Nutritional Anemias

Definition of nutritional
anemia.

Hemoglobin g/dl cut off- . (WHO/UNU-1996)

6mo-5yr <11.0;

12-13 yr -12.0g/dl; Men 13.0

Women Non-pregnant - 12.0;Pregnant 11.0

Irrespective of Hb level , if an individual shows rise in

hemoglobin after hematinics administration he/she is
anemic (Garby et al 1969).

5-11 yr. - 11.5;

Why adult & Child Hemoglobin

level differ

No satisfactory answer-

Children have 50% more inorganic

phosphate, associated with

Elevated RBC adenosine triphosphate

and 2,3 diphosphoglycerate content-

Thus oxygen affinity is decreased in

children as compared to adults.
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Nutrients in hemoglobin
synthesis.

Proteins- all essential amino acids are necessary; methionine deficiency

megaloblastic anemia

Vitamins- B12 and folic acid megaloblastic anemia

-C- Fe+++ to Fe++ & Releases Fe from stores.
-A- mobilises Fe from stores & improves utilisation
-B6- macro/micro anemia,
-B2- BONE MARROW-hypoplasia---ANOREXIA NERVOSA-Affects all cell lines.

Thus in PEM and other hematopoietic nutrient(s) anemia on Fe- suppl

alone will have poor response.
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Clinical Features:

Insidious onset- even Hb<8g/dl, child patient may be

comfortable; physical activity may not be decreased
even <6g/dl- ADJUSTMENT

Rapid breathlessness, dizziness, faintness, fatigue,

CHF, heart murmurs-systolic in timing heard at
pulmonary area.

Pallor eyelids, tongue, nail bed (changes less common

below 6 yr.) PICA

Psycho neurological changes- B12 and or Folic acid

deficiency- Megaloblastic anemia.

Dyspigmentation /pigmentation- megaloblastic anemia

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Effects of maternal iron deficiency

on feto placental unit:

Transport of iron from mother to fetus remains

proportionate to the degree of maternal hypoferriemia
(Agarwal et al.AJCN 1979, Acta Paediatr 1978 & 1984).

Placental iron content reduces significantly.

Fetal brain iron content and neurotransmitters are

reduced (BJN 2001; Agarwal).

Fetal Liver iron stores are reduced.

However, Breast milk iron content is increased

(Agarwal et al. Acta Paediatr 1985).
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Physiological anemia of infancy

Normal newborn- High Hb level progressively

declines by 8-12 wk -9-11g/dl.- Hypoxia
stimulates Renal and Hepatic oxygen sensors
erythropoietin production increases.

Preterm- Hb decline is extreme & rapidly falls

to 7-9 g/dl by 3-6 wk of age.- Sampling for Lab
tests. There are relatively insensitive Hepatic
oxygen sensors; as Renal Oxygen sensors
switch on at 40 wk of gestation.
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Prevalence of nutritional
anemia

NFI 2002-2003- 7 states (Assam, HP, Hy, Kerala, MP, Orissa,

TN ) anemia prevalence- Pregnancy 86.1%(Hb <7.0g/dl9.5%); Lactation 81.7 %(Hb <7.0g/dl - 7.3%) Agarwal et al
2005..

ICMR 1999-2000- 11 states 19 districts 84.6% (Hb <7.0 g/dl9.9% ).

90% adolescents were also anemic Teoteja et al 2000.

>80% < 3 yr children are anemic NFHS-II& Agarwal et al.

Magnitude and severity of anemia at all ages seems to show

life cycle with nutritional anemia in INDIA.
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Megaloblastic Anemias

Hypersegmented Neutrophil 98% had one cell

with >6 lobes;

Oval macrocytes.

Bone-marrow- Large Erythrocyte and

Leucocyte series; Megaloblasts have sieve like
chromatin- dissociation between nucleus and
cytoplasm maturity.

Vitamin B12 and folate levels to differentiate.

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Fetal Latent Iron Deficiency- brain iron content &

neurotransmitters- irreversible reduction

Brain iron content was reduced.

Excitatory and inhibitory

neurotransmitters and their receptors were
reduced.

MRI-spectroscopy:There was an increase in

creatinine and aspartate and reduction in
choline concentration(BJN Agarwal 2001)
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Control & Treatment of

Anemias

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Feeding in early infancy

Baby should be breast fed colostrum and

mature milk, both have 49% absorbable
iron this is sufficient with available fetal
stores till baby doubles the birth weight.

Weaning foods from 6 months onwards

should have one iron rich dietary item
and iron supplementation be given as
recommended. Cook in iron vessels.
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Iron fortified food.

Iron EDTA has been highly effective in fortification

trials with Egyptian flat breads, curry powder in
South Africa, fish sauce in Thailand, and sugar in
Guatemala.

In Grenada , flour used in commercial baking is

enriched with iron and B vitamins,.

Indian researchers have field tested with success iron

fortified salt.

Pasteurized milk (iron 15 mg/ l and Vit. C 100 mg/l.)Stekel 1986

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Availability of dietary iron by

cooking in cast iron utensils:

WHO 1992 prevalence of pregnancy anemia report,

records that lowest, rates of all the subregions of the
developing world were observed in southern Africa,
due to wide spread use of iron cooking pots by
indigenous people.

Agarwal et al (Lal et al IJMR-1973) had

demonstrated that cooking in cast iron utensils, for
boiling milk, cooking vegetables etc, provided extra
dietary iron. This available dietary iron is well
absorbed.

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Diagnosis of Deficiency
Anemias
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Iron deficiency Diagnosis

RBC-hypochromic microcytic,
progressive fall in- MCV, MCH & MCHC
.

Reduction in Reticulocyte Hb content.

sTfR-soluble transferrin receptor

increases in iron def. and ineffective
erythropoiesis, No change in Chr. Inf.
anemia.
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Contd.

TfR index-ratio of sTfR to the log of ferritin,

value >1.5 Iron def; <1.5 anemia chronic
diseases.

EPP- Erythrocyte Porphyrin increases in iron

def, lead poisoning and chr. Inflammatory
anemia.

Serum Ferritin with negative CRP.

Absence of Bone marrow iron content. Low

hepatic iron content.

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Epidemiological studies show a prevalence of

cobalamin deficiency of around 20% (between 5%
and 60%, depending on the definition of cobalamin
deficiency used in the study) in the general
population of industrialized countries. The
Framingham study demonstrated a prevalence of
12% among elderly people living in the community.
Other studies focusing on elderly people,
particularly those who are in institutions or who
are sick, have suggested a higher prevalence:
30%40%. However, these figures are questionable
since they depend directly on normality thresholds
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We at all ages live in life cycle with

anemia.
Nutritional Anemia is treatable and
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