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NUTRITIONAL CARE IN

م ر ن ر مم ر ن ر م

NUTRITIONAL CARE IN ANEMIA

Nutrition DepartementFac lt of MedicineFaculty of MedicineUniversity of North Sumatera

Definition

• Deficit of circulating RBC associated with diminished oxygen-carrying capacity of the diminished oxygen carrying capacity of the blood

• Most common hematologic disorder by far• Hb < 12 g/dLHb 12 g/dL• Hb < 13 or 13.5 g/dL

ClassificationClassificationMicrocytic (small cell)• Microcytic (small cell)- Major nutritional cause is iron deficiency- Minor pirydoxin & copper deficiencyMinor 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 p pthe most common nutritional deficiency

disorder in the worlddisorder in the world

• Characterized by the production of small erythrocytes and diminished level of erythrocytes and diminished level of circulating hemoglobin

• Last stage of iron deficiency

• Represent the end point of a long period of iron deprivationiron deprivation

• The greatest risk :• The greatest risk :- Between 6 month – 4 year

E l d l- Early adolescent- During the menstruating years- During pregnancy

C f I D fi iCauses of Iron Deficiency• Dietary inadequacy the most common cause• Dietary inadequacy the most common cause

- poor diet (vegetarian)

• Inadequate absorptionDi h i t ti l di t hi t iti – Diarrhea ; intestinal disease ; atrophic gastritis ;

– Achlorhydria ; partial or total gastrectomy ; drug interference• Increased Iron requirement

Pregnancy– Pregnancy– Infancy– Adolescence– lactation

• Increased excretion- excessive menstrual blood- hemorrhage from injury

h i bl d l- chronic blood loss

Dietary Ironf h d l b• Heme Fe (meat, fish and poultry) best

absorbedN h F ( l t bl ) t k l • Non-heme Fe (cereal, vegetables) taken up less avidlyHeme Fe 20% bioavailable nonheme only 3%• Heme Fe 20% bioavailable, nonheme only 3%

• Ionic Fe (Fe++) also well absorbed1/3 f F f f tifi ti f fl• >1/3 of Fe from fortification of flour

• Tea inhibits Fe absorption

Iron AbsorptionIron Absorption

• Proximal small bowel, esp duodenum• Enhanced by gastric acid (Fe+2 is valance

b b d)absorbed)• Heme Fe > non-heme Fe

R i l l ti hi t i t• Reciprocal relationship to iron stores• Direct relationship to erythropoiesis; ↑↑ with

ineffective erythropoiesisineffective erythropoiesis• Inhibited by inflammation, phytates

FeFe

Plasma

16%4%15%

65%65%

IRONBody Compartments - 75 kg man

StoresStores1000 mg

Tissue500 mg 30 mg

Absorption < 1 mg/day

Excretion < 1 mg/dayg

Red Cells2300 mgg

IRON STORESI D fi i A iIron Deficiency Anemia

StoresStores0 mg

Tissue500 mg 3 mg

Absorption 2-10 mg/day

Excretion Dependent on Cause500 mg g

Red Cells1500 mg

Mechanisms for maintaining iron balance :

- continuous reutilization of ironl ti f th b ti f i- regulation of the absorption of iron

- access to specific storage protein (ferritin)

• Typical diet : formerly ~10-15 mg/d, Typical diet : formerly 10 15 mg/d, now ~24 mg/d

• 10-15% comes from heme sources (meats & • 10 15% comes from heme sources (meats & seafood)

• 85-90% comes from non heme sources (dried 85 90% comes from non heme sources (dried beans, peas, leafy green vegetable)

• > 1/3 of Fe from fortification of flour. 3 o e o o t cat o o lou .

Medical Management

– Treatment should focus on the underlying di lth h thi i ft diffi ltdisease, although this is often difficult

– Repletion of iron stores, not merely alleviation of the anemia should be the goalgoal

TherapyTherapy

• Oral ferrous formOral ferrous form- ferrous sulfate most widely used- 50 - 200 mg elemental Fe/d (60 mg50 200 mg elemental Fe/d (60 mg,

1-3 x / day)6 0 mg elemental Fe/kg per day in children- 6.0 mg elemental Fe/kg per day in children

- Duration- 6 monthsParenteral Fe d t 50 g/ l 100 g/d i /i• Parenteral- Fe dextran 50 mg/ml, 100 mg/d im/iv- more expensive & not as safe

IRON THERAPYIRON THERAPYResponse

• Initial response takes 7-14 daysp y• Modest reticulocytosis (7-10%)• Correction of anemia requires 2-3 monthsCorrection of anemia requires 2 3 months• 6 months of therapy beyond correction of

anemia needed to replete stores, assuming no p , gfurther loss of blood/iron

• Parenteral iron possible, but problematicp p

If supplementation fails, maybe that :

1 Th i b ki h1. The patients may not be taking the medication, most likely because of unpleasant side effectunpleasant side effect

2. Bleeding may be continuing3. The supplemental iron is not being absorbed3 e supp e e ta o s ot be g abso bed

Parenteral route

M di l N t iti ThMedical Nutrition Therapy

• In addition to supplementation, attention should be given to the amount of absorbable di t idietary iron

k d b f lk d d f d d • Liver, kidney, beef, egg yolk, dried fruit, dried peas and beans, nuts, green leafy vegetables, whole grain breads and cereals and fortified whole grain breads and cereals, and fortified food.

Factors affecting absorptionFactors affecting absorption

• Enhancing factors : • Inhibiting factors :Enhancing factors :

- Ascorbic acid

Inhibiting factors :

- Carbonates- Ascorbic acid- MFP

- Carbonates- Oxalates

Phytates- 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 irony

• Include a source of vitamin C at every meal• Include MFP at every meal if possibley p• Avoid drinking a large amounts of tea or

coffee with meals

MACROCYTIC ANEMIAS

• Characterized by an MCV greater than 100 μ3

• Also called megaloblastic anemias → large, immature red cell precursors (megaloblasts) accumulate in the bone marrow

Vitamin B12 DeficiencyVitamin B12 Deficiency

• Most often caused by impaired absorptionMost often caused by impaired absorption

St i t t i ( ) h• Strict vegetarian (vegans) who consume no dairy products, eggs or meat → i d i k f d fi i iincreased risk for deficiencies

• The main cause of vitamin B12 deficiency is PERNICIOUS ANEMIA

• Vitamin B12 deficiency should beVitamin B12 deficiency should be considered when the plasma concentration → < 150 – 200 pg/ml

• If there is a deficiency, the plasma folate y, plevel may be elevated to 15 or 20 ng/ml ~ impaired tissue folate uptake and turnover ( h l f l )(methyl-folate trap)

The development of vitamin B12 deficiencyThe development of vitamin B12 deficiency

• First stage, characterized by a negative vitamin B12 balance, g y gDuring 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 fallsWhen 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 SourcesDietary Sources

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

RDARDAand 2 μg / day

During pregnancy 2 2 μg / dayDuring pregnancy 2,2 μg / dayDuring lactation 2,6 μg / day

• Remission of the sign & symptoms → a single intramuscular injection of 100 to 1000 μg ofintramuscular injection of 100 to 1000 μg of cyanocobalamins or hydroxocobalamins

• Daily administration of 100 μg for several days

• For PA patients & other who need continued parenteral therapy → injections of 100 μg everyparenteral therapy → injections of 100 μg every month

F li A id D fi iFolic Acid Deficiency

• Large, immature red blood cells

• DNA synthesis slows & cells lose their bilit t di idability to divide

The nucleus of the cells is not released as normally immat re blood cells are enlarged & o al shaped→ immature blood cells are enlarged & oval shaped

Causes of Folic Acid DeficiencyCauses o o c c d e c e cy

• Insufficient intake

RDA : 180 μg / day200 μg / day

D i 400 / dDuring pregnancy 400 μg / dayDuring lactation 260 - 280 μg / day

S b ti l f l t i t k d i l ( ith tSuboptimal 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 Crohn’s disease, celiac disease and

i ltropical sprue

• Alcoholics• Alcoholics

• Cigarette smokersC ga ette s o e s

• Drug-nutrient interactions (e.g. anticonvulsants, di ti tibi ti d ti l i l )diuretics, antibiotics and antimalarials)

Dietary Sources

• Widely distributed in :– Yeast– Yeast– Liver and other organ meat– Leafy vegetables

Fresh fruit– Fresh fruit– Enriched bread and cereal products

O j i th hi h t t ib t f f li id t th• 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

TreatmentTreatment

Plasma level should be used to guide therapyPlasma level should be used to guide therapy

• Readily resolved with a 1 mg daily oral supplementReadily resolved with a 1 mg daily oral supplement

• In the patients with malabsorptionIn the patients with malabsorption,– Initial treatment → parental folate– Maintenance → oral therapypy

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