NUTRITIONAL CARE IN

ANEMIA

Nutrition Departement
Faculty of Medicine
University of North Sumatera

Definition
Deficit of circulating RBC associated with
diminished oxygen-carrying capacity of the
blood
Most common hematologic disorder by far
Hb < 12 g/dL
Hb < 13 or 13.5 g/dL

Classification
Microcytic (small cell)
- Major nutritional cause is iron deficiency
- Minor pirydoxin & copper deficiency

Normocytic anemia
- PEM & various chronic disease
Macrocytic
- Vitamin B12 & folic acid deficiency

Iron-deficiency anemia is the most

common nutritional anemia and perhaps
the most common nutritional deficiency
disorder in the world

 Characterized by the production of small

erythrocytes and diminished level of
circulating hemoglobin
Last stage of iron deficiency
Represent the end point of a long period of
iron deprivation

 The greatest risk :

- Between 6 month 4 year
- Early adolescent
- During the menstruating years
- During pregnancy

Causes of Iron Deficiency

Dietary inadequacy the most common cause
- poor diet (vegetarian)

Inadequate absorption

Diarrhea ; intestinal disease ; atrophic gastritis ;

Achlorhydria ; partial or total gastrectomy ; drug interference

Increased Iron requirement

Pregnancy
Infancy
Adolescence
lactation

Increased excretion

- excessive menstrual blood

- hemorrhage from injury
- chronic blood loss

Dietary Iron
Heme Fe (meat, fish and poultry) best
absorbed
Non-heme Fe (cereal, vegetables) taken up less
avidly
Heme Fe 20% bioavailable, nonheme only 3%
Ionic Fe (Fe++) also well absorbed
>1/3 of Fe from fortification of flour
Tea inhibits Fe absorption

Iron Absorption
Proximal small bowel, esp duodenum
Enhanced by gastric acid (Fe+2 is valance
absorbed)
Heme Fe > non-heme Fe
Reciprocal relationship to iron stores
Direct relationship to erythropoiesis; with
ineffective erythropoiesis
Inhibited by inflammation, phytates

Fe
Plasma
16%

4%

15%

65%

IRON
Body Compartments - 75 kg man
Stores
1000 mg

Tissue
500 mg

Absorption < 1 mg/day

30 mg

Red Cells
2300 mg

Excretion < 1 mg/day

IRON STORES
Iron Deficiency Anemia
Stores
0 mg

Tissue
500 mg

Absorption 2-10 mg/day

3 mg

Red Cells
1500 mg

Excretion Dependent on Cause

Mechanisms for maintaining iron balance :

- continuous reutilization of iron
- regulation of the absorption of iron
- access to specific storage protein (ferritin)

 Typical diet : formerly ~10-15 mg/d,

now ~24 mg/d
10-15% comes from heme sources (meats &
seafood)
85-90% comes from non heme sources (dried
beans, peas, leafy green vegetable)
> 1/3 of Fe from fortification of flour.

Medical Management
Treatment should focus on the underlying
disease, although this is often difficult
Repletion of iron stores, not merely
alleviation of the anemia should be the
goal

Therapy
Oral ferrous form
- ferrous sulfate most widely used
- 50 - 200 mg elemental Fe/d (60 mg,
1-3 x / day)
- 6.0 mg elemental Fe/kg per day in children
- Duration- 6 months
Parenteral- Fe dextran 50 mg/ml, 100 mg/d im/iv
- more expensive & not as safe

IRON THERAPY
Response

Initial response takes 7-14 days

Modest reticulocytosis (7-10%)
Correction of anemia requires 2-3 months
6 months of therapy beyond correction of
anemia needed to replete stores, assuming no
further loss of blood/iron
Parenteral iron possible, but problematic

If supplementation fails, maybe that :

1. The patients may not be taking the
medication, most likely because of
unpleasant side effect
2. Bleeding may be continuing
3. The supplemental iron is not being absorbed

Parenteral route

Medical Nutrition Therapy

In addition to supplementation, attention
should be given to the amount of absorbable
dietary iron
Liver, kidney, beef, egg yolk, dried fruit, dried
peas and beans, nuts, green leafy vegetables,
whole grain breads and cereals, and fortified
food.

Factors affecting absorption

Enhancing factors :
- Ascorbic acid
- MFP

Inhibiting factors :
-

Carbonates
Oxalates
Phytates
Tanin

Prevention
Iron supplementation, i.e. giving iron tablets
to certain target groups
Iron fortification of certain foods
Education about food in order to improve the
absorption

Recommendations :
Improve food choices to increase amount of
total dietary iron
Include a source of vitamin C at every meal
Include MFP at every meal if possible
Avoid drinking a large amounts of tea or
coffee with meals

MACROCYTIC ANEMIAS
Characterized by an MCV greater than 100 3

Also called megaloblastic anemias large,

immature red cell precursors (megaloblasts)
accumulate in the bone marrow

Vitamin B12 Deficiency

Most often caused by impaired absorption
Strict vegetarian (vegans) who consume
no dairy products, eggs or meat
increased risk for deficiencies

The main cause of vitamin B12 deficiency

is PERNICIOUS ANEMIA

 Vitamin B12 deficiency should be

considered when the plasma concentration
< 150 200 pg/ml

If there is a deficiency, the plasma folate

level may be elevated to 15 or 20 ng/ml ~
impaired tissue folate uptake and turnover
(methyl-folate trap)

The development of vitamin B12 deficiency

First stage, characterized by a negative vitamin B12 balance,
During which the plasma vitamin B12 level is marginal and only
vitamin B carries in plasma (transcobalamins) may be
abnormally low
Subsequently, the plasma vitamin B12 level falls
When the level reaches 100 150 pg/ml, neutrophils begins to
appear hypersegmented
Finally, macroovalocytes appear, the MCV is elevated and the Hb
level drops
Anemia develops IN THE LATER STAGES of vitamin B12 deficiency
like iron deficiency

Dietary Sources
Found ONLY in food of animal origin
Most meat and dairy products contain B12
Beef liver : an especially rich sources

RDA
and 2 g / day
During pregnancy 2,2 g / day
During lactation 2,6 g / day

 Remission of the sign & symptoms a single

intramuscular injection of 100 to 1000 g of
cyanocobalamins or hydroxocobalamins
Daily administration of 100 g for several days
For PA patients & other who need continued
parenteral therapy injections of 100 g every
month

Folic Acid Deficiency

Large, immature red blood cells
DNA synthesis slows & cells lose their
ability to divide
The nucleus of the cells is not released as normally
immature blood cells are enlarged & oval shaped

Causes of Folic Acid Deficiency

Insufficient intake
RDA : 180 g / day
200 g / day
During pregnancy 400 g / day
During lactation 260 - 280 g / day
Suboptimal folate intake during early pregnancy (even without
other manifestations of folate deficiency major risk factor for
neural tube birth effects

Person who rarely consume green leafy vegetables or other

sources of folate

 Associated with a variety of intestinal disorders

such as Crohns disease, celiac disease and
tropical sprue
Alcoholics

Cigarette smokers
Drug-nutrient interactions (e.g. anticonvulsants,
diuretics, antibiotics and antimalarials)

Dietary Sources
Widely distributed in :

Yeast
Liver and other organ meat
Leafy vegetables
Fresh fruit
Enriched bread and cereal products

Oranges juice the highest contributor of folic acid to the

American diet

Between 50% and 90% of folate in the food destroyed

by prolonged cooking and processing

Treatment
Plasma level should be used to guide therapy
Readily resolved with a 1 mg daily oral supplement

In the patients with malabsorption,

Initial treatment parental folate
Maintenance oral therapy