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LAPORAN PRAKTIKUM DIETETIK 2

TATA LAKSANA DIET PADA PASIEN


FRAKTUR INTERTROCHANTER FEMUR DEXTRA
DI RUANG RAWAT INAP CEMPAKA BAGIAN BEDAH
RSUD WONOSARI GUNUNGKIDUL YOGYAKARTA

Disusun Oleh :
NIKMATUS SHOLIHAH
NIM. 170400381

PROGRAM STUDI S1 ILMU GIZI


FAKULTAS ILMU-ILMU KESEHATAN
UNIVERSITAS ALMA ATA YOGYAKARTA
TAHUN 2018
BAB I
PENDAHULUAN

A. ASSESMENT GIZI

1. ANAMNESIS
a. Identitas Subjek
Nama : Tn. WM No RM : 00656958
Umur : 91 tahun Ruang : Cempaka 3
Jenis kelamin: laki-laki Tgl Masuk : 04/11/2018
Pendidikan : tidak sekolah Tgl Kasus : 05/11/2018
Suku : Jawa Alamat : Kayubimo Wonosari
Agama : Islam Klasifikasi alamat:
Kebiasaan merokok: Ya/tidak Perkotaan/perdesaan
Jika ya, frekuensi: 2-3x/hari Diagnosis medis : fraktur
Keterbatasan fisik: intertrochanter femur dextra
Gangguan penglihatan (ya/tidak),
gangguan pendengaran (ya/tidak),
Gangguan berjalan (ya/tidak),
Kemampuan mobilitas:
Bedrest

b. Data Sosio Ekonomi


Pekerjaan Tidak bekerja
Penghasilan -
Jumlah anggota 3 (istri, anak dan menantu)
Keluarga
Kondisi yang Kehilangan pekerjaan (ya/tidak), kehilangan anggota
mempengaruhi keluarga (ya/tidak), trauma (ya/tidak), riwayat operasi
Psikologis (ya/tidak)

c. Data Berkaitan dengan Riwayat Penyakit


Keluhan Utama Pasien merasakan nyeri pada panggul sebelah kanan
Riwayat Penyakit Pada tanggal 4 november sekitar jam 3 sore, saat
Sekarang membersihkan kerikil di depan rumah, saat pasien berdiri tiba-
tiba pusing lalu jatuh dalam posisi miring. Pasien mengalami
patah panggul bagian kanan.
Riwayat Penyakit Tidak ada
Dahulu
Riwayat Penyakit Tidak ada
Keluarga

d. Data Berkaitan dengan Riwayat Gizi


Alergi makanan Tidak ada
Pantangan Tidak ada
makanan
Masalah Nyeri ulu hati (ya/tidak), Mual (ya/tidak), Muntah (ya/tidak),
gastrointestinal Diare (ya/tidak), Konstipasi (ya/tidak ), Anoreksia (ya/tidak)
Perubahan pengecapan/penciuman (ya/tidak )
Kesehatan Sulit menelan (ya/tidak), Stomatitis (ya/tidak), Gigi
Mulut lengkap (ya/tidak)
Perubahan Bertambah/berkurang: (ya/tidak), disengaja/tidak disengaja.
berat badan
Riwayat / pola Pola makan pasien tidak teratur 2-3x makan perhari.
makan Makan pokok 2-3x/hari, jarang makan selingan
Makanan pokok: nasi @1 centong sekali makan,
jagung, umbi-umbian
Lauk hewani: telur, ikan, ayam
Lauk nabati: tahu dan tempe setiap kali makan
Buah: pisang, pepaya, jeruk
Sayur: labu siam, wortel, bayam, gambas, pasien tidak terlalu
menyukai sayuran yang berkuah
Minum: teh tawar 2-3 kali perhari, air putih

2. ANTROPOMETRI
Rentang Lengan LILA
66 cm 22 cm

a. Status gizi berdasarkan pengukuran LLA :


Lila diukur
%LLA : standar LLA 𝑥 100%
22
: 29,5 𝑥 100%

: 74,5%
Berdasarkan klasifikasi jelliffe and jelliffe (1989) termasuk dalam
status gizi kurang.

b. Estimasi TB berdasarkan rentang lengan (Sufiati, 2016)


TB laki-laki : 118,24 + (0,28 x RL) – (0,07 x U)
: 118,24 + (0,28 x 132) – (0,07 x 91)
: 118,24 + 36,96 – 6,37
: 148,8 cm

c. Berat Badan Ideal (BBI) : 90% (TB-100)


: 90% (148,8-100)
: 43,9 kg

3. BIOKIMIA
Tanggal Pemeriksaan Satuan/Nilai
Nilai Keterangan
Pemeriksaan Biokimia Normal
05/11/2018 GDS 107 80 - 140 mg/dl Normal
Albumin 4,9 3,5 - 5,2 g/dl Normal
SGOT 9 10 – 50 UL Normal
SGPT 5 10 – 50 UL Normal
Kalium 3 3,4 – 5,3 mmol L Normal
Clorida 95 95 – 108 mmol L Normal
Hemoglobin 5 14 – 18 gr% Rendah
Kesimpulan : berdasarkan pemeriksaan biokimia, nilai Hemoglobin
pasien rendah yaitu 5 gr/dl

4. FISIK-KLINIS
a. Kesan Umum : sedang, compos mentis
b. Tanda vital
Tanggal Satuan/Nilai
Vital sign Nilai Keterangan
Pemeriksaan Normal
05/11/2018 Tekanan darah 140/80 ≤ 130 mmHg Tinggi
Nadi 78x/menit 60-100x/menit Normal
Suhu 36,30C 36-370C Normal
RR 19x/menit 14-20x/menit Normal
Keterangan : berdasarkan pemeriksaan fisik klinis tekanan darah pasien
tinggi yaitu 140/80 mmHg, tetapi pasien tidak memiliki
riwayat penyakit hipertensi dan tidak ada diagnosa medis
hipertensi

5. ASUPAN ZAT GIZI


Hasil recall 24 jam asupan makanan sebelum masuk rumah sakit
Tanggal : 5/11/2018
Implementasi Energi (kcal) Protein (g) Lemak (g) KH (g)
Asupan 682,50 23,60 24,40 94,20
Kebutuhan gizi 1975,50 68,85 54,86 304,50
Asupan/Kebutuhan (%) 34,50 34,20 44,50 30,90
6. TERAPI MEDIS
Interaksi
Jenis Obat Fungsi Solusi
dengan zat gizi
Inj. Ranitidin 2x1 Mengobati masalah Tidak ada Diminum 30-60
tukak pada lambung menit sebelum
dan duodenum (usus makan
12 jari) dan mencegah
penyakit
gastroesopageal reflux
(GERD), gastritis atau
sakit maag, perut
kembung, sendawa
Inj. Ketorolac 3x1 Obat anti-inflamasi Tidak ada Penggunaan obat
untuk mengatasi diiringi dengan
peradangan pasca pemeriksaan
operasi teratur ke dokter
dan jangan
melewati dosis
yang sudah
ditentukan
Inj. Ceftriaxon Mengobati dan Tidak ada Penggunaan obat
mencegah infeksi luka diiringi dengan
operasi yang pemeriksaan
disebabkan antibiotik teratur ke dokter
dan jangan
melewati dosis
yang sudah
ditentukan

KESIMPULAN ASSESMENT GIZI :


- Status gizi pasien berdasarkan pengukuran LILA termasuk status
gizi kurang
- Nilai biokimia hemoglobin rendah (5 g/dl)
- Asupan makan pasien berdasarkan recall 24 jam sebelum masuk
rumah sakit tergolong rendah ≤ 50% (energi, protein, lemak,
karbohidrat)
B. DIAGNOSIS GIZI
Domain Intake
NI. 2.1 Asupan oral tidak adekuat berkaitan dengan menurunnya nafsu
makan dan trauma fraktur ditandai dengan hasil recall 24 jam
rendah, Energi 34,5%, protein 34,2%, lemak 44,5%, karbohidrat
30,9%

Domain Klinis
NC 3.1 Berat Badan kurang berkaitan dengan pola makan yang tidak
teratur ditandai dengan persentil LILA 74,5%

NC 2.2 Perubahan nilai laboratorium terkait gizi berkaitan dengan


pendarahan dan riwayat penyakit fraktur intertrochanter femur
ditandai dengan nilai HB rendah yaitu 5gr/dl
C. INTERVENSI GIZI
1. PLANNING
a. Tujuan Diet
- Memberikan asupan makanan pada pasien ≥80% sesuai dengan
kebutuhan
- Mempertahankan berat badan dan mencegah penurunan berat
badan yang berlebihan
- Membantu meningkatkan nilai HB

b. Syarat/Prinsip Diet
- Energi tinggi, yaitu 45 kcal/kg BB
- Protein tinggi, yaitu 1,5 gr/kg BB
- Lemak cukup, yaitu 25% dari total kebutuhan
- Karbohidrat cukup, yaitu sisa dari total kebutuhan
- Makanan diberikan sesuai dengan kemampuan pasien
- Makanan dalam bentuk mudah cerna
- Vitamin dan mineral cukup sesuai dengan kebutuhan normal.

c. Perhitungan Kebutuhan Gizi

Perhitungan TETP (Almatsier, 2006)


Energi = 45 kcal/kg BB
= 45 x 43,9
= 1975,5 kcal
Protein = 1,5 gr/kg BB
= 1,5 x 43,9
= 65,85 gram
= 263,4 kcal
Lemak = 25% x 1975,5
= 493,75 kcal
= 54,86 gram
KH = Energi – (protein + lemak)
= 1975,5 – (263,4 + 493,75)
= 1218,35 kcal
= 304,5 gram
Kesimpulan :

karena pasien membutuhkan asupan untuk persiapan pemulihan


pasca operasi dan kemampuan pasien dalam menghabiskan makanan
sebelum dilakukan monitoring serta nafsu makanan yang membaik
sehingga kebutuhan gizi yang diberikan yaitu tinggi energi tinggi
protein.

d. Terapi Diet, Bentuk Makanan dan Cara Pemberian


1) Terapi Diet
Makanan biasa + extra enteral susu 2 x 200cc
2) Bentuk Makanan : biasa
3) Cara pemberian : oral
4) Frekuensi makan : 3x makan utama, 2x selingan, 2x extra susu

e. Rencana Monitoring dan Evaluasi


Kriteria Yang diukur Pengukuran Evaluasi/target
Biokimia Hb Sesuai anjuran dokter Normal
Fisik klinik KU, TD, nadi, RR Setiap hari Normal
Asupan zat gizi Energi, protein, Setiap kali makan Asupan makan ≥80%
lemak, karbohidrat

f. Rencana Konsultasi Gizi


Masalah gizi : Asupan tidak adekuat dan berat badan kurang
Topik : Diet Tinggi Energi Tinggi Protein
Tujuan : Memberikan edukasi mengenai diet yang diberikan
rumah sakit untuk memenuhi kebutuhan gizi melalui
makanan
Sasaran : keluarga pasien
Waktu : 5 menit
Tempat : ruang rawat inap cempaka 3
Media : leaflet
Metode : diskusi dan tanya jawab
Materi konseling gizi :
- Edukasi kepada pasien dan keluarga mengenai diet tinggi energi
tinggi protein
- Edukasi kepada pasien dan keluarga mengenai kebutuhan gizi
pasien
- Edukasi kepada pasien dan keluarga mengenai kebutuhan pasien
pra bedah.

2. IMPLEMENTASI
a. Kajian Terapi Diet Rumah Sakit
Jenis diet/bentuk makanan/cara pemberian : biasa/biasa/oral
Implementasi Energi (kcal) Protein (g) Lemak (g) KH (g)
Standar RS 2164,51 69,27 59,95 354,01
Kebutuhan gizi 1975,5 68,85 54,86 304,5
% Asupan/Kebutuhan 109,56% 100,61% 109,27% 116,25%

b. Rekomendasi Diet
STANDAR DIET RS REKOMENDASI DIET
Makan pagi Nasi 150 gr Nasi 150 gr
Lauk hewani 50 gr Lauk hewani 50 gr
Lauk nabati 25 gr Lauk nabati 25 gr
Sayur 100 gr Sayur 100 gr
Selingan Teh manis 200 ml Susu 200 cc
Snack 1 pcs Snack 1 pcs
Makan siang Nasi 150 gr Nasi 150 gr
Lauk hewani 100 gr Lauk hewani 50 gr
Lauk nabati 25 gr Lauk nabati 25 gr
Sayur 100 gr Sayur 100 gr
Buah 100 gr Buah 100 gr
Selingan Teh manis 200 ml Susu 200 cc
Snack 1 pcs Snack 1 pcs
Makan malam Nasi 150 gr Nasi 150 gr
Lauk hewani 50 gr Lauk hewani 50 gr
Lauk nabati 25 gr Lauk nabati 25 gr
Sayur 100 gr Sayur 100 gr
Buah 100 gr Buah 100 gr
Nilai Gizi Energi : 2164,51 kcal (109,56%) Energi : 2109 kcal (106,75%)
Dibanding Protein : 69,27 g (100,61%) Protein : 76 g (110,38%)
Kebutuhan Lemak : 59,95 g (109,27%) Lemak : 57,6 g (104,99%)
Karbohidrat : 354,01 g (116,25%) Karbohidrat : 107,29 g (107,29%)

c. Penerapan Diet Berdasarkan Rekomendasi


Pemesanan : diet makanan biasa + extra enteral susu 2x200 cc
BAB 2

DASAR TEORI

A. Faktur
Fraktur atau patah tulang merupakan suatu kondisi terputusnya
kontinuitas jaringan tulang dan/atau tulang rawan yang umumnya
disebabkan oleh rudapaksa. Trauma yang menyebabkan tulang patah dapat
berupa trauma langsung dan trauma tidak langsung (Sjamsuhidajat, 2005).
Pada keadaan fraktur, jaringan sekitarnya juga akan terpengaruh
dimana akan terjadi edema jaringan lunak, perdarahan ke otot dan sendi,
dislokasi sendi, ruptur tendon, kerusakan saraf dan kerusakan pembuluh
darah (Brunner, 1997). Kerusakan-kerusakan diatas menimbulkan beberapa
manifestasi klinis yang khas, salah satunya yaitu nyeri.
Pada penderita fraktur, nyeri merupakan masalah yang paling sering
dijumpai (Murwani, 2009). Foley dick, 2000 mengumpulkan data sebanyak
85% pasien fraktur mengelihkan nyeri. Nyeri dapat dibedakan menjadi dua,
yakni nyeri akut dan nyeri kronis. Nyeri akut datangnya tiba-tiba atau
singkat, dapat hilang dengan sendiri, dapat diprediksi, dan merupakan reaksi
fisiologi akan sesuatu yang berbahaya (Murwani, 2009).
Nyeri pada fraktur bersifat kronis,nyeri kronis tidak dapat diprediksi
sehinggamembuat pasien frustasi dan seringkali mengarah pada depresi
psikologi (Purwandari, 2008). Pasien nyeri fraktur yang mengalami stres,
maka tekanan darahnya akan meningkat dan denyut jantung bekerja
semakin cepat, sehingga dapat menurunkan sistem imun yang berdampak
negatif bagi tubuh (Syaifuddin, 1997)

1. Etiologi
Menurut Sachdeva (1996), penyebab fraktur dapat dibagi menjadi tiga,
yaitu :
a. Cedera traumatik cedera traumatik pada tulang dapat disebabkan
oleh :
1) Cedera langsung berarti pukulan langsung terhadap tulang
sehingga tulang patah secara spontan. Pemukulan biasanya
menyebabkan fraktur melintang dan kerusakan pada kulit di
atasnya.
2) Cedera tidak langsung berarti pukulan langsung berada jauh dari
lokasi benturan, misalnya jatuh dengan tangan berjulur dan
menyebabkan fraktur klavikula.
b. Fraktur yang disebabkan kontraksi keras yang mendadak dari otot
yang kuat.
1) Fraktur Patologik Dalam hal ini kerusakan tulang akibat proses
penyakit dimana dengan trauma minor dapat mengakibatkan
fraktur dapat juga terjadi pada berbagai keadaan berikut :
- Tumor Tulang ( Jinak atau Ganas ) : pertumbuhan jaringan
baru yang tidak terkendali dan progresif.
- Infeksi seperti osteomielitis : dapat terjadi sebagai akibat
infeksi akut atau dapat timbul sebagai salah satu proses yang
progresif, lambat dan sakit nyeri.
- Rakhitis : suatu penyakit tulang yang disebabkan oleh
defisiensi Vitamin D yang mempengaruhi semua jaringan
skelet lain, biasanya disebabkan kegagalan absorbsi Vitamin
D atau oleh karena asupan kalsium atau fosfat yang rendah.
- Secara spontan disebabkan oleh stress tulang yang terus
menerus misalnya pada penyakit polio dan orang yang
bertugas dikemiliteran.

2. Patofisiologi
Fraktur ganggguan pada tulang biasanya disebabkan oleh trauma
gangguan adanya gaya dalam tubuh, yaitu stress, gangguan fisik,
gangguan metabolic, patologik. Kemampuan otot mendukung tulang
turun, baik yang terbuka ataupun tertutup. Kerusakan pembuluh darah
akan mengakibatkan pendarahan, maka volume darah menurun. COP
menurun maka terjadi peubahan perfusi jaringan. Hematoma akan
mengeksudasi plasma dan poliferasi menjadi edem lokal maka
penumpukan di dalam tubuh.
Fraktur terbuka atau tertutup akan mengenai serabut saraf yang
dapat menimbulkan ganggguan rasa nyaman nyeri. Selain itu dapat
mengenai tulang dan dapat terjadi revral vaskuler yang menimbulkan
nyeri gerak sehingga mobilitas fisik terganggau. Disamping itu fraktur
terbuka dapat mengenai jaringan lunak yang kemungkinan dapat terjadi
infeksi dan kerusakan jaringan lunak akan mengakibatkan kerusakan
integritas kulit.
Fraktur adalah patah tulang, biasanya disebabkan oleh trauma
gangguan metabolik, patologik yang terjadi itu terbuka atau tertutup.
Baik fraktur terbuka atau tertutup akan mengenai serabut syaraf yang
dapat menimbulkan gangguan rasa nyaman nyeri. Selaian itu dapat
mengenai tulang sehingga akan terjadi neurovaskuler yang akan
menimbulkan nyeri gerak sehingga mobilitas fisik terganggu, disamping
itu fraktur terbuka dapat mengenai jaringan lunak yang kemungkinan
dapat terjadi infeksi terkontaminasi dengan udara luar.
Pada umumnya pada pasien fraktur terbuka maupun tertutup akan
dilakukan immobilitas yang bertujuan untuk mempertahankan fragmen
yang telah dihubungkan tetap pada tempatnya sampai sembuh. (Sylvia,
1995 : 1183).

3. Tanda dan Gejala


a. Deformitas Daya tarik kekuatan otot menyebabkan fragmen tulang
berpindah dari tempatnya perubahan keseimbangan dan contur
terjadi seperti :
1) Rotasi pemendekan tulang.
2) Penekanan tulang.
b. Bengkak : Edema muncul secara cepat dari lokasi dan ekstravaksasi
darah dalam jaringan yang berdekatan dengan fraktur.
c. Echimosis dari perdarahan Subculaneous.
d. Spasme otot spasme involunters dekat fraktur.
e. Tenderness / keempukan.
f. Nyeri mungkin disebabkan oleh spasme otot berpindah tulang dari
tempatnya dan kerusakan struktur didaerah yang berdekatan
g. Kehilangan sensasi ( mati rasa, mungkin terjadi dari rusaknya
syaraf/perdarahan ).
h. Pergerakan abnormal.
i. Dari hilangnya darah.
j. Krepitasi.

B. Fraktur Intertrochanter
Fraktur intertrochanter sering terjadi pada lansia dengan kondisi
osteoporosis. Fraktur ini memiliki prognosis yang baik dibandingkan
fraktur intrakapsular, di mana risiko nekrosis avaskular lebih rendah. Pada
riwayat umumnya didapatkan adanya trauma akibat jatuh dan memberikan
trauma langsung pada trokhanter mayor. Pada beberapa kondisi, cedera
secara memuntir memberikan fraktur tidak langsung pada intertrokhanter.
Lebih dari 16,6 kejadian patah tulang pinggul dicatat di seluruh dunia
dan dengan meningkatnya harapan hidup angka-angka ini meningkat
perkiraan kejadian 62,6 lakh pada tahun 2050. Bergström dkk mencatat
bahwa 53% dari fraktur ini memiliki cedera kecepatan rendah pada orang
yang berusia 50 tahun ke atas. Lebih dari 80% dari fraktur ini terjadi pada
orang di atas 75 tahun. Osteoporosis dan fraktur geometri dianggap sebagai
faktor penting yang menyebabkan hasil yang buruk. Karena fiksasi internal
memiliki tingkat komplikasi yang tinggi, operasi penggantian telah
menunjukkan hasil yang menjanjikan dan direkomendasikan oleh penulis
sebagai pengobatan utama. Penggantian prostetik telah menunjukkan untuk
mencapai rehabilitasi awal pasien dan hasil jangka panjang yang baik.

C. Telaah Jurnal
“The Relationship Between Incidence of Fractures and Anemia in
Older Multiethnic Women”
Zhao Chen, PhD, MPH* , Cynthia A. Thomson, PhD, Mikel Aickin,
PhD, J. Skye Nicholas, MS* , David Van Wyck, MD§, Cora E. Lewis,
MD¶, Jane A. Cauley, Dr.PH#, Tamsen Bassford, MD, and Short list of
Women's Health Initiation (WHI) Investigators. J Am Geriatr Soc. 2010
December ; 58(12): 2337–2344. doi:10.1111/j.1532-
5415.2010.03183.x.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3058294/pdf/nihms-
243674.pdf

Resiko patah tulang panggul memberi kontribusi terjadinya anemia


(Hb rendah). Resiko fraktur meningkat disebabkan karena co-morbiditas,
jatuh atau faktor gaya hidup lainnya. Kejadian Hb rendah yang disebabkan
karena fraktur sekitar 7-38% di seluruh fraktur. Anemia dikaitkan dengan
kepadatan tulang yang rendah. Kadar hemoglobin ditemukan berkaitan
dengan sifat otot skeletal, konsentrasi hemoglobin yang lebih rendah
berkorelasi dengan massa otot dan kekuatan skeletal yang lebih rendah.
Massa dan kekuatan otot skeletal yang berkurang dapat berdampak
langsung pada kepadatan tulang yang responsif terhadap rangsangan
mekanik. Massa otot skeletal yang rendah juga meningkatkan resiko fraktur.
Selain itu banyak faktor resiko yang menyebabkan kejadian anemia pada
lansia seperti ketidak cukupan androgen, peradangan kronis, insufiensi
ginjal terkait usia, penuaan sel induk, dan kekurangan gizi termasuk zat besi,
kobalamin (B12) dan defisiensi folat juga dikenal sebagai faktor risiko
osteoporosis dan fraktur.
Dalam jurnal ini menyebutkan bahwa ada hubungan tidak langsung
antara anemia dan resiko fraktur, kadar HB yang rendah dapat secara
langsung mempengaruhi sel tulang. Pada pasien fraktur dengan kadar
hemoglobin kurang dari 12 gr/dl kemungkinan akan memperpanjang lama
rawat inap dan mengakibatkan kematian dibandingkan dengan kadar
hemoglobin yang normal. Hasil analisis menunjukkan bahwa anemia
dikaitkan dengan resiko patang tulang yang lebih tinggi.
Intervensi yang dilakukan pada kasus ini lebih menekan pada
peningkatan kadar hemoglobin pasien karena berkaitan dengan tindakan
pembedahan yang akan dilakukan pada pasien. Sehingga pemberian diet
tinggi energi tinggi protein dapat membantu meningkatkan kadar
hemoglobin dari makanan secara tidak langsung.
BAB 3
PEMBAHASAN

A. Monitoring, Evaluasi, dan Tindak Lanjut


MONITORING DAN EVALUASI KESIMPULAN & TINDAK
TGL DIAGNOSIS LANJUT (ASSESMEN, DIAGNOSIS
Antropometri Biokimia Fisik dan klinis Asupan
GIZI, INTERVENSI GIZI)
06/11/18 Fraktur Tidak Tidak ada hasil KU : sedang, - Energi : 1426,1 kcal A : data antropometri lingkar
intertrochanter dilakukan pemeriksaan CM (79,36%) lengan dan rentang lengan
femur pengukuran -T : 140/70 - Protein : 54,9 g diambil pada saat skrining
mmHg (84,46%) awal pasien
-N : 84x/menit - Lemak : 45,9 g (91,2%) B : tidak ada pemeriksaan biokimia
pada hari pertama evaluasi.
-R : 20x/menit - KH : 196,8 g (69,3%)
C : kesan umum:sedang, CM.
-t : 360C
Pemeriksaan tekanan darah pasien
menunjukkan 140/80 mmHg
D : asupan energi, protein dan lemak
sesuai dengan tujuan yang
diinginkan, sedangkan asupan KH
tergolong deficit karena makan pagi
pasien yang hanya separo dimakan
dikarenakan pasien sebelumnya
mendapatkan transfusi darah
sehingga menurunkan nafsu makan.

Diagnosis Gizi : (NI-1.2), (NC-3.1),


(NC-2.2)
Intervensi Gizi : makanan biasa +
ekstra susu
07/11/18 Fraktur Tidak -HB : 8,1 gr/dl -T : 140/70 - Energi : 1928,5 kcal A : data antropometri lingkar
intertrochanter dilakukan mmHg (97,62%) lengan dan rentang lengan
MONITORING DAN EVALUASI KESIMPULAN & TINDAK
TGL DIAGNOSIS LANJUT (ASSESMEN, DIAGNOSIS
Antropometri Biokimia Fisik dan klinis Asupan
GIZI, INTERVENSI GIZI)
femur pengukuran -N : 83x/menit - Protein : 70,4 g diambil pada saat skrining
-R : 20x/menit (102,25%) awal pasien
0
-t : 36,4 C - Lemak : 64,0 g B : hasil pemeriksaan kadar Hb
(106,6%) menunjukkan peningkan nilai
- KH : 265,8 g (87,29%) Hb menjadi 8,1 g/dl. Hal ini
dikarenakan pasien telah
mendapatkan transfusi darah 2
kantong pada hari sebelumnya
C : kesan umum:sedang, CM.
Pemeriksaan tekanan darah pasien
menunjukkan 140/70 mmHg,
belum terdapat penurunan tekanan
darah sistol tetapi tekanan diastol
sudah menurun
D : asupan makanan (energi, protein,
lemak, dan karbohidrat) sudah
mencapai target ≥ 80% kebutuhan

Diagnosis Gizi : (NC-3.1), (NC-2.2)


Intervensi Gizi : makanan biasa +
ekstra susu
08/11/2018 Fraktur Tidak Tidak ada hasil -T : 130/70 - Energi : 1872,3 kcal A : data antropometri lingkar
intertrochanter dilakukan pemeriksaan mmHg (94,77%) lengan dan rentang lengan
femur pengukuran -N : 83x/menit - Protein : 66,9 g diambil pada saat skrining
-R : 20x/menit (97,16%) awal pasien
-t : 360C - Lemak : 60,3 B : tidak dilakukan pemeriksaan
biokima
(104,91%)
C : kesan umum:sedang, CM.
- KH : 264,8 g (86,96%)
Pemeriksaan tekanan darah pasien
menunjukkan 136/70 mmHg,
MONITORING DAN EVALUASI KESIMPULAN & TINDAK
TGL DIAGNOSIS LANJUT (ASSESMEN, DIAGNOSIS
Antropometri Biokimia Fisik dan klinis Asupan
GIZI, INTERVENSI GIZI)
tekanan darah mengalami
penurunan deibandingkan dengan
hari sebelumnya
D : asupan makan pasien stabil
(energi, protein, lemak, dan
karbohidrat) sudah mencapai target
≥80% kebutuhan

Diagnosis Gizi : (NC-3.1), (NC-2.2)


Intervensi Gizi : makanan biasa +
ekstra susu
09/11/2018 Fraktur - Hb 11,4 gr/dl A : data antropometri lingkar
Intertrochanter lengan dan rentang lengan
Femur Dextra diambil pada saat skrining
awal pasien
B : hasil pemeriksaan kadar Hb
menunjukkan peningkan nilai
Hb menjadi 11,4gr/dl dan
pasien dijadwalkan untuk
pembedahan pada tanggal 10
November
C : tidak dilakukan pengukuran fisik
klinis
D : tidak dilakukan monitoring asupan

Diagnosis Gizi : (NC-3.1) (NC-2.2)


Intervensi Gizi : makanan
biasa + esktra susu
B. PEMBAHASAN
Dihadapkan pada subjek berusia 91 tahun dengan diagnosis medis
fraktur intertrochanter femur dextra. Pada saat skrining gizi, pasien
mengalami penurunan nafsu makan setelah jatuh di depan rumah kemudian
dibawa ke RS. Pasien tidak memiliki riwayat penyakit sebelumnya.
Berdasarkan hasil skrining pasien menggunakan SNST (Simple Nutrition
Simple Tools), didapatkan skor 4 yang berarti pasien beresiko malnutrisi
sehingga harus dilakukan asuhan gizi dan dilakukan intervensi lebih lanjut.
1. Antropometri
Berat badan pasien diukur pada saat skrining gizi dengan
menggunakan LILA (lingkar lengan atas) karena pasien tidak dapat
ditimbang. Hasil pengukuran LILA menunjukkan hasil 22 cm, setelah
dihitung didapatkan status gizi pasien termasuk kurang yaitu 74,45%.
Pengukuran antropometri juga diukur menggunakan rentang lengan
untuk mengetahui tinggi badan pasien karena keadaan pasien dengan
penyakit fraktur femur yang tidak memungkinkan untuk berdiri. Selain itu
pada pasien lansia cukup sulit dilakukan pengukuran tinggi badan yang
tepat karena masalah postur tubuh, kerusakan spinal atau kelumpuhan.
Penurunan massa tulang dan penurunan massa otot dan berat badan pada
lansia dapat mengubah struktur tulang. Hal ini dapat menyebabkan
perubahan postur tubuh dan menipisnya diskus vertebralis yang
berkontribusi pada penurunan tinggi badan seseorang, bahkan kyphosis
pada individu lansia dengan osteoporosis (Vasant, 2008)
Rentang lengan berkorelasi dengan tinggi badan lebih baik daripada
pengukuran menggunakan tulang panjang lainnya. Lagipula pengukuran
ini murah, dan sederhana. Rentang lengan dalam pertumbuhannya juga
dipengaruhi oleh faktor-faktor yang sama dengan tinggi badan.
Perbedaannya dengan tinggi badan perkembangan tulang panjang ini tidak
dipengaruhi oleh usia, sehingga relatif lebih stabil (Haitamy & Brahmadi,
2016).
Hasil pengukuran rentang lengan menunjukkan hasil 132 cm dan
dihitung perkiraan estimasi tinggi badan didapatkan hasil 148,8 cm. Pada
kelompok lansia terlihat adanya penurunan nilai rentang lengan yang lebih
lambat dibandingkan dengan penurunan TB sehingga dapat disimpulkan
bahwa rentang lengan cenderung tidak banyak berubah sejalan
penambahan usia. Rentang lengan direkomendasikan sebagai parameter
prediksi tinggi badan (Astriana, et.al 2018)

2. Biokimia
Parameter biokimia yang menunjukkan angka tidak normal (rendah)
adalah nilai hemoglobin. Hasil laboratorium pasien menunjukkan nilai HB
rendah (5 gr/dl) pada saat masuk rumah sakit. Nilai HB rendah sering
terjadi pada lansia usia lebih dari 50 tahun. Resiko patah tulang panggul
memberi kontribusi terjadinya anemia (Hb rendah). Selain itu banyak
faktor resiko yang menyebabkan kejadian anemia pada lansia seperti
ketidak cukupan androgen, peradangan kronis, insufiensi ginjal terkait
usia, penuaan sel induk, dan kekurangan gizi termasuk zat besi, kobalamin
(B12) dan defisiensi folat juga dikenal sebagai faktor risiko osteoporosis
dan fraktur (Chen, et.al. 2010)
Intervensi yang dilakukan selama 3 hari sudah dilakukan sebanyak 4
kali transfusi darah untuk menambah kadar hemoglobin pasien untuk
persiapan tindakan pembedahan orthopedi. Pemeriksaan laboratorium
kedua menunjukkan peningkatkan kadar Hemoglobin sebanyak 8,1 gr/dl.
Sedangkan pada hari terakhir intervensi kadar hemoglobin pasien
menunjukkan 11,4 gr/dl dan akan segera dilakukan proses pembedahan.

3. Fisik-klinis
Tanda fisik klinis yang diamati adalah meliputi vital sign yaitu
tekanan darah, nadi, dan suhu. Secara umum tanda fisik klinis pasien
dikategorikan normal. Kecuali pada tekanan darah pasien yang tinggi
selama intervensi. Selama 2 hari tekanan darah pasien menunjukkan hasil
140/80 mmHg yang berarti tergolong hipertensi. Tetapi selama monitoring
tidak terdapat perubahan diagnosis medis yang menyebutkan hipertensi
karena memang pasien sebelumnya tidak memiliki riwayat penyakit
hipertensi.

4. Dietary/Asupan Makan
Asupan makanan pasien pada saat skrining awal sangat rendah yaitu
≤80% dari kebutuhan total. Hal ini disebabkan karena pola makan pasien
yang memang tidak teratur dan pasien yang jatuh sehingga menyebabkan
nafsu makan pasien menurun sesaat. Setelah dilakukan evaluasi, nafsu
makan pasien membaik kemudian bisa meningkatkan asupan hingga ≥50%
dari kebutuhan sehingga diberikan makanan biasa.
Terapi diet yang diberikan saat intervensi adalah Diet TETP yang
bertujuan untuk mempercepat penyembuhan pasien dan mencegah
penurunan berat badan yang berlebihan dari pasien. Selain itu diet TETP
juga untuk mempersiapkan keadaan pasien pada masa pra bedah dan
penyembuhan pasca bedah.
Selama 3 hari monitoring asupan pasien terdapat peningkatan yang
signifikan. Grafik peningkatan asupan pasien dapat dilihat pada gambar
berikut

Asupan Makan Pasien Selama 3 Hari

120
100
% Kebutuhan

80
60
40
20
0
Energi Protein Lemak karbohidrat
Hari 1 79,36 84,46 91,2 69,3
Hari 2 97,62 102,25 106,6 87,29
Hari 3 94,77 97,16 109,91 86,96

Hari 1 Hari 2 Hari 3


Dapat dilihat pada grafik diatas bahwa asupan hari 1 monitoring
pasien cukup baik hal ini dikarenakan nafsu makan pasien yang sudah
membaik dan juga peran keluarga penunggu pasien yang telaten dalam
memberikan makanan kepada pasien. Selain itu anjuran ahli gizi untuk
memberikan makanan secara bertahap dan sering sehingga asupan pasien
meningkat. Diagnosa gizi asupan oral tidak adekuat pada protein dan lemak
telah tercapai pada monitoring hari pertama.
Pada monitoring hari kedua dan ketiga prosentase asupan relatif lebih
stabil dan sesuai dengan kebutuhan pasien. Selain itu penambahan ekstra
enteral susu dapat menambah asupan pasien lebih banyak. Hal ini berarti
bahwa tujuan diet yang diberikan telah tercapai sesuai dengan yang
dianjurkan yaitu ≥ 80% dari kebutuhan total. Metode penilaian asupan
makanan yang digunakan pada kasus ini adalah :
a) Metode Recall 1 × 24 jam yaitu dilakukan dengan mencatat jenis dan
jumlah bahan makanan yang dikonsumsi pada periode 24 jam yang
lalu meliputi makanan dan minuman yang dikonsumsi dan cara
memasaknya.
b) Metode Comstock yaitu penilaian konsumsi makan dengan cara visual
atau melihat sisa makanan pasien selama dirawat di rumah sakit
kemudian dikonversi ke nilai gizi (Wahyuningsih, 2013).

5. Diagnosa Medis dan Diagnosa Gizi


Diagnosa medis bersifat tetap selama penyakit pasien tersebut masih
ada. Dalam kasus ini selama monitoring dan intervensi tidak berubah pada
saat awal pasien masuk rumah sakit hingga selesai implementasi. Pasien
akan dilakukan operasi pembedahan orthopedi pada saat kadar hemoglobin
pasien mencapai target normal.
Diagnosa gizi bersifat dapat berubah-ubah sesuai dengan keadaan
pasien, asupan, dan lain-lain. Diagnosa gizi yang ditegakkan pada kasus ini
meliputi domain intake (asupan tidak adekuat) dan domain klinis
(perubahan nilai lab dan berat badan kurang). Selama intervensi, diagnosa
asupan pasien sudah hilang pada hari kedua intervensi hal ini dikarenakan
asupan pasien yang telah memenuhi target dan nafsu makan yang
membaik. Sedangkan diagnosa klinis pasien masih tetap ada hingga akhir
intervensi.
BAB 4
KESIMPULAN DAN SARAN

A. KESIMPULAN
1. Antropometri
Berdasarkan pengukuran LILA didapatkan status gizi pasien kurang yaitu
74,5%. Tidak terdapat perubahan berat badan maupun status gizi pasien
karena intervensi gizi hanya dilakukan selama 3 hari
2. Biokimia
Terdapat peningkatan nilai laboratorium hemoglobin 11,4 gr/dl pada saat
akhir intervensi
3. Fisik-Klinis
Tidak terdapat perubahan vital sign yang terlalu signifikan selama intervensi
berlangsung dan vital sign pasien dapat dikategorikan normal.
4. Dietary/asupan makan
Terdapat peningkatan asupan makan pasien selama intervensi dan mencapai
target yang ditentukan yaitu ≥80%
5. Diagnosa Medis dan Gizi
Tidak terdapat perubahan diagnosa medis selama intervensi karena pasien
akan dilakukan operasi pembedahan. Terdapat perubahan diagnosa gizi pada
domain intake karena asupan makan yang telah sesuai target.

B. SARAN
Perlu dilakukan intervensi gizi lebih lanjut untuk mengetahui status dan
asupan gizi pasien pasca operasi. Selain itu perlu diberikan konseling lebih
lanjut mengenai penyembuhan pasca operasi dan kebutuhan gizi pasca bedah.
DAFTAR PUSTAKA

Almatsier, S. Penuntun Diet Edisi Baru. Jakarta: PT. Gramedia Pustaka. 2006

Astriana et.al, Hubungan rentang lengan, tinggi lutut, panjang ulna dengan tinggi badan
lansia perempuan di Kecamatan Sewon. Universitas Respati Yogyakarta. Jurnal
Ilmu Gizi Indonesia. ISSN 2598-7844 Vol. 01, No. 02, 87-92. Februari 2018

Chen, et.al. The Relationship Between Incidence of Fractures and Anemia in Older
Multiethnic Women. Short list of Women's Health Initiation (WHI)
Investigators. J Am Geriatr Soc. 2010 December ; 58(12): 2337–2344.
doi:10.1111/j.1532-5415.2010.03183.x.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3058294/pdf/nihms-
243674.pdf

Haitamy & Brahmadhi. Hubungan Antara Rentang Lengan Terhadap Tinggi Badan
Dalam Penentuan Indeks Massa Tubuh (IMT) Pada Lansia Di Kelurahan
Adipala Kabupaten Cilacap. Program Studi Kedokteran Universitas
Muhammadiyah Purwokerto. Jurnal Sainteks volume XIII no. 2, Oktober 2016

Vasant H., Jennifer M. A Comparison of Measured Height and Demi-span Equivalent


Height in theAssessment of Body Mass Index among People Aged 65 Years
and Over in England department of epidemiologi and public health, university
college London. Am J Clin. Nutrition. 2008.

Wahyuningsih, R. Penatalaksanaan Diet pada Pasien. Jakarta: Graha Ilmu. 2013


LAMPIRAN
Lampiran 1. Skrining Gizi Pasien

A. Simple Nutrition Screening Tool (SNST)

Nama : Tn. MW
Usia : 91 tahun
Diagnosa Medis : Fraktur Intertrochanter Femur Dextra
Tanggal Skrining : 5 November 2018

Jawaban (Skor)
No. Pertanyaan
Ya (1) Tidak (0)

1 Apakah pasien terlihat kurus √


2 Apakah pakaian pasien terasa lebih longgar? √
Apakah 6 bulan terakhir ada penurunan berat
3 badan ? √
Apakah pasien mengalami penurunan asupan
4 √
makan selama 1 minggu terakhir ?
Apakah pasien menderita suatu penyakit yang
5 mengakibatkan perubahan jumlah atau jenis √
makanan yang dimakan?
6 Apakah pasien terlihat lemas? √
TOTAL SKOR 4
Kesimpulan :
Skor 0-2 = Tidak beresiko malnutrisi
Skor ≥ 3 = Beresiko malnutrisi
Sumber : Data Primer Terolah (2018)

Berdasarkan hasil skrining gizi, pasien beresiko malnutrisi sehingga


perlu dilakukan asuhan gizi lebih lanjut.
Lampiran 2. Dokumentasi Sisa Makan Pasien

Tanggal Pagi Siang Malam

06/11/18
-
07/11/18

07/11/18
-
08/11/18

08/11/18
-
09/11/18
Lampiran 3. Sisa Makan Pasien Selama 3 Hari Intervensi

% Sisa Makanan

Tanggal Nama
Monev Makanan

0% 5% 25% 50% 75% 95% 100%


P S S P S S P S S P S S P S S P S S P S S

Nasi  

L. Hewani  

06/11/18 L. Nabati  

Sayur  

Buah 

Nasi   

L. Hewani   
07/11/18
L. Nabati  

Sayur  

Buah
Nasi   

L. Hewani   

08/11/18 L. Nabati   

Sayur   

Buah 

Nasi 

L. Hewani 

09/11/18 L. Nabati 

Sayur 

Buah
Keterangan
Habis Sisa

Keterangan
sisa makanan 0% = makanan habis
Sisa makanan 25% = sisa makanan 1⁄4 porsi
Sisa makanan 50% = sisa makanan 1⁄2 porsi
Sisa makanan 75% = sisa makanan 3⁄4 porsi
Sisa makanan 95% = sisa maknaan hampir utuh (±1sdm dikonsumsi)
Sisa makanan 100% = makanan utuh (tidak ada yang dikonsumsi)
Lampiran 4. Hasil Recal 24 Jam SMRS
=============================================================
========
HASIL PERHITUNGAN DIET/recall 24 jam
=============================================================
========
Nama
Makanan Jumlah energy carbohy
dr.
____________________________________________________________________
__________

makan pagi
nasi putih kukus 50 g 65,0 kcal
14,3 g
daging sapi 10 g 26,9 kcal 0,0
g
tempe goreng 25 g 88,5 kcal 3,8
g

Meal analysis: energy 180,4 kcal (26 %), carbohydrate 18,1 g (19 %)

snack
kue bolu kukus 20 g 41,4 kcal 8,6
g
teh manis 200 g 25,8 kcal 6,4
g

Meal analysis: energy 67,2 kcal (10 %), carbohydrate 15,0 g (16 %)

makan siang
nasi putih 50 g 65,0 kcal
14,3 g
daging ayam goreng 20 g 66,4 kcal 0,7
g
sayur sop 5g 5,2 kcal 0,5
g

Meal analysis: energy 136,6 kcal (20 %), carbohydrate 15,6 g (17 %)

snack
tahu 25 g 51,5 kcal 0,4
g
Meal analysis: energy 51,5 kcal (8 %), carbohydrate 0,4 g (0 %)

makan malam
nasi putih 75 g 97,5 kcal
21,5 g
telur ceplok 30 g 57,3 kcal 0,3
g
pisang mas 100 g 92,0 kcal
23,4 g

Meal analysis: energy 246,8 kcal (36 %), carbohydrate 45,2 g (48 %)

=============================================================
========
HASIL PERHITUNGAN
=============================================================
========
Zat Gizi hasil analisis rekomendasi persentase
nilai nilai/hari pemenuhan
____________________________________________________________________
__________
energy 682,5 kcal 1900,0 kcal 36 %
protein 23,6 g(14%) 48,0 g(12 %) 49 %
fat 24,4 g(31%) 77,0 g(< 30 %) 32 %
carbohydr. 94,2 g(55%) 351,0 g(> 55 %) 27 %
dietary fiber 4,0 g 30,0 g 13 %
PUFA 5,6 g 10,0 g 56 %
cholesterol 157,8 mg - -
Vit. A 100,0 µg 800,0 µg 13 %
carotene 0,0 mg - -
Vit. E 0,0 mg - -
Vit. B1 0,2 mg 1,0 mg 19 %
Vit. B2 0,4 mg 1,2 mg 33 %
Vit. B6 0,9 mg 1,2 mg 73 %
Vit. C 9,1 mg 100,0 mg 9%
sodium 70,3 mg 2000,0 mg 4%
potassium 725,3 mg 3500,0 mg 21 %
calcium 81,2 mg 1000,0 mg 8%
magnesium 107,8 mg 310,0 mg 35 %
phosphorus 273,4 mg 700,0 mg 39 %
iron 3,4 mg 15,0 mg 22 %
m.uns.f.acids 5,6 g - -
sat. FA 11,0 g - -
tot. fol.acid 55,8 µg 400,0 µg 14 %
zinc 2,6 mg 7,0 mg 38 %
lampiran 5. Monitoring Asupan Hari 1
=============================================================
========
HASIL PERHITUNGAN DIET/MONITORING HARI-1
=============================================================
========
Nama
Makanan Jumlah energy carbohy
dr.
____________________________________________________________________
__________

MAKAN SIANG
nasi putih 150 g 195,0 kcal
42,9 g
telur ceplok 25 g 47,7 kcal 0,3
g
tahu goreng 15 g 30,9 kcal 0,3
g
sayur bayam jagung 100 g 37,0 kcal 8,3
g
pepaya 100 g 39,0 kcal 9,8
g

Meal analysis: energy 349,7 kcal (25 %), carbohydrate 61,5 g (31 %)

Snack SORE
bakpau daging 100 g 249,0 kcal
36,3 g

Meal analysis: energy 249,0 kcal (17 %), carbohydrate 36,3 g (18 %)

MAKAN MALAM
nasi putih 150 g 195,0 kcal
42,9 g
sayur telur 45 g 68,0 kcal 1,2
g
tempe bacem 40 g 94,8 kcal 7,0
g
sayur gambas 50 g 15,1 kcal 3,8
g

Meal analysis: energy 372,9 kcal (26 %), carbohydrate 55,0 g (28 %)
SARAPAN
nasi putih 40 g 52,0 kcal
11,4 g
daging ayam 25 g 71,2 kcal 0,0
g
minyak kelapa sawit 3g 25,9 kcal 0,0
g
tempe goreng 25 g 88,5 kcal 3,8
g
sayur bayam wortel 25 g 4,7 kcal 1,0
g

Meal analysis: energy 242,3 kcal (17 %), carbohydrate 16,3 g (8 %)

Snack SIANG
susu proten 100 g 212,1 kcal
27,7 g

Meal analysis: energy 212,1 kcal (15 %), carbohydrate 27,7 g (14 %)

=============================================================
========
HASIL PERHITUNGAN
=============================================================
========
Zat Gizi hasil analisis rekomendasi persentase
nilai nilai/hari pemenuhan
____________________________________________________________________
__________
energy 1426,1 kcal 1900,0 kcal 75 %
protein 54,9 g(16%) 48,0 g(12 %) 114 %
fat 45,9 g(28%) 77,0 g(< 30 %) 60 %
carbohydr. 196,8 g(56%) 351,0 g(> 55 %) 56 %
dietary fiber 8,4 g 30,0 g 28 %
PUFA 10,7 g 10,0 g 107 %
cholesterol 295,5 mg - -
Vit. A 839,2 µg 800,0 µg 105 %
carotene 0,0 mg - -
Vit. E 0,0 mg - -
Vit. B1 0,4 mg 1,0 mg 43 %
Vit. B2 0,7 mg 1,2 mg 60 %
Vit. B6 0,7 mg 1,2 mg 57 %
Vit. C 70,5 mg 100,0 mg 71 %
sodium 564,8 mg 2000,0 mg 28 %
potassium 1050,9 mg 3500,0 mg 30 %
calcium 184,9 mg 1000,0 mg 18 %
magnesium 180,8 mg 310,0 mg 58 %
phosphorus 545,5 mg 700,0 mg 78 %
iron 6,3 mg 15,0 mg 42 %
m.uns.f.acids 11,2 g - -
sat. FA 15,1 g - -
tot. fol.acid 174,7 µg 400,0 µg 44 %
zinc 5,1 mg 7,0 mg 73 %
Lampiran 6. Monitoring Asupan Hari 2

HASIL PERHITUNGAN DIET/MONITORING HARI 2


=============================================================
========
Nama
Makanan Jumlah energy carbohy
dr.
____________________________________________________________________
__________

MAKAN SIANG
nasi putih 125 g 162,5 kcal
35,8 g
telur dadar 50 g 93,5 kcal 0,6
g
semur tahu 25 g 34,2 kcal 2,7
g
sayur gambas 100 g 30,1 kcal 7,7
g
pisang raja uli 100 g 92,0 kcal
23,4 g

Meal analysis: energy 412,3 kcal (21 %), carbohydrate 70,1 g (26 %)

Snack SORE
susu proten 100 g 212,1 kcal
27,7 g
donat 50 g 200,0 kcal
23,1 g

Meal analysis: energy 412,2 kcal (21 %), carbohydrate 50,8 g (19 %)

MAKAN MALAM
nasi putih 75 g 97,5 kcal
21,5 g
telur ayam 40 g 62,0 kcal 0,4
g
kecap 5g 3,0 kcal 0,3
g
tahu goreng 25 g 51,5 kcal 0,4
g
sayur lodeh 100 g 55,9 kcal 6,0
g
Meal analysis: energy 170 kcal (14%), carbohydrate 28,6 g (2 %)

SARAPAN
nasi putih 125 g 162,5 kcal
35,8 g
daging sapi 45 g 121,0 kcal 0,0
g
kecap 5g 3,0 kcal 0,3
g
minyak kelapa sawit 2g 17,2 kcal 0,0
g
tempe goreng 25 g 88,5 kcal 3,8
g
sayur gambas 75 g 22,6 kcal 5,8
g

Meal analysis: energy 414,8 kcal (22 %), carbohydrate 45,6 g (17 %)

Snack SIANG
cake 100 g 207,0 kcal
42,9 g
susu proten 100 g 212,1 kcal
27,7 g

Meal analysis: energy 419,1 kcal (22 %), carbohydrate 70,6 g (27 %)

=============================================================
========
HASIL PERHITUNGAN
=============================================================
========
Zat Gizi hasil analisis rekomendasi persentase
nilai nilai/hari pemenuhan
____________________________________________________________________
__________
energy 1928,5 kcal 1900,0 kcal 101 %
protein 70,4 g(15%) 48,0 g(12 %) 147 %
fat 64,0 g(29%) 77,0 g(< 30 %) 83 %
carbohydr. 265,8 g(56%) 351,0 g(> 55 %) 76 %
dietary fiber 9,4 g 30,0 g 31 %
PUFA 13,8 g 10,0 g 138 %
cholesterol 491,4 mg - -
Vit. A 400,5 µg 800,0 µg 50 %
carotene 0,0 mg - -
Vit. E 0,0 mg - -
Vit. B1 0,4 mg 1,0 mg 40 %
Vit. B2 1,0 mg 1,2 mg 81 %
Vit. B6 1,3 mg 1,2 mg 107 %
Vit. C 27,3 mg 100,0 mg 27 %
sodium 736,3 mg 2000,0 mg 37 %
potassium 1285,1 mg 3500,0 mg 37 %
calcium 189,4 mg 1000,0 mg 19 %
magnesium 186,1 mg 310,0 mg 60 %
phosphorus 629,2 mg 700,0 mg 90 %
iron 6,9 mg 15,0 mg 46 %
m.uns.f.acids 15,0 g - -
sat. FA 19,4 g - -
tot. fol.acid 130,6 µg 400,0 µg 33 %
zinc 6,2 mg 7,0 mg 89 %
lampiran 7. Monitoring Asupan Hari 3
=============================================================
========
HASIL PERHITUNGAN DIET/MONITORING HARI 3
=============================================================
========
Nama
Makanan Jumlah energy carbohy
dr.
____________________________________________________________________
__________

MAKAN SIANG
nasi putih 150 g 195,0 kcal
42,9 g
sayur telur 50 g 75,5 kcal 1,4
g
tempe goreng 25 g 88,5 kcal 3,8
g
bayam segar 40 g 14,8 kcal 2,9
g
toge kacang hijau mentah 10 g 6,1 kcal 0,5
g
wortel 10 g 4,2 kcal 0,9
g
kacang tanah kulit 10 g 41,4 kcal 1,2
g
semangka 100 g 32,0 kcal 7,2
g

Meal analysis: energy 457,6 kcal (24 %), carbohydrate 60,8 g (23 %)

Snack SORE
kue bolu 75 g 155,2 kcal
32,2 g
susu proten 100 g 212,1 kcal
27,7 g

Meal analysis: energy 367,4 kcal (20 %), carbohydrate 59,9 g (23 %)

MAKAN MALAM
nasi putih 125 g 162,5 kcal
35,8 g
telur ayam 25 g 38,8 kcal 0,3
g
kecap 5g 3,0 kcal 0,3
g
minyak kelapa 3g 25,9 kcal 0,0
g
tempe bacem 25 g 59,3 kcal 4,4
g
sayur bayam wortel 25 g 4,7 kcal 1,0
g

Meal analysis: energy 294,2 kcal (16 %), carbohydrate 41,7 g (16 %)

SARAPAN
nasi putih 125 g 162,5 kcal
35,8 g
daging sapi 25 g 67,2 kcal 0,0
g
minyak kelapa sawit 5g 43,1 kcal 0,0
g
semur tahu 25 g 34,2 kcal 2,7
g
tumis kacang panjang belu 100 g 21,0 kcal 2,8
g

Meal analysis: energy 328,1 kcal (18 %), carbohydrate 41,2 g (16 %)

Snack SIANG
nagasari 100 g 213,0 kcal
33,5 g
susu proten 100 g 212,1 kcal
27,7 g

Meal analysis: energy 425,1 kcal (23 %), carbohydrate 61,2 g (23 %)

=============================================================
========
HASIL PERHITUNGAN
=============================================================
========
Zat Gizi hasil analisis rekomendasi persentase
nilai nilai/hari pemenuhan
____________________________________________________________________
__________
energy 1872,3 kcal 1900,0 kcal 99 %
protein 66,9 g(14%) 48,0 g(12 %) 139 %
fat 60,3 g(28%) 77,0 g(< 30 %) 78 %
carbohydr. 264,8 g(57%) 351,0 g(> 55 %) 75 %
dietary fiber 9,8 g 30,0 g 33 %
PUFA 9,5 g 10,0 g 95 %
cholesterol 365,8 mg - -
Vit. A 1120,7 µg 800,0 µg 140 %
carotene 0,0 mg - -
Vit. E 0,0 mg - -
Vit. B1 0,5 mg 1,0 mg 52 %
Vit. B2 0,9 mg 1,2 mg 74 %
Vit. B6 1,4 mg 1,2 mg 114 %
Vit. C 38,8 mg 100,0 mg 39 %
sodium 426,7 mg 2000,0 mg 21 %
potassium 1537,8 mg 3500,0 mg 44 %
calcium 250,2 mg 1000,0 mg 25 %
magnesium 218,5 mg 310,0 mg 70 %
phosphorus 615,4 mg 700,0 mg 88 %
iron 8,1 mg 15,0 mg 54 %
m.uns.f.acids 14,9 g - -
sat. FA 20,5 g - -
tot. fol.acid 186,8 µg 400,0 µg 47 %
zinc 6,1 mg 7,0 mg 87 %
LAMPIRAN JURNAL

Published in final edited form as:


J Am Geriatr Soc. 2010 December ; 58(12): 2337–2344. doi:10.1111/j.1532-5415.2010.03183.x.

The Relationship Between Incidence of Fractures and Anemia in


Older Multiethnic Women

Zhao Chen, PhD, MPH*, Cynthia A. Thomson, PhD+, Mikel Aickin, PhD‡, J. Skye
Nicholas, MS*, David Van Wyck, MD§, Cora E. Lewis, MD¶, Jane A. Cauley,
Dr.PH#, Tamsen Bassford, MD‡, and Short list of Women's Health Initiation (WHI)
Investigators
* Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ
+
Department of Nutritional Sciences, University of Arizona, Tucson, AZ, USA

Department of Family and Community Medicine, University of Arizona, Tucson, AZ, USA
§ Department of Medicine, University of Arizona, Tucson, AZ, USA

Division of Preventive Medicine, University of Alabama, Birmingham, AL, USA
#
Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA

Abstract
Objectives—The purpose of this study was to prospectively examine the
relationship between anemia and incident fractures of the hip, spine and all
skeletal sites in women from diverse racial and ethnic backgrounds enrolled in the
Women's Health Initiative (WHI) Observational Study and Clinical Trials.
Design—Prospective cohort study.
Setting—40 WHI clinical centers across the US.
Participants—Postmenopausal women (n = 160,080), mean age 63.2 (SD:
7.2) years, were recruited and followed for an average of 7.8 years.
Measurements—Anemia was defined as hemoglobin levels at baseline less
than 12 g/dL. All fractures were self-reported. Hip fractures were further
confirmed by trained physicians using medical records.
Results—Among the participants 8,739 women (5.5%) were anemic. The age-
adjusted incidence rate of hip fractures per 10,000 person years were 21.4 in
women with anemia and 15.0 in women without anemia; a higher incidence rate
for spine or all fractures in anemic women was also observed. After multiple
covariates were included in the Cox proportional hazards models, significant
increased fracture risk associated with anemia still existed as demonstrated by the
hazards ratios (95% confidence interval) of fractures associated with anemia being
1.38 (1.13–

Corresponding Author: Zhao Chen, PhD, MPH Professor and Director Division of Epidemiology and Biostatistics Mel and Enid
Zuckerman College of Public Health University of Arizona 1295 N Martin Ave. PO Box 245163 Tucson, AZ 85724
zchen@email.arizona.edu. Alternate author: J. Skye Nicholas, MS Mel and Enid Zuckerman College of Public Health University of
Arizona 1540 E. Drachman PO Box 245203 Tucson, AZ 85724 jola@email.arizona.edu.
Author Contributions: Study concept and design: Chen,Thomson, Bassford, Aickin, Van Wyck, Lewis, Cauley; Acquisition of
subjects/data: Chen, Thomson, Bassford, Nicholas, Lewis, Cauley; Interpretation of data: Chen, Thomson, Van Wyck, Aickin,
Nicholas, Lewis, Cauley; Preparation of manuscript (drafting, revising, and final approval): Chen, Thomson, Aickin, Nicholas, Van
Wyck, Lewis, Cauley and Bassford.
Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that
the authors have no financial or any other kind of personal conflicts with this paper.
Chen et al. Page 2

1.68), 1.30 (1.09–1.55) and 1.07 (1.01–1.14) for hip, spine and all-types
respectively. No significant racial/ethnic difference was found in these
relationships.
Conclusion—A significantly increased fracture risk was observed in multi-
ethnic postmenopausal women with anemia. Given the high prevalence of
anemia in the elderly population, it is important to better understand the
relationship and mechanisms linking anemia to fracture risk.

Keywords
fracture risk; anemia; hemoglobin; prospective studies

INTRODUCTION
Anemia is a common health problem in older populations. The World Health
Organization (WHO) defines anemia as a hemoglobin level of less than
13g/dL in men, and less than 12g/ dL in women.[1,2] In the Third National
Health and Nutrition and Examination Survey (NHANES III) the prevalence
of anemia, as defined by WHO criteria, was over 10% for adults age 65
years and older.[3] The prevalence of anemia varies by race/ethnicity and
increases with age.[3]

Anemia in older adults has been shown to be associated with disability,


declines in physical performance,[4] low muscle strength, reduced muscle
density[5] and increased mortality independent from other co-morbidities.[6]
In addition, bone density has been found to be significantly lower in older
people with anemia as compared to people of the same age. This difference
in bone density was persistent even after adjusting for body mass index
(BMI).[7] Studies have also demonstrated low muscle mass and strength and
higher risk of fall among older people with anemia.[8–11] Elevated fall rates
and reduced muscle mass, muscle strength, and bone density are well known
risk factors for bone fractures. Therefore, intuitively, anemia may elevate an
individual's risk of fractures. To our knowledge no direct evidence are
available demonstrating a greater fracture risk in older people with anemia
versus those without anemia. It is well known that African Americans have
an increased risk for anemia[3] but a lower risk for fractures[12,13] in
comparison to people from other race/ ethnic backgrounds. In contrast, both
fracture[12,13] and anemia[3] risks increase with aging. However, whether
the association between anemia and fracture varies by age and race/ethnicity
is unknown and should be investigated in order to better identify anemic
people at increased risk for fractures.

In this prospective cohort study we aimed to investigating the association of


anemia with fracture risk in U.S. post-menopausal women from diverse
racial and ethnic backgrounds enrolled in the Women's Health Initiative
J Am Geriatr Soc. Author manuscript; available in PMC 2011 December 1.
(WHI) Observational Study (OS) and Clinical Trials (CT). The following
hypotheses were tested: 1) anemia is associated with an increased fracture
risk in post-menopausal women and 2) in spite of the variations in anemia
rates by age and/or race/ethnicity, the magnitude of the increased fracture
risk associated with anemia is similar in all age and racial/ethnic groups. To
evaluate potential mediating factors that link anemia with fractures we have
also examined the contribution of falls and self-reported general health
(fair/poor health versus good/excellent health) to the relationship between
anemia and fracture risk.

J Am Geriatr Soc. Author manuscript; available in PMC 2011 December 1.


Chen et al. Page 3

METHODS
Participants
This study was conducted using data from the WHI, the largest U.S. health
study among postmenopausal women. Between 1993 and 1998, WHI
recruited 161,808 participants from 40 WHI clinical centers across the
United States. To qualify for the WHI enrollment, women had to be
between age of 50–79, post-menopausal and not likely to relocate or die
within 3 years of study enrollment. Additional inclusion and exclusion
criteria were applied to women in the WHI clinical trials. Details regarding
the study design, inclusion and exclusion criteria, recruitment procedures,
participants characteristics, intervention regimens, randomization, blinding,
and follow-up have been previously published in a number of papers[14–17]
for the WHI-OS[18] and WHI-CT[17] arms. The study protocol and consent
forms were approved by the institutional review boards for all participating
institutions.

Data Collection
Self-administered or interviewer-administered questionnaires were
completed by WHI participants for eligibility screening and collection of
baseline characteristics (such as demographic, reproductive, and health
status information). Physical examinations were conducted and a blood
specimen was collected at baseline. The WHI OS women visited the WHI
clinical center at 3 year intervals and the WHI CT women visited the clinic
every year for follow-up physical measurements and blood collections. The
CT participants completed additional questionnaires every 6 months and OS
participants every year. The average follow-up time was 7.8 years in this
current analysis.

Anemia definition
Hemoglobin levels were measured on all WHI participants at baseline in the
context of a complete blood count (CBC) test conducted by designated
clinical labs in the surrounding areas of each WHI clinical center. For this
analysis, a woman was considered to have anemia if her hemoglobin
concentration at baseline was less than 12g/dL, using the WHO criteria. A
total of 160,080 study participants had baseline hemoglobin measurements
(CT= 68,080, OS=91,999).

Fracture Assessments
During follow-up, 160,934 women (CT = 67,881 and OS = 93,053) had
completed at least one medical history update providing information
regarding new fracture diagnosis (in the previous 12 months for OS and 6
months for CT participants). Specifically, women were asked, “Since (last
J Am Geriatr Soc. Author manuscript; available in PMC 2011 December 1.
reporting date), has a doctor told you that you had a broken, fractured, or
crushed bone?” If “Yes” was selected, then they were asked to answer
“Which bone did you break, fracture, or crush?” by marking all that apply
from the following list: 1) Hip, 2) Upper leg (not hip), 3) Pelvis, 4) Knee
(patella), 5) Lower leg or ankle, 6) Foot (not toe), 7) Tailbone (coccyx), 8)
Spine or back (vertebra), 9) Lower arm or wrist, 10) Hand (not finger), 11)
Elbow, 12) Upper arm or shoulder, 13) Other (specify). The term “all-type”
includes any reported fracture from the previous list. Self-reported hip
fractures were adjudicated with medical records by trained adjudicators; all
non-hip fractures were self- reported without adjudication.

Assessments of Covariates
Information on age, race/ethnicity, education, cohabitation, smoking, use of
hormone therapy, history of fracture, number of falls in last 12 months,
medication or supplement use (corticosteroids, thiazide, estrogen, calcium
regulators, calcium, vitamin D, and iron)

J Am Geriatr Soc. Author manuscript; available in PMC 2011 December 1.


Chen et al. Page 4

chronic diseases (depression, diabetes, cardiovascular disease, hypertension,


arthritis, osteoporosis, cancer, asthma, and emphysema), number of
hospitalization, parental fracture after age 40, parity, self-reported health
status (poor/fair health versus good/excellent health), physical activity (total
METS/wk) and nutrient intakes (calcium, vitamin D, iron, and total energy)
were assessed from baseline questionnaires or follow-up questionnaires.
Physical function and depression at baseline were measured using the 10-
item Medical Outcomes Study Scale[19] and the shortened Center for
Epidemiologic Studies Depression Scale (CES-D),[20] respectively. Weight
was measured to the nearest 0.1kg on a balance beam scale with the
participant dressed in indoor clothing without shoes. Height was measured
to the nearest 0.1 centimeter using a wall-mounted stadiometer. Body mass
index (BMI) was calculated as: weight (kg)/height (m)2.[21,22]

Statistical Analysis
Descriptive analyses were done on baseline characteristics of the study
participants and the results were presented as mean (95% confidence
interval (CI), median (interquartile range) or frequencies (%) by anemia
group at baseline. T-tests, Wilcoxon rank sum or chi-square tests were
conducted on the baseline characteristics of the participants. Age-adjusted
incidence rates of fractures (all-types and site specific), including 95% CI,
were presented by anemia status for total participants and by race/ethnicity.
Absolute incidence rate difference (anemia – no anemia) by 10 year age
groups was calculated and presented in a bar chart. The likelihood ratio test
was used to test the null hypothesis of equal incidence rate difference
across age groups.

The Cox-proportional hazards model was used to test differences in the


relative risk of fractures by anemia status. Potential confounding effects of
covariates, including co- morbidity, falls, physical activity, nutrient intakes,
self reported general health status, physical function and demographic
characteristics were examined and controlled for when applicable. Potential
confounding factors were identified in the marginal analysis if the p- value
was less than 0.2, and then examined one by one and as a group in the Cox
proportional hazards regression analysis to assess their independent and
collective impacts on the relationship between anemia and fracture risk. If a
variable significantly affected the hazards ratio (change a hazards ratio more
than 10%), then it was considered as a confounding factor and included in
the final model. Three sets of models were developed. The first set was
adjusted for study components (OS participants versus CT controls and
interventions, each separately). The second was adjusted for study
assignment/intervention plus race/ethnicity, the only statistically significant
confounding factor for all models. The third model set included all the
above plus the following: age, height, weight, general health status
(fair/poor health versus good/excellent health), baseline number of falls,
total calcium intake, total vitamin D intake, total iron intake, physical
function, physical activity, smoking, hormone use, fractured after the age of
J Am Geriatr Soc. Author manuscript; available in PMC 2011 December 1.
55, depression, diabetes ever, osteoporosis ever, and cancer ever. The large
number of covariates in model 3 was selected from previously reported risk
factors for osteoporotic fractures and WHI interventions.[21,22] The third
model set was developed to get a more conservative assessment on the
fracture risk after adjusting for the reported factors that are related to
fracture risk. Interaction terms of race/ethnicity and anemia, and age group
and anemia were tested for possible racial/ ethnic and age group variations
in the association between anemia and fracture.

Kaplan Meier cumulative incidence probability curves were generated to


show longitudinal differences in fracture risk by anemia status.

Stratified analyses were also conducted by race/ethnicity in the Cox


proportional hazards regression. All analyses were performed with Stata
statistical software (version 10.0, Statacorp, College Station, TX).

J Am Geriatr Soc. Author manuscript; available in PMC 2011 December 1.


Chen et al. Page 5

RESULTS
A total of 160,080 women who had a baseline hemoglobin measurement
were included in this study. Among them, 8,739 women had hemoglobin
levels below 12 g/dL. Descriptive analyses by baseline anemia status (Table
1) showed that women with anemia were significantly different from women
without anemia in regards to most of the baseline characteristics examined.
A markedly higher percent of African American women were anemic. In
general, women with anemia were older, had a lower body weight and
reported poorer health, lower physical function, lower level of physical
activity, higher risk for depression, and a slightly higher frequency of falls.
Women with anemia also reported lower intakes of calcium, vitamin D and
iron. No significant difference in history of bone fractures at age 55 years or
older was observed by baseline anemia status. However, women with anemia
versus women without were more likely to report a previous diagnosis of
osteoporosis.

Absolute Risk for Fractures---Incidence Rates


The age-adjusted incidence rates for all-types, hip, and spinal fractures by
baseline anemia status are presented in Table 2. Women with anemia,
among the entire cohort and the non- Hispanic white ethnic group,
compared to women without anemia had a higher fracture incidence rate of
the hip, spine and all-types. Since the numbers of fractures in the anemia
group were small among minorities no clear patterns of associations
between anemia and higher fracture incidence rates could be identified for
these groups.

In Figure 1, differences in fracture incidence rates between anemic and non-


anemic women are presented by 10 year age groups. The magnitude of
increased fracture incidence rate by anemia appears larger in the 70 or older
age group in comparison to the younger age groups, especially for the hip
and all-types fracture groups.

Relative Risk for Fractures---Hazard Ratios


The results from the Cox model indicated that the risk for hip, spinal and all-
types of fractures were increased among women with anemia and the largest
elevated risk was for hip fractures. After adjusting for study
assignment/intervention and the confounding factor, race/ethnicity, the
hazards ratios (95%CI) were 1.81 (1.53–2.15), 1.41 (1.20–1.64), and 1.14
(1.08–1.20) for hip, spine and all-types of fractures, respectively (Table 3).
The cumulative incidence of fracture based on model 2 is presented in
Figure 2, showing greater incidence rate for hip, spine and all-types of
fractures even after adjusting for the significant confounder, race/ethnicity.

In model 3 (Table 3), where baseline number of falls, self-reported general


health and a large number of other covariates were adjusted for, the hazards
J Am Geriatr Soc. Author manuscript; available in PMC 2011 December 1.
ratios (95% CI) were changed slightly to 1.38 (1.13–1.69), 1.30 (1.09–1.55),
1.07 (1.01–1.14) for hip, spine and all-types of fractures, respectively. No
significant multiplicative interactive effect of race/ ethnicity with anemia on
all-types of fracture risk was observed. However, stratified analysis (not
shown) showed the direction is the same for these associations among the
minorities.
The number of fractures was too small for hip and spine regions in
minorities so no interactions of race/ethnicity with anemia were examined
for these site-specific fractures. The only statistically significant
interaction for age group and anemia was found for all types of fractures
in the 70–79 year old group.

Sensitivity analysis
We limited the above analyses to non-Hispanic white women (data not
shown). Results from the stratified analyses were similar to the results from
the entire cohort.

J Am Geriatr Soc. Author manuscript; available in PMC 2011 December 1.


Chen et al. Page 6

DISCUSSION
Anemia is common among older people and the prevalence increases with
advancing age.[3] Both clinical and epidemiologic research has suggested
that anemia is a significant risk factor for morbidity and mortality
particularly among older persons. Anemia may be a clinical indicator of
disease pathology or may present as a co-morbid condition which increases
the severity of existing health conditions.[5,6,8,10,11,23–27]

The WHI, with its large sample size and diverse race/ethnic sample,
presents a great opportunity to prospectively assess the relationship
between anemia and fracture risk in post-menopausal women from
different racial and ethnic backgrounds. Our analysis provides direct
evidence of a significant increase in risk for hip fracture among U.S.
postmenopausal women who present with anemia. The results also suggest
elevated spinal and all fracture risks associated with anemia. The increased
fracture risk could not be completely explained by co-morbidity, falls, or
other life-style factors. The increased fracture risk associated with anemia
in our study ranged from 7% to 38% across fracture sites, after including
multiple covariates. Our study cannot determine whether the association
between anemia and fracture is a causal relationship, but these results
highlight the importance of further understanding the underlying
mechanisms of this association.

No prior study has prospectively evaluated the relationship between anemia


and fracture risk. However, our study results are consistent with the results
from the InCHIANTI study in Italy, which showed that anemia was
associated with lower bone density, an association that was most significant
in older women as compared to older men. Interestingly, anemia- related
bone loss was mostly associated with cortical bone loss rather than trabecular
bone loss in the InCHIANTI study.[7] In contrast, our study found increased
fracture risk at both high trabecular and high cortical composition bone sites,
such as spine and hip. In this same Italian cohort, hemoglobin levels were
also found to be related to skeletal muscle properties: lower hemoglobin
concentrations were correlated with lower skeletal muscle mass and
strength.[5] Reduced skeletal muscle mass and strength may have direct
impacts on bone density since bone is responsive to mechanical stimulation.
Low skeletal muscle mass may also increase the risk of falling. Indeed,
findings have unequivocally pointed to a significant association between
anemia and falls in older adults. [8,28,29] However, in our study, falls did
not contribute significantly to the observed association between anemia and
fracture risk.

The prevalence of anemia increases with age. In NHANES III one-fifth of


women 85 or older presented with anemia. Specifically, the rates of anemia
in older women doubled from 10% to 20% when comparing prevalence
J Am Geriatr Soc. Author manuscript; available in PMC 2011 December 1.
among 75 to 84 year olds to those over 85 years of age.[3] Our findings are
in agreement with previous studies showing an increased prevalence rate of
anemia with aging. In addition, we have found that the anemia-associated
prevalence rate for hip fracture and all fractures was significantly higher in
the 70–79 year old group in comparison to the younger age groups. A
similar trend was observed for spinal fractures but the result did not reach
the level of statistical significant at the p-value of 0.05. These results suggest
that the absolute fracture risk and the difference of absolute risk were
greatest within the oldest group of women in our study. The reason for this
differential risk relationship between fractures and anemia by age group
cannot be determined in this study.

We demonstrated significant race/ethnic differences in the prevalence of


anemia in this population supporting the findings from other reports. In
NHANES III, the lowest overall prevalence in persons over age 65 was seen
in Non-Hispanic whites (9.0%). Mexican Americans (10.4%) had a slightly
higher rate, but African Americans (27.8%) had a rate 3 times higher than
non-Hispanic whites when the same WHO criteria for anemia was applied.
[3] In spite of the strikingly high prevalence of anemia in African Americans, one study has

J Am Geriatr Soc. Author manuscript; available in PMC 2011 December 1.


Chen et al. Page 7

suggested that older African Americans, classified as anemic by WHO


criteria, were not at risk for higher mortality and disability; however, an
increased risk of death and disability was found in whites with anemia from
the same cohort study.[30] Their results suggest racial differences in the
association between WHO defined anemia and adverse health events, thus
lending support for different anemia cutoff points by race/ethnicity. We did
not find race/ethnic differences in the association between anemia and risk
for all fractures.
However, smaller numbers of fractures in some minority groups have
limited our ability to make a conclusive statement.

The underlying mechanisms of the relationship between anemia and


fractures are most likely to be complicated and heterogeneous. The
association we observed here may be the reflection of direct, indirect or a
combination of direct and indirect effects of anemia on fracture risk. Many
known risk factors of anemia in older adults, such as androgen insufficiency,
chronic inflammation, age-associated renal insufficiency, stem cell
aging,[31] and nutrient deficiency including iron, cobalamin (B12) and
folate deficiencies, [32,33] are also known risk factors for osteoporosis and
fractures. Thalassemia patients are at higher risk for bone diseases, including
severe osteoporosis and fractures,[34] but we do not have information on
thalassemia in this current study. Sickle cell disease predisposes an
individual to low bone density[35] and hence increases the person's risk for
future fractures. It is unlikely that the increased risk of fracture in our study
was mainly due to sickle cell disease since only two participants reported
having the disease in the baseline questionnaire. In addition to these possible
indirect links for the association between anemia and fracture risk, low
hemoglobin levels may directly affect precursors of bone cells.[36–38] In
future investigations, bone density, geometric structures and bone metabolic
markers may be used to help understand the underlying mechanisms related
to this increased fracture risk among older anemic women.

Anemia has been considered a modifiable risk factor for adverse health
consequence.[39,40] Although anemia is associated with an increased risk of
fractures in our study, whether improving hemoglobin concentration in
anemic women can reduce risk for fractures remains to be studied. One prior
study[41] showed that after hip fractures women who had hemoglobin levels
less than 12 g/dL stayed longer in the hospital and more likely died from the
fracture than those with normal hemoglobin levels at the time of hospital
admission. Our analysis indicates anemia is associated with higher risk for
fractures, but does not provide evidence as to whether a pre-existing anemic
condition contributes to longer-term health outcomes of fractures.

In this study only hip fractures were adjudicated. Non-hip fractures were
self-reported so they are subject to reporting error. Although the agreement
between self-report of fractures and medical record confirmed diagnosis of
J Am Geriatr Soc. Author manuscript; available in PMC 2011 December 1.
fractures is estimated to be 70% in this cohort, there was a range of variation
in the accuracy of the self-reported fractures by fracture anatomical site,[42]
which may have prevented us from accurately assessing the associations
between non-hip fractures and anemia. In the current study, spine fractures
referred to clinical spinal fractures only, so under-reporting for undiagnosed
spinal fractures might have also occurred. It is unknown if these information
biases differ by anemia status; hence, their impact on the study findings is
difficult to assess. It has been suggested that only anemia linked with renal
disease or chronic inflammation are associated with a higher mortality rate.
[43] A case-control study in the WHI has suggested that poor renal function,
as measured by cystatin, is associated with increased hip fracture risk.[44]
Lack of renal function measurements is a limitation of this current study and
needs to be addressed in future investigations. Anemia was defined using a
single baseline measurement of hemoglobin and may not reflect persistent
anemia. No information on inflammation status was collected during the
study. Previous studies have shown that one third of the anemia cases in
older

J Am Geriatr Soc. Author manuscript; available in PMC 2011 December 1.


Chen et al. Page 8

populations are due to nutrient deficiency; one third to renal insufficiency


and chronic inflammation; and one third related to factors that are less
understood and difficult to detect in clinical settings.[33] The contributing
causes for anemia could not be determined in our study. Whether different
subtypes of anemia are associated with fracture risk differently is
impossible to be addressed in this study, but remains an interesting research
topic for future investigation.

WHI is the largest health study ever undertaken among postmenopausal


women in the United States. The racially and ethnically diverse cohort
makes this study unique in understanding possible differential associations
between anemia and fracture risk across racial and ethnic sub-groups. Over
the course of the study, 20,006 fractures were diagnosed between January
1999 and September, 2006, making WHI the largest number of reported
fractures in post-menopausal women. Hence the study results have provided
first hand evidence on the association between anemia and fracture risk in
postmenopausal women.

CONCLUSION
In conclusion, in this prospective cohort study we have found that anemia is
significantly associated with increased fracture risk in postmenopausal
women from the Women's Health Initiative. Given the high prevalence of
anemia in older women it is of great public health interest for future
research to investigate the mechanisms contributing to this observed
association between fracture risk and anemia and to further understand
whether age and race/ethnicity modify the relationship between anemia and
fracture risk.

Acknowledgments
SHORT LIST OF WHI INVESTIGATORS Program Office: (National Heart, Lung, and Blood Institute,
Bethesda, Maryland) Elizabeth Nabel, Jacques Rossouw, Shari Ludlam, Linda Pottern, Joan McGowan, Leslie
Ford, and Nancy Geller.

Clinical Coordinating Center: (Fred Hutchinson Cancer Research Center, Seattle, WA) Ross Prentice, Garnet
Anderson, Andrea LaCroix, Charles L. Kooperberg, Ruth E. Patterson, Anne McTiernan; (Wake Forest University
School of Medicine, Winston-Salem, NC) Sally Shumaker; (Medical Research Labs, Highland Heights, KY) Evan
Stein; (University of California at San Francisco, San Francisco, CA) Steven Cummings.

Clinical Centers: (Albert Einstein College of Medicine, Bronx, NY) Sylvia Wassertheil-Smoller; (Baylor College
of Medicine, Houston, TX) Jennifer Hays; (Brigham and Women's Hospital, Harvard Medical School, Boston, MA)
JoAnn Manson; (Brown University, Providence, RI) Annlouise R. Assaf; (Emory University, Atlanta, GA)
Lawrence Phillips; (Fred Hutchinson Cancer Research Center, Seattle, WA) Shirley Beresford; (George
Washington University Medical Center, Washington, DC) Judith Hsia; (Los Angeles Biomedical Research Institute
at Harbor- UCLA Medical Center, Torrance, CA) Rowan Chlebowski; (Kaiser Permanente Center for Health
Research, Portland, OR) Evelyn Whitlock; (Kaiser Permanente Division of Research, Oakland, CA) Bette Caan;
(Medical College of Wisconsin, Milwaukee, WI) Jane Morley Kotchen; (MedStar Research Institute/Howard
University, Washington, DC) Barbara V. Howard; (Northwestern University, Chicago/Evanston, IL) Linda Van
Horn; (Rush Medical Center, Chicago, IL) Henry Black; (Stanford Prevention Research Center, Stanford, CA)
Marcia L. Stefanick; (State University of New York at Stony Brook, Stony Brook, NY) Dorothy Lane; (The Ohio
State University, Columbus, OH) Rebecca Jackson; (University of Alabama at Birmingham, Birmingham, AL)
Cora E. Lewis; (University of Arizona, Tucson/Phoenix, AZ) Tamsen Bassford; (University at Buffalo, Buffalo,
NY) Jean Wactawski-Wende; (University of California at Davis, Sacramento, CA) John Robbins; (University of
J Am Geriatr Soc. Author manuscript; available in PMC 2011 December 1.
California at Irvine, CA) F. Allan Hubbell; (University of California at Los Angeles, Los Angeles, CA) Howard
Judd; (University of California at San Diego, LaJolla/Chula Vista, CA) Robert D. Langer; (University of
Cincinnati, Cincinnati, OH) Margery Gass; (University of Florida, Gainesville/Jacksonville, FL) Marian Limacher;
(University of Hawaii, Honolulu, HI) David Curb; (University of Iowa, Iowa City/Davenport, IA) Robert Wallace;
(University of Massachusetts/Fallon Clinic, Worcester, MA) Judith Ockene; (University of Medicine and Dentistry
of New Jersey, Newark, NJ) Norman Lasser; (University of Miami, Miami, FL) Mary Jo O'Sullivan; (University of
Minnesota, Minneapolis, MN) Karen Margolis; (University of Nevada, Reno, NV) Robert Brunner; (University of
North Carolina, Chapel Hill, NC) Gerardo Heiss; (University of Pittsburgh, Pittsburgh, PA) Lewis Kuller;
(University of Tennessee, Memphis, TN) Karen C. Johnson; (University of Texas Health Science Center, San
Antonio, TX) Robert Brzyski; (University of Wisconsin, Madison, WI) Gloria E. Sarto; (Wake Forest University

J Am Geriatr Soc. Author manuscript; available in PMC 2011 December 1.


Chen et al. Page 9

School of Medicine, Winston-Salem, NC) Denise Bonds; (Wayne State University School of Medicine/Hutzel
Hospital, Detroit, MI) Susan Hendrix.

Sponsor's Role: This study was supported by National Institute of Aging grant 1R01AG029133-01. The WHI
program is funded by the National Heart, Lung and Blood Institute, U.S. Department of Health and Human
Services. Sponsor had no role in design, methods, data collection, analysis, or preparation of manuscript.

Appendix

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Figure 1.
Differences in incidence rates of fracture per 10,000 person-years between
anemic and non- anemic women (absolute incidence rate difference=
anemia group incidence – no anemia group incidence)

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Chen et al. Page 13

Figure 2.
Cumulative incidence of fracture, adjusted for study arm assignment and race/ethnicity

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Chen et al. Page 14

Table 1

Baseline characteristics by anemia (N=


160,080)

No Anemia N= 151,341 Anemia N= 8,739


N % N %

Age at Baseline ***


50–59 50,204 33.2 2,729 31.2
60–69 67,998 44.9 3,853 44.1
70–79 33,139 21.9 2,157 24.7
Ethnicity ***
American Indian or Alaskan Native 652 0.4 52 0.6
Asian or Pacific Islander 3,970 2.6 170 1.9
African-American 12,101 8.0 2,316 26.6
Hispanic/Latino 6,118 4.1 318 3.7
White (not of Hispanic origin) 126,450 83.8 5,726 65.8
Other 1,673 1.1 121 1.4
Study arm ***
OS 86,459 57.1 5,540 63.4
CT 64,881 42.9 3,199 36.6
Smoking Status ***
never smoked 75,952 50.8 4,600 53.5
past smoker 62,760 42.0 3,639 42.4
current smoker 10,685 7.2 352 4.1
Hormone therapy use ***
Never 66,402 43.9 3,790 43.4
past user 24,412 16.1 1,248 14.3
current user 60,402 39.9 3,694 42.3

fracture at age 55+


No 96,403 83.6 5,618 82.9
yes 18,850 16.4 1,156 17.1
Depression ***
No 131,118 89.0 7,354 87.5
Yes 16,119 11.0 1,052 12.5
Diabetes ever ***
No 142,525 94.2 7,942 91.0
Yes 8,721 5.8 785 9.0
Osteoporosis ever ***
No 137,937 92.4 7,762 90.5
yes 11,276 7.6 820 9.5
Cancer ever ***
no 136,402 90.9 7,691 88.8
yes 13,623 9.1 974 11.2

J Am Geriatr Soc. Author manuscript; available in PMC 2011 December 1.


General self-reported health status ***

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Chen et al. Page 15

No Anemia N= 151,341 Anemia N= 8,739


N % N %

excellent 25,890 17.2 1,172 13.5


very good 61,867 41.1 3,067 35.4
good 49,417 32.9 3,126 36.1
fair 12,122 8.1 1,173 13.5
poor 1,087 0.7 128 1.5

Physical Functioning Score † ***

<80 44,885 30.2 3,410 40.1


80–90 48,307 32.5 2,440 28.7
91–100 55,317 37.3 2,655 31.2
Number of falls in past year ***
none 97,948 67.6 5,662 66.5
1 time 29,087 20.1 1,678 19.7
2 times 11,977 8.3 748 8.8
3 or more times 5,993 4.0 423 5.0

Mean SD Mean SD

Physical Activity (mets) 12.4 13.7 11.7 13.6***


Height (cm) 161.8 6.6 161.2 6.7***
Weight (kg) 73.6 16.8 73.0 18.3***

BMI (kg/m2) 28.0 5.9 27.9 6.5

Median IQR Median IQR


Total intake of Iron (mg) 16.2 10.4–27.9 15.4 9.6–27.7***
Total intake of Calcium (mg) 1035.0 654.6–1,542.9 925.4 554.5–1,444.2***
Total intake of Vitamin D (IU) 306.2 135.3–552.6 257.5 113.6–525.6***
***
p≤0.001; calculated using chi-square T-tests, or Wilcoxon rank sum tests IRQ: interquartile range

better physical function with higher score

J Am Geriatr Soc. Author manuscript; available in PMC 2011 December 1.


Table 2

Chen et al.
Incidence rates* of fractures per 10,000 person-years (95% CI) by race/ethnicity
Hip Spine All-types
Anemia No Anemia Anemia No Anemia Anemia No Anemia

#Fx IR (95% CI) #Fx IR (95% CI) #Fx IR (95% CI) #Fx IR (95% CI) #Fx IR (95% CI) #Fx IR (95% CI)

Total WHI 150 21.4 (17.9, 24.8) 1,756 15.0 (14.3, 15.7) 174 25.5 (21.7, 29.3) 2,692 23.0 (22.1, 23.9) 1,449 234.3 (222.2, 246.4) 25,245 232.5 (229.6, 235.4)
J Am Geriatr Soc. Author manuscript; available in PMC 2011 December 1.

White 128 26.6 (21.9, 31.2) 1,657 16.8 (16.0, 17.7) 159 34.4 (29.0, 39.8) 2,502 25.4 (24.4, 26.4) 1,129 275.9' (259.7, 292.1) 22,549 248.1 (244.9, 251.4)
Hispanic 1 4.8 (0, 14.1) 23 5.2 (3.1, 7.3) 3 13.0 (0, 27.9) 47 10.6 (7.5, 13.6) 33 161.0 (105.6, 216.5) 639 150.9 (139.2, 162.6)
African American 14 7.4 (3.5, 11.4) 37 4.1 (2.8, 5.4) 4 2.3 (0.04, 4.6) 51 5.6 (4.1, 7.1) 235 142.0 (123.7, 160.2) 1,215 139.4 (131.6, 147.2)
Asian 3 16.6 (0, 35.3) 15 5.1 (2.5, 7.6) 4 25.4 (0, 50.9) 45 15.2 (10.8, 19.7) 21 158.5 (86.0, 230.9) 428 151.3 (137.0, 165.6)
American Indian 0 NA 8 16.6 (5.1, 28.1) 0 NA 10 20.6 (7.8, 33.4) 6 153.8 (28.2, 279.3) 120 272.3 (223.6, 321.1)

*
age-adjusted; #Fx: number of fractures; IR: incidence rate; CI: confidence interval

Page 16
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a
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3

Risk of fracture by anemia status

Model 1 (N= 159,218)* Model 2 (N=158,809)† Model 3 (N=112,269)‡

HR 95% CI HR 95% CI HR 95% CI

Hip 1.55 1.32, 1.84 1.81 1.53, 2.15 1.38 1.13, 1.69
Spine 1.17 1.01, 1.37 1.41 1.20, 1.64 1.30 1.09, 1.55
J Am Geriatr Soc. Author manuscript; available in PMC 2011 December 1.

All-types 1.04 0.98, 1.09 1.14 1.08, 1.20 1.07 1.01, 1.14

*
adjusted for study arm assignment and interventions (observation study participants versus clinical trial controls or
interventions)

adjusted for all in model 1 plus race/ethnicity

adjusted for all in model 2 plus age, height, weight, self reported general health (fair/poor health versus good/excellent health), baseline
number of falls (none versus one, two, or three or more falls), diabetes ever, osteoporosis ever, cancer ever, total calcium intake, total
vitamin D intake, total iron intake, physical function(< 80 score versus 80–90 score or 91–100 score), physical activity (total METS/ wk),
smoking (never versus past or current smoker), hormone therapy (never versus past or current u