusions: Ash of date seeds and fennel water can be consumed as herbal infusions to support iron absorption.

4. Protein-rich foods: Red meat, chicken liver, and fish are excellent sources of iron and essential amino acids.

5. Legumes: Lentils, chickpeas, and other legumes are rich in iron, fiber, and other essential nutrients.

6. Green Leafy Vegetables: Spinach, fenugreek, and other green leafy vegetables are rich in iron, vitamins, and minerals.

Unani literature suggests a diet derived from plant, mineral, and animal sources to promote health and address anemia. The recommended foods include:

Nutrient-Rich Diets:

• Ghiza-e-Lateef (soft diet)
• Kaseerut-Taghzia (highly nutritious diet)
• Jaiyyad-ul-Kaimus (easily absorbable foods)
• Yakhni (broth made with meat and rice)
• Shorbae Teetar (bird’s soup)
• Masoosat (soups prepared with aromatic spices)
• Zirbaj (a sour meat dish with vinegar, honey, acid syrup, raisins, and figs)
• Sikbaz (acidic minced meat similar to Zirbaj)
• Zardah (rice cooked with Crocus sativa)

 

 

Animal and Dairy-Based Foods	Vegetables	Fruits
Liver Kidney Meat (Ghost Daraj, Fish) Eggs Milk Paneer (cheese)	Bathua (Chenopodium album) Palak (Spinacia oleracea) Cholai (Amaranthus polygamous) Hulba (Trigonella foenum) Kaddu (Cucurbita maxima)	Amrood (Psidium guajava) Rumman (Punica granatum) Bahi (Cydonia oblonga) Ananas (Ananas comosus) Injeer (Ficus carica) Aam (Mangifera indica)

 

 

This diet, recommended by ancient Unani scholars, aligns with modern nutritional principles. It is rich in essential nutrients like iron, folic acid, vitamin A, vitamin B12, protein, and minerals, which are crucial for overall health and combating anemia.^{21, 22, 23}

 

2. Ilaj bil Dawa (Drug Therapy):

Unani Herbal Remedies for Iron Deficiency Anemia; Unani practitioners employ a range of herbs single and compound drugs renowned for their blood-purifying and hematopoietic properties. Key herbs utilized in the treatment of iron deficiency anemia include:

 

 

NO.	Mufrad Dawa (Single Drugs)	Murakkab Dawa (Compound Drugs)
1   2   3   4   5   6   7   8   9  10	Zafran (Crocus sativus) Maweez Munaqqa (Vitis vinifera linn) Asaroon (Asarum europaeum) Balchhar (Nardostachys jatamansi) Halela (Terminalia chebula) Balela (Terminalia bellerica) Amla (Emblica officinalis) Qaranfal (Eugenia caryophyllata) Bisfaij (Polypodium vulgare) Rai (Brassica juncea)	Sharbat-e-Faulad Sharbat-e-Anarain  Sharbat-e-Afsanteen Sharbat-e-Ananas  Qurs Khusta Faulad Kushta Sammul Far Kushta Nuqrah Majoon-e-Dabeed-ul-Ward Majoon Khabsul Hadeed   Jawarish Amla

 

 

These drugs are carefully selected and combined to create personalized treatments that address the underlying causes of iron deficiency anemia, promote healthy blood production, and restore overall well-being.^4,5,7

Ilaj bil Tadbeer (Regimental Therapy):

Regimental therapies enhance blood circulation, detoxify the body, encompasses lifestyle modifications and procedures tailored to enhance digestion, and promote the production of Khoon Saleh (pure blood), which is vital for Affal Haiwaniya (vital functions). Recommended therapies include:

1. Massage Therapy (Dalk): Enhances blood circulation, promoting the delivery of oxygen and nutrients to tissues.^5,21

2. Warm Compress (Takmeed) is a therapeutic approach employed in Unani medicine to augment the body's innate capacity for producing and maintaining healthy blood. Given the association between anemia and a cold, moist temperament (Barid wa Ratab Mizaj), Takmeed counterbalances these characteristics by introducing warmth and stimulating blood production (Dam).^5,21

3. Steam Bath Therapy (Hammam): Facilitates detoxification, improves overall health, and boosts the immune system.^5,21

4. Physical Exercise (Riyazat): Augments blood flow, strengthens the body's natural capacity for blood production and enhances overall physical fitness.^5,21

5. Controlled Bloodletting (Fasd) or Cupping Therapy (Hijama): In selected cases, controlled cupping may be employed to eliminate impure blood (fasad-e-dam), restoring the body's natural balance and promoting healthy blood production.^5,21

6. Emetic Therapy (Qai) it is not a direct treatment for anemia, This approach is particularly relevant when anemia is linked to impaired digestive function (Zof-e-Meda), blood impurities (Fasad-e-Dam), or the presence of viscous phlegm (Balgham) that hinders nutrient absorption.^5,24

Authors Contribution Statement: All authors have contributed equally to this work.

Conflicts of Interest: None

Funding: Nil 

Source of Support: Nil

Informed Consent Statement: Not applicable. 

Data Availability Statement: The data supporting in this paper are available in the cited references. 

Ethics approval: Not applicable.

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