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.

Diagnos
e

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.

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

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

are a result of the decrease
of oxygen in the cells or
"hypoxia."

Symptoms of anemia
include :
Fatigue
Weakness
Fainting
Breathlessness

Heart palpitations (rapid or

irregular beating)
Headache
Ringing in the ears
(tinnitus)
Difficulty sleeping
Difficulty concentrating

Tanda/sign meliputi:

Kulit pucat
Kelopak mata pucat
Irama jantung cepat (tachycardia)

SEVERITY OF ANEMIA
Severity

Hb Range
(g/dL)

Symptoms

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:

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

Fish & Shelfish

Dried peas & beans

Greens

Eggs
Fruits
Dried fruit

Grains
Iron-fortified breads

Juices
Most fresh fruits

Dry cereals

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, kacangkacangan, dan jeruk.

Other Nutritional Anemias

Copper deficiency anemia

Anemia of protein-energy malnutrition
Sideroblastic (pyridoxine-responsive) anemia
Vitamin Eresponsive (hemolytic) anemia