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 Inadequate absorption
- poor diet (vegetarian)
Diarrhea ; intestinal disease ; atrophic gastritis ; Achlorhydria ; partial or total gastrectomy ; drug interference Pregnancy Infancy Adolescence lactation

Increased Iron requirement

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%
15%

4%

65%

IRON
Body Compartments - 75 kg man
Stores 1000 mg

Tissue 500 mg

Absorption < 1 mg/day

30 mg

Excretion < 1 mg/day

Red Cells 2300 mg

IRON STORES
Iron Deficiency Anemia
Stores 0 mg
Absorption 2-10 mg/day

Tissue 500 mg

3 mg

Excretion Dependent on Cause

Red Cells 1500 mg

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