MEDICAL NUTRITION

THERAPY FOR ANEMIA

DEFINITION
Anemia is a condition in which a deficiency in the
size or number of erythrocytes, or the amount of
hemoglobin they contain.

Hemoglobin is the red pigment in red blood cells

that transports oxygen.

Not a disease but a symptom of conditions including

extensive blood loss, excessive blood cell
destruction, or decreased blood cell formation.
DIAGNOSE
Assessment of the complete blood count and select
biochemical markers will aid in determination of the
etiology of most anemias.

Complete Blood
Count Indices
Diagnose
Biochemical
Markers
COMPLETE BLOOD COUNT INDICES

Includes :
Red Blood Cells Count (RBC count):.. in millions/L

(normal range : 4,5 5,5 millions/L)

Hb (g/dl)

Ht (%) : the percentage of blood by volume that is

occupied by the red cells
Mean Corpuscular Volume (MCV) : the average size
of the red blood cells expressed in femtoliters (fL)
MCV (fL) = Ht (%) x 1000
RBC count (in millions/L)
(normal range : 80-94 fL, 1 fL= 10-15L)
 Mean corpuscular hemoglobin (MCH) : the
average amount of hemoglobin inside an RBC
expressed in picograms (pg)
MCH (pg) = Hemoglobin (g /dL) x 10
RBC count (in millions/L)
(Normal range: 27-31 pg,1 pg =10-12 g)

Mean corpuscular hemoglobin concentration

(MCHC) : the average hemoglobin concentration
per unit volume of packed red blood cells
expressed in g/dl.
 MCHC (g/dL) = MCH x 100
MCV
or

MCHC (g/dL) = Hemoglobin (g/dL)

Hematocrit

(Normal Range : 32-36 g/dl)

 The MCV reflects the size of red blood cells.
MCH and MCHC reflect the hemoglobin content of red
blood cells.
These RBC measures are used to diagnose types of
anemia.
 Classification of Anemia

Based on cell size (MCV)

Macrocytic (large) : MCV > 94 fL.

Normocytic (normal) : MCV = 82-92 fL.

Microcytic (small) : MCV < 80 fL.

Based on hemoglobin content (MCH)

Hypochromic (pale color)

Normochromic (normal color)

CLASSIFICATION OF ANEMIA

Normochromic Normocytic (MCV=82-92

fL,MCHC>30 g/dl

Normochromic Macrocytic (MCV>94 fL,

MCHC>31 g/dl

Hypochromic Microcytic (MCV<80 fL,

MCHC <31 g/dl)
1. Normochromic Normocytic Anemia

These include :
anemias of chronic disease

hemolytic anemias

anemia of acute hemorrhage

aplastic anemias

Kidney diseases

2. Normochromic Macrocytic Anemia :

These include :
Vitamin B12 deficiency

Folic acid deficiency

3. Hypochromic Microcytic Anemia
These include :
Iron deficiency anemia

Thalassemia, sikcle cell anemia

Anemia sideroblastik.
Biochemical Markers

Biochemical markers, though often nonspecific,

may support specific diagnoses.
These include :
Serum or plasma ferritin

Serum or plasma iron

Transferrin

Trasferrin saturation

Transferrin IBC

RBC Protoporphyrin
CAUSES OF ANEMIA

Potential causes include :

- infections
- certain diseases
- certain medications (medical reactions)
- lack of nutrients required for normal erythrocyte
synthesis : nutritional anemia
- blood loss
Who Are At Risk For Developing Anemia
?

infants who may not have adequate iron intake

children going through a rapid growth spurt,
during which the iron available cannot keep up
with the demands for a growing red cell mass
women in childbearing years who have an
excessive need for iron because of blood loss
during menstruation
pregnant women, in whom the growing fetus
creates a high demand for iron.
Symptoms of Anemia

Most symptoms of anemia Heart palpitations (rapid or

are a result of the decrease irregular beating)
of oxygen in the cells or Headache
"hypoxia."
Ringing in the ears
(tinnitus)
Symptoms of anemia Difficulty sleeping
include :
Difficulty concentrating
Fatigue

Weakness

Fainting

Breathlessness
Tanda/sign meliputi:

Kulit pucat
Kelopak mata pucat
Irama jantung cepat (tachycardia)
SEVERITY OF ANEMIA

Severity Hb Range Symptoms

(g/dL)
Mild 9.5-13.0 Often no signs
or symptoms
Moderate 8.0 9.5 May presents
with symptoms
Severe < 8.0 Symptoms
usualy presents
Effects of Anemia

18
Adults
Reduced work capacity
Reduced mental capacity
Reduced immune competence
Poor pregnancy outcomes
Increased risk of maternal death

Infants and children

Reduced cognitive development
Reduced immune competence
Reduced work capacity
IRON DEFICIENCY ANEMIA

Causes of Iron Deficiency Anemia

Decreased supply of iron due to inadequate

intake of iron and reduced in bioavailability of

dietary iron
Decreased absorption of iron : Cause of iron
malabsorption
Increased requirement of iron : during the

periods of growth as in infancy and

adolescence, lactation, pregnancy.
Increased blood loss or excretion
Fase Fase terjadinya anemia defisiensi Fe:
Pengurasan cadangan Fe sbg akibat penurunan kadar feritin
serum

- Pe kandungan Fe dlm plasma dan pe TIBC.

- Pe protoporfirin sel darah merah krn pasokan Fe tidak cukup
untuk mensintesis heme sementara kadar Hb masih dalam batas
normal.

- Terjadi anemia mikrositik hipokromik dimana terjadi penurunan

nilai MCHC .
 DIAGNOSIS
Serum or plasma ferritin
Serum or plasma iron
Transferrin
Trasferrin saturation
Transferrin IBC
RBC Protoporphyrin
Anemia Megaloblastik
Sel darah merah penderita tidak normal
dengan ciri-ciri bentuknya lebih besar,
jumlahnya sedikit dan belum matang.
95% kasus berhubungan dengan defisiensi
asam folat dan vitamin B12.
Vitamin B12 Deficiency
Vitamin B12 deficiency can result from pernicious
anemia, achlorhydria due to decreased iron stores,
or other disorders leading to reduced cobalamin
intake or absorption.
Pernicious Anemia
Merupakan salah satu bentuk defisiensi vit B12.
Pernicious anemia is caused by failure of gastric
parietal cells to produce sufficient intrinsic factor
(IF) for vitamin B12 absorption : dihubungkan
dgn reaksi autoimun.
IF : suatu protein (glikoprotein) pada cairan
lambung
Vitamin B12
Absorption Physiology
Etiologi Defisiensi Vitamin B12
1. Diet :
Diet vegetarian yang ketat : pada kaum vegan tanpa
suplementasi vitamin B12
Poor diet in infant

Poor maternal nutrition during pregnancy

2.Infeksi (parasit pada usus, infeksi bakteri)

3.Penyakit pada saluran cerna, seperti celiac disease
(sprue), Crohns disease, gastrektomi.
4.Obat : colchicine, neomycin, ethanol, metformin,
tuberculosis treatment dengan para amino salicylic acid).
5.Kelainan metabolik (homosistinuria, methylmalonic
aciduria)
Folic Acid Deficiency
Associated with excessive alcohol intake
Associated with pregnancy
20% are folate-deficient
Occurs with decreased intake, malabsorption
syndromes
Pemeriksaan Laboratorium
Kadar asam folat serum rendah (< 3 mg/dl)
Kadar asam folat dalam sel darah merah
rendah (<140 ng/ml).
Treating Nutritional Anemia : Iron
Deficiency Anemia
Iron Supplementation :
Oral iron salts
Ferrous forms better absorbed than ferric (ferrous
sulfate, ferrous lactate, ferrous fumarate)
Best absorbed on an empty stomach but if irritation
occurs, give with meals.
Gastrointestinal effects of iron supplementation :
nausea, epigastric discomfort, hearburn, diarrhea,
constipation.
Dosage 50-200 mg of elemental iron for adults; 6
mg/kg body weight for children.
Generally supplement for 3 months (4-5 months if
taken with meals)
 Oral iron supplementation may result in normal
hemoglobin levels after a few weeks.
There is no benefit to taking iron supplement with
orange juice because vit C does not enhance
absorption from supplement as it does from foods.

If patient fails to respond

May not be taking supplements

May not be absorbing iron (celiac disease,

steatorrhea, hemodialysis)
May be bleeding

May need parenteral administration of iron, in the form

of IV iron dextran more expensive & not as safe
as oral administration
Nutritional Management of Iron-Deficiency
Anemia

Increase absorbable iron in the diet

Include vitamin C at every meal
Include meat, fish or poultry at every meal
Decrease tea and coffee consumption with
meals.
Restoring Iron Levels
Factors to consider:
Bioavailability of iron

Vitamin Cbinds iron to form a readily

absorbed complex
Heme sources (meat, poultry, fish) about
15% absorbable
Nonheme iron (grains, vegetables, eggs)
about 3% to 8% absorbable. Iron in egg yolk is
poorly absorbed the presence of phosvitin.
 Faktor Faktor yang Mempengaruhi
Penyerapan Fe

Bentuk besi di dlm makanan. Besi-hem (banyak

terdapat dlm daging hewan) dpt diserap dua x
lipat drpd besi non hem.
Asam organik, seperti vitamin C dan asam sitrat.
Asam fitat dan faktor lain dlm serat serealia dan
asam oksalat di dlm sayuran menghambat
penyerapan Fe.
 Tanin, merupakan senyawa polifenol, terutama terdapat
dalam kopi/teh : menghambat penyerapan Fe.
Tingkat keasaman lambung : meningkatkan daya larut Fe.
Kekurangan asam klorida di dalam lambung atau
penggunaan obat2an yg bersifat basa seperti antasid
menghambat absorbsi Fe.
Keb. tubuh akan Fe. Bila tubuh kekurangan Fe atau
kebutuhan meningkat pada masa pertumbuhan, absorbsi
besi non-heme dapat sampai 10 x, sdgkan besi hem 2
x.
Nutritional Management of Iron-Deficiency
Anemia

Increase absorbable iron in the diet

Include vitamin C at every meal
Include meat, fish or poultry at every meal
Decrease tea and coffee consumption with
meals.
 Diet for Iron Deficiency:
Avoid excess caffeine
Eat iron-rich foods
Protein foods
Vegetables
Meats Greens
Fish & Shelfish Dried peas & beans
Eggs
Fruits Grains
Dried fruit Iron-fortified breads
Juices Dry cereals
Most fresh fruits Oatmeal cereal
Treating Nutritional Anemia :
Vit B 12 Deficiency Anemia

Individuals with abnormal B12 absorption but without

pernicious anemia : high protein diet (1.5 g/kg) with
meat, liver, eggs, milk, milk products, green leafy
vegetables

Individuals with B12 deficiency due to pernicious anemia

usually must receive injections of vitamin B12
Treating Nutritional Anemia :
Folic Acid Deficiency Anemia

Individuals with folic acid deficiency usually

benefit from oral folic acid supplementation
Diet : Diberikan makanan yang mengandung
banyak asam folat : sayuran hijau, hati, daging
tanpa lemak, serealia, biji-bijian, kacang-
kacangan, dan jeruk.
Other Nutritional Anemias
Copper deficiency anemia
Anemia of protein-energy malnutrition
Sideroblastic (pyridoxine-responsive) anemia
Vitamin Eresponsive (hemolytic) anemia