Microminerals

Prof. Chandrani Liyanage

Objectives








Sources
Body pools
Prevalence of deficiency
Clinical features in deficiency
Absorption
Requirements and recommendations
Deleterious effects
Implications
National plan to combat the deficiency

Iron

young children in tropical and subtropical regions Has the greatest overall effect in terms of premature death.women of reproductive age (15-49y) . ill-health and lost earnings .Iron deficiency is the most common nutritional disorder in the world Affects .

Metabolism and physiology • Iron in human body . tissue Fe 6-8mg.5g in men Of which 73% haemoglobin (2-2.about 2.3g in adult women 3.5g of iron) 10% myoglobin (130mg of iron) 3% active iron containing heme and flavin enzymes and transport iron (labile Fe 80.3g) 25% in men in storage (1.0g) . trans Fe 3mg) Remainder 14% in women and children in storage SF & haemosiderin (0.90mg.

Childhood & adolescence • ID less common as rate of growth decreases • During adolescence prevalence rises again as iron needs increase with adolescent growth spurt • More common among pregnant adolescents .

. • Term infants at a greater risk of developing ID between 4-12 months and after.Iron needs • Pregnancy – imposes increased needs. Risk largely depends on the complementary feeding.needs are primarily for growth. High Hb conn and abundant neonatal iron stores protect until 4 months (stores deminish by 4th month). At risk of developing an iron responsive depression in Hb conn in the 3rd Trimester • Infancy . • In infants absn is 4 times greater than excretion and the difference is used for growth.

Iron deficiency • Is rare in formula fed infants • Is common in unfortified formula or cow milk fed • Exclusively breastfed infants develop after 6 months • Low birth infants develop after 2 months – need iron supplements • Fe needs are greater due to low neo stores and rapid relative growth rate • A dose of 2-3mg elemental iron/kg /day recommended .

sex. Trf.Deficiency . elevation of Erythrocyte protopophyrin or Trf receptor levels . and stage of pregnancy • Iron deficiency anaemia Anaemia associated with additional laboratory evidence of iron depletion (low SF. MCV.Definitions • Anaemia Hb conn or Hct <95% range for healthy well nourished individuals of the same age.

• Iron deficiency Lack of iron that is severe enough to impair the production of RBC. but not necessarily to the extent that Hb falls <normal. Can progress to iron deficiency anaemia • Iron deficiency without anaemia Relatively mild iron deficiency diagnosed on impaired iron status (combination of 2 or more Bio-chemical indicators). but Hb remains in normal range .

4% in preschool children 25.Prevalence of anaemia • Global in 2005 47.9% in elderly • SEAsia 65.8% in pregnant women 30.7% in non-preg.5% in preschoolers 48. Women 45.2% in non-pregnant women 2. women .7% in men 23.2% in preg.4% in school children 41.

9% preschool 29. Women 56-78% preg.In Sri Lanka • • • • 1973 38% men 68% women 78 primary schoolers 1996 15% preschoolers 58% children of 6-11y 36% adolescents 45% nonpreg.3% prelimenary school 40% pregnant 35% nonpregnant (15-49) .3% pregnant 21.6 nonpregnant 2006/07 20. women 2001 29.

WHO recommended standards below which anaemia is likely to be present Cut-off level of haemoglobin • Up to 6 years 110g/l • 6-14 years 120g/l • 15-74 years 120g/l • Pregnancy 110g/l (100g/l in 2 nd Trime) • Adults (male) 130g/l .

9 . .moderate PH • > 40 mild PH pr.Classification of anaemia as a problem of public health significance • Prevalence % < 4.9 - • 20-39.9 - no PH problem • 5-19.severe PH ..

5mg/day) • About 10% women loose more than 30ml. likely anaemic and. chronic malaria. diahorreal diseases . bile and desquamated cells & through blood in minute quantities • In women through menstruation (30ml/month) (additional req 0.Iron loss • Loss – primarily through faeces in healthy individuals (0.6mg/day) • And. need additional iron each day • If total loss > 1.5mg/d – positive balance not maintained • Losses occur due to aspirin intake. parasitic infections • Method of contraception – pill decreases to ½ and IUCD doubles the bleeding . bleeding tumours & ulcers.

Iron absorption • Chemical form of Fe – more important than the amount determines the potentially available Fe for abs n • Heme Fe is absorbed more than twice as effeciently as nonheme Fe • Low pH helps in dissolving ingested Fe and facilitates enzyme reduction of ferric to ferrous by a brush-border ferrireductase. • Duodenal crypt cells mature into absorptive enterocytes for absn of Fe .

fiber.Factors determine absorption 1. foods rich in vit C meat factor animal proteins 2.phytates and phytic acid polyphenols high Ca and Mg intake tea. non-albuminous part of egg soy protein . Enhancers – vit C. Inhibitors . coffee.

Increased requirements during – infancy.3. adolescence after surgery . pregnancy. Fe losses from the body 5. Physiological factors Low stores – increases Good stores – decreases 4.

complementary foods. alone or as part of vitamin-mineral supplement Slow-release Fe preparations better . take in between meals. sugar etc. vitamin drops.Absorption of Fe from iron fortified foods and supplements • Eg. sauces. Cereals. iron stores. (not good for long term storage due to soluble form of Fe promote fat oxidation and rancidity) • Influenced by the dose (<120mg/day). • Ferrous sulphate is usually used. milk powders.

Absn of Fe from multi mineral supp & fortified foods • Less is absorbed from certain MMSs than when given alone (CaCO3 and MgO are inhibitory). • The Ca level should not go beyond 250mg in a MMS. If the dose is reduced to 250mg and 25mg the absn is almost double. .

tinnitus and taste disturbances Pallor of conjunctiva. impaired cognition Short attention spans. nails beds (and soft palate as severity increases) Long term IDA – papillary atrophy of the tongue and spoon shaped nails Enlargement of spleen Behavioral changes in children. poor learning ability . tongue.Clinical features Due to low Hb – shortness of breath lead by physical exertion Increasing lethargy and fatigue Headache.

angular stomatitis.Deleterious effects of IDA • In children – Impairment in neuronal growth and brain function Become irritable and apathetic Impaired mental and physical development Permanent neurological damage Hinders defense against infection and temp regulation Increased attacks of malaria. glossitis .

Contd… • In pregnant women – Increased risk of –maternal morbidity and mortality .foetal morbidity and mortality Milder degrees of anaemia assocoated with LBW Placental hypertrophy Low stores of Fe and folate in the new born Poor maternal weight gain .premature delivery .

Contd. • In adults – Reduced work capacity (related to Hb) Work out put is significantly less Reaching socio-economic consequences Increased lactic acid levels and tachycardia with exercise Reduced activity of intestinal enzymes Reduced growth rate Impaired bodily functions ..

EDR 0-1yr 1-2 2-6 6-12 boys 12-16 girls 12-16 men >16 women(menstruating) (postmenopausal) (pregnant) (lactating) 21 12 14 23 36 40 23 48 19 30-60 26 RDA. 2001 (US-FNB) 4-8yr 9-13yr 14-18yr 14-18 yr >18yr >51yr <18yr 11 07 10 08 11 15 08 18 08 27 10 .Estimated dietary requirement (EDR) and RDA of iron mg/day.

esp with intense exercises • Reduced productivity • Increases risk of lead toxicity (due to shared absorptive mechanism) .Public health implications of IDA • Associated with poor reproductive performance • Higher proportion of maternal deaths (10-20% of total deaths) • Higher incidence of LBW • Higher incidence of IUM • Impairs scholastic performance • Impaired psychomotor devt. interlectual performance • Decreased resistance to infection • Reduced work capacity.

hook worm infestation and ascariasis.Risk factors for IDA • Poor iron stores at birth • Dietary inadequacy • Increased demands due to rapid growth(preg. puberty. childhood) • Malabsorption and increased losses (repeated episodes of doarrhoea. repeated attacks of malaria in endemic areas) . inf.

use of intra uterine contraceptive devices • Haeglobinopathies – Thalassemias and sickle cell anaemia (abnormal formation of Hb – a nonnutritional factor) • Drugs and other factors Radiation therapy.Contd. leukemia Anti-cancer and anti-convulsant drugs In chronic inflammatory conditions (arthritis) In GI blood loss . prolonged lactation. • Closely spaced pregnancies. pph. poor obstetric care..

Control of nutritional anemia • Direct intervention a) supplementation b) fortification • Indirect intervention a) start breast feeding immediately and continue b)educational programmes c) reduction of pathological losses (control of hook worm and malaria) d) Regular and frequent assessment of Hb and iron status of population e) study the causal factors in the area f) train field staff to identify the risk individuals g) encourage regular ANC visits .

rice).Supplementation & Fortification • Iron pills and drops • Complementary foods and milk powders enriched with iron • Centrally processed infant foods • Cereal-legume supplements (Thriposha) • School biscuits • Cereals (wheat flour. . salt. sauces. sugar etc.

Edu programmes • • • • • • • • • Increased production and consumption of iron and folate rich foods Include even small quantities of non-veg foods Vit C rich foods to minimize inhibition by phytates & poly Avoidance of tea and minimize coffee Inclusion of yoghurt and fruit juices in the diet Inclusion of pulses and green leaves in daily diet Intake of supplements in between meals Emphasize the special needs and importance of Fe Encourage home gardening • Intake of supplemental iron helps to reduce fatigue and increase ability to work • Introduce cheap and locally produced iron rich foods • .

Promoting fermented and germinated food. nausea. even a small amt of animal food. not to include much tea and Ca supplements.). Correct consumption of supplements and regular clinic visits. green leafy veg in addition to meat and fish Inclusion of vit C and rich foods. Mothers be made aware of side effects (vomiting.National Plan to combat anaemia in pregnant mothers • Advises on good iron sources (pulses & legumes. • To supplement all the preg mothers with Fe and folic acid supplements after 12 weeks of gestation. . loss of appetite etc.

. • To treat and control paracitic infections after 1st trimester (100mg mebendazole twice daily for 3 consecutive days). moderate and severe. Advise them on high protein diet. good health habits etc. use latrines. To prevent worm infection. • To treat and prevent malaria in endemic areas (300mg of chloroquin once a week during preg and 42 days after delivery).• To identify anaemic mothers by the Hb level and report as mild. • To give parenteral iron to severe anaemics. hygeinic source of water. wearing slippers.

urban poor. education and communication Obtain information about anaemia from the FHWs & people in the area Implementation of proper health education programes Risk groups (young women. working women. estate workers & refugees) be given more attention Make all the health workers more concern about the health message and find that they convey the messages to the public Doctors to supervise all these educational programs .• Information.