Transcript Medical nutrition therapy

Nutritional anemia

A condition when the Hb content of the blood is
lower than normal as a result of a deficiency of
one or more of the essential nutrients regardless
the cause of such deficiency. Causes of
nutritional anemia are deficiency of : iron, vitamin
B12, folic acid, protein, vitamin C,
Iron Deficiency anemia (IDA):
IDA is the most common nutritional disorder and
is a problem in both developed and developing
countries.
 Around 30% of total world population is anemic
and half of this percentage are women of
childbearing age and young children .
Iron

The most important of the trace elements.
Iron exist in small amount in the body. Total
quantity of iron in the body of adult is 4gm.
About 65% of which is in the form of Hb.
4% of which is in the form of myoglobin.
1% is in the form of various heme
compounds that promote intracellular
oxidation
(cytochrome,
cytochrome
oxidase, peroxidase, catalase,…). about
15-30% is stored, mainly in the RES & the
liver paranchymal cells principally in the
form of ferritin.
Requirements of iron;

Dietary iron is needed to replace basal loss
of iron in the stool, urine and through the
skin. The normal daily loss of iron is 1 mg
 In female, iron loss during menstruation will
increase her requirement to 2.4. infants,
children and adolescents require iron for
their expanding red cell mass & growing
body tissue.
Dietary requirement
Children 1-10
: 10 mg per day
11-18 male
: 12 mg per day
11-18 females
: 15 mg per day
19-50 male
: 10 mg per day
19-50 female
: 15 mg per day
Pregnant women : 30 mg per day
Lactating women :15 mg per day

Risk groups :
 LBW infant, preschool children, school age
children, & adolescents. pregnant woman, other
women in child bearing age, and the elderly,
causes iron-deficiency anemia
1- diets low in iron •
Iron is obtained from foods in our diet,
however, only 1 mg of iron is absorbed for
every 10 to 20 mg of iron ingested. A
person unable to have a balanced iron-rich
diet may suffer From some degree of irondeficiency anemia.
2-body changes •
An
increased
iron
requirement
and
increased red blood cell production is
required when the body is going through
changes such as growth spurts in children
and adolescents, or during pregnancy and
lactation.
3- gastrointestinal tract abnormalities
Mal-absorption of iron is common after some
forms of
gastrointestinal surgeries. (e.g. resection of the
stomach or small bowel)which lead to malabsorption of iron & or vitamin B12 ). Any
abnormalities in the gastrointestinal tract could
alter iron absorption and result in iron-deficiency
anemia.
4- blood loss •
Loss of blood can cause a decrease of iron and
result in iron deficiency anemia. Sources of blood
loss may include GI bleeding, menstrual bleeding,
or injury, hemoglobinuria ,repeated labour &
abortion, parasite , polyps , hemorrhoid
Factors affecting the prevalence of anemia:
The prevalence of anemia varies
according to both host factors (age,
gender, physiological status & infection)
and environmental factors (diet &
socioeconomic factors).

physiological demand for red blood
cells Increases in
 Lactation
 Pregnancy
 Growth spurt


High risk groups for iron deficiency
1- children , adolescent , pregnant & lactating
women .
2- menstruating females ,
3. those with frank or
occult hemorrhoid or surgery and those who
use aspirin and other prostoglandine inhibitor
drugs due to increased losses of blood .
4- vegetarians .
5-malabsorption syndrome, low Vitamin C
intake .
Heavy use of tea , coffee , and antacid , high
dietary intake of oxalate, phosphate and
phytate & chronic exposure to lead and
cadmium.
Prevention and control of IDA anemia:
1-Nutritional education of the population :
 increased
iron
intake
through
consumption of iron rich food
 increased consumption of foods which •
enhanced iron absorption such as fruit ,
vegetables and meat .
 reduced intake of inhibitors to iron
absorption such as tea or coffee with meal
2- fortification :
Is recommended especially for
those areas of target groups which
have no access to fresh or high
quality nutritious food ( fruits ,
vegetables , meat , ….)
The food selected to fortification
should reach the population at risk.
The fortification process should not
changes food appearance , or tests
& must be bio-available without
being inhibited by other compounds
of the diet .
3-Iron supplementation :
whether to prevention or treatment of IDA
4-Eradication of parasitic infestation :
Hookworm infestation not only causes blood
loss , but also affects the absorptive capacity
of the intestinal mucosa . Deworming should
be combined with supplementation or
fortification.
Endemic diseases such as malaria or
schistosomiasis have their impact on iron
deficiency , should be controlled , diagnosed
& managed.
5-promotion of breast – feeding .
Although breast milk does contain
much iron , this iron is highly
bioavailable & it protect the child from
infection .
6- family planning programs including child
spacing & improvement nutritional status of
women .
7- decreasing frequency of infections
through sanitation , immunization & control
of diarrheal diseases .
Medical nutritional therapy:

There are two forms of iron in the food, haem
and non haem iron, the former of which is
present in meat, fish, and poultry (MFP factor)
and is about 15% absorbable and is much
better absorbed than nonhaem iron.
 Nonheam iron is present in cereals, vegetables
and fruits; and it is absorption rate vary
between 3-8% depending on the presence of
dietary enhancing factors specifically ascorbic
acid and MFP.
The rate of absorption depends on
the iron status in the individual, as
reflected in the level of iron stores.
The lower the iron store, the greater
will be the rate of iron absorption.
 Individuals
with iron deficiency
anemia absorb 20-30% of dietary iron
compared with the 5-10% absorbed
by those without iron deficiency

Factors affecting absorption of nonheme iron:
A-Substances that inhibit nonheme-iron absorption
1.
Phytates, tannins , oxalate, phosphates and Plant polyphenolics .
2.
A chlorhydria, Calcium-rich antacids.
High iron store
Inorganic elements: calcium, manganese, copper, lead and cadmium.
High dietary amounts of zinc and other divalent cat ions
Soy protein
Bran
Egg
Milk
Tea, cola and coffee
3.
4.
5.
6.
7.
8.
9.
10.
B-Substances that enhance nonheme-iron
absorption
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Ascorbic acid (vitamin C),citrus fruit,
green leafy vegetables .
Meat, poultry, and fish (MPF).
Citric, lactic, tartaric acids, and other
organic acids
Fermentation products of soybean
Pregnancy,
a plastic anemia,
hemolytic anemia
Low iron stores of individuals
Low iron content of meals
Iron in ferrous form
Factors influencing haem- Fe Absorption
A- enhancers :
-low Fe status
-low haem intake
- meat
B- inhibitors :
-high Fe status
-high haem intake
-Ca
dietary manipulation
 that
involve enhancing the
bioavailability of the iron ingested.
This could be achieved through
promoting the intake of iron
absorption enhancers ( citrus
fruits and meat) or reducing the
intake of iron absorption inhibitors
(tannin, phytic acid).
 It
could be achieved also through
encouraging the use of common
household processing methods
( germination, milting, fermentation)
which can enhance iron absorption by
lowering tannin or phytic acid contents
or increase vitamin C contents.
The following are some of the dietary guides suggested
by the WHO:
Separate tea drinking from meal time (1 or
2 hours later).
 Ad orange or fruit juice or other source of
ascorbic acid to meal. Consume fresh
vegetable.
 Remove milk or cheese from meal and
consume it between meal snakes.
 Move the consumption of inhibitors to the
meals lowest in iron contents.

Tips to Increse Iron Intake






To achieve the recommended daily intake of Iron/day of 8mg for
males and 18mg for females
Red meat and poultry are rich sources of heme iron (a wellabsorbed form of iron)
• Lean meat can be consumed 1-2 times per week
• Poultry can be consumed 2- 3 times per week
Liver, kidney, beef, dried fruits, dried peas and beans, nuts, green
leafy vegetables, and fortified whole grain breads, muffins, cereals,
and nutrient bars are among the foods that rank highest in iron
content.
Eat more dark green vegetables (e.g. spinach, Jews mallow, etc.)
and make sure to include a source of vitamin C (e.g. lemon juice,
orange juice) or some form of meat in plant-based dishes in order
to enhance the absorption of iron
Tips to Increse Iron Intake

Consume pulses (e.g. lentils, fava
beans, beans, chickpeas) at least 3
times per week and make sure to
include a source of vitamin C or some
form of meat in the same meal

Food fortification: can be targeted to
reach some or all the population. It
doesn't require cooperation of the
individual. Thus it overcome compliance
problem
&
make
the
program
sustainable. Iron fortification is primarily
a preventive program, not intended to
treat severe anemia in large section of
the population
Iron-Rich Foods
Foods
Iron (mg)
Organ meats (liver, giblets), cooked, 90g
5.2—9.9
Pumpkin and squash seed kernels, roasted, 30g
4.2
White beans, canned, ½ cup
3.9
Lentils, cooked, ½ cup
3.3
Spinach, cooked from fresh, ½ cup
3.2
Kidney beans, cooked, ½ cup
2.6
Sardines, canned in oil, drained, 90g
2.5
Iron dietary sources:
A- Very good sources of Fe :
Animal sources- meat, liver, kidney, fish, egg
yolk.
B- Good sources of Fe :
bread & flour •
breakfast cereals
vegetables ( dark green )
nuts & dried fruit – prunes , figs ,
apricots
yeast extract
pulses, beans, peas,
C- Milk-Human milk -0.29-0.45mg/dl
(Cow’s milk –poor source with 0.01–0.38mg/dl)
Megaloblastic anemia:

Megaloblastic anemia is usually caused
by a deficiency of vitamin B12 or folic
acid, both of which are essential to the
synthesis
of
nucleoproteins.
Hematologic changes are the same for
both; however, the folic acid deficiency
is the first to appear.

Normal body folate stores are depleted
within
2-4
months in individuals
consuming folate-dificient diets; by
contrast, vitamin B12 stores are
depleted only after several years of
vitamin B12- deficient diet.
Causes of vitamin B12 deficiency:

Inadequate ingestion: Poor diet ( strict
vegetarianism, chronic alcoholism,
poverty).
 Inadequate absorption:
 addisonian pernicious anemia
 Gastrectomy: either total or subtotal.
 Antibody to intrinsic factor

Tropical sprue.
 Regional enteritis
Medical nutritional therapy:


A high protein diet (1.5g/kg of body weight) is
desirable both for liver function and for blood
regeneration.
Because leafy green vegetables contain
both iron and folic acid, the diet should
contain increased amount of these foods.
 Liver
should be included frequently
because it carries a good supply of iron,
vitamin B12, folic acid, and other important
nutrients.
Meats (especially beef), eggs, milk, and
milk products are particularly rich in vitamin
B12
 People over the age of 50, it is
recommended to consume vitamin B12 in
its crystalline form (i.e., fortified cereals or
supplements) to overcome the effect of
atrophic gastritis.
 The
recommended dietary allowance
(RDA) for adult men and women is 2.4

mcg daily.
Examples of Foods Rich in
Vitamin B12
Food
Vitamin B12 (μg)
Mollusks, cooked, 90g
84.1
Liver, beef, braised, 1 slice
47.9
Salmon, cooked, 90g
4.9
Beef, lean, broiled, 90g
2.4
Yogurt, 1 cup
1.4
Tuna, white, canned in water, 90g
1.0
Egg, hard boiled, 1 whole
0.6
Chicken breast, roasted, ½ breast
0.3
Causes of folate deficiency
Inadequate ingestion: poor diet either
 Nutritional (tropical, nontropical, scurvy).
 Chronic alcoholism, with or without
cirrhosis.
 Inadequate absorption
 Malabsorption syndromes as celiac
disease

use of Drugs (anticonvulsants,
barbiturates, metformine, choletyramine,
cycloserine, ethanol, amino acid excess,
sulfasalazine).
 Increased requirement

 Extra tissue demand (pregnancy, lactation,
malignancy)
 Infancy.
Increased excretion
 Vitamin B12 deficiency.
 Liver disease.
 Kidney dialysis.
 Chronic exfoliative dermatitis

Medical nutritional therapy:
A daily intake of 400 μg/day of folic acid is
necessary to decrease risk of anemia and
neural tube defects in newborns. To achieve this
intake, women of child-bearing age should
consume:
 - Folate-rich foods, notably leafy greens, fruits
and dried beans and peas.
 - Synthetic Folic acid (from fortified foods or
supplements)

Food
Beef liver, cooked, braised, 90g
Spinach, frozen, boiled, ½ cup
Asparagus, boiled, 4 spears
Spinach, raw, 1 cup
Green peas, frozen, boiled, ½ cup
Broccoli, frozen, cooked, ½ cup
Lettuce, Romaine, shredded, ½ cup
Turnip greens, frozen, boiled, ½ cup
Cantaloupe, ¼ medium
Banana, 1 medium
Folic acid (μg)
185
100
85
60
50
50
40
30
25
20
Sickle cell anemia:
Medical nutrition therapy:
The food should contain enough calories
and protein for growth and development.
 They should be provided by food high in
calories, folic acid (400-600 mcg daily),
zinc and copper and vitamin A, C, D,
and E.
 A multivitamin/mineral supplements
containing 50-150% of the RDA for
folate.

2-3 quarts of water is also important.
 It is also important to remember that
patients with sickle cell disease may require
higher than RDA amounts of protein
 Iron rich foods, such as liver, iron fortified
formula, iron fortified cereals, and iron
fortified energy bars are excluded
 Alcohol and ascorbic acid supplements and
other substances that enhance iron
absorption should be avoided.

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