NUTRITIONAL ANEMIA Nurpudji Astuti. MD, MPH, Sp.GK

Nutrition DepartmentSchool of MedicineHasanuddin University

Anemia giziAnemia yang disebabkan oleh defisiensi nutrien yang merupakan faktor eritropoesis dalam pembentukan sel darah merah

Fe, vit.B.12, vit.B6, Vit.C, Cu dan Co, asam folat dan protein

Definisi AnemiaKeadaan dimana kadar hemoglobin darah lebih rendah dari normal

Penyebab Asupan tidak adekuat ( Primer)Absorbsi tidak adekuat ( TGI disease )Utilisasi tidak adekuat (keganasan, infeksi)Kebutuhan yang meningkat (kehamilan)Eksresi yang meningkat ( peny.hati)

TIPE ANEMIA GIZIBERDASARKAN PEMERIKSAAN HEMATOLOGIKAnemia mikrositik hipokromikdisebabkan oleh defisiensi zat besi

Anemia makrositik hiperkromik atau megaloblastik anemia disebabkan oleh defisiensi vitamin B.12 dan asam folat

NILAI HEMOGLOBIN DAN HEMATOCRIT/PCV DAN MCHC

GEJALA KLINIK ANEMIA GIZIGEJALA KLINIK ANEMIA AKAN MEMBERIKAN GAMBARAN SERUPA APAPUN PENYEBABNYA

DEFISIENSI ZAT BESI PADA ANAKDITEMUKAN PADA NEGARA MAJU DAN BERKEMBANG

PADA ANAKCadangan besi yang terbatasPertumbuhan yang cepatVariasi makanan yang terbatasMakanan tambahan yang terlambatMetabolisme yang meningkatAbsorbsi yang berkurang

ETIOLOGIANEMIA PADA ANAKBayi < 6 bulanCadangan besi tidak adekuatMakanan tambahan terlambatUmur 1 - 2 tahunInfeksi sal. cerna dan nafasDiet tidak adekuat5 tahunInfeksi parasit ( ankylostomiasis, trichuris, amubiasis )

ANEMIA PADA WANITA DEWASAKeperluan yang meningkat pada masa menstruasiKehamilanLaktasi

Pada saat menstruasiRata-rata kehilangan darah 30 ml/hariDibutuhkan 0,1 mg FeAbsorbsi dalam makanan 20%, untuk itu dibutuhkan asupan zat besi sebanyak 10 mg dalam makananAbsorbsi makanan akan ditingkatkan oleh protein hewaniAkan dihambat oleh kandungan pytat dari tumbuh2an

KEHAMILAN DAN LAKTASIKehilangan besi pada kehamilan normalFe foetus400 mgPersalinan325 mgLaktasi175 mgTotal900 mgUntuk periode selama 460 hari membutuhkan tambahan 2mg Fe/hari

Patogenesis terjadinya defisiensi zat besi pada wanitaPerubahan metabolisme zat besi selama kehamilanFaktor lainPerubahan komposisi darahPerubahan pada sumsum tulangPertumbuhan dan perkembangan foetusIntake yang kurang Absorbsi meningkat 20-40% ( ibu anemi)Pool bumil yang rendah (jarak hamil dekat)

Total zat besi dalam tubuh4-5gr (dewasa) & 400mg (Bayi)

KEHILANGAN BESI DARI TUBUH

IRONHuman body contains 3 to 5 g ironApproximately 2 g as Hemoglobin and 8 mg as enzymesWell conserved by the body ; approximately 90% is recovered and reused extensively.Highly reactive element that can interact with oxygen to form intermediates able to damage cell membrane or degrade DNA.Iron must be tightly bound to proteins to prevent destructive effects.

IRON COMPOUND IN THE BODYMETABOLIC PROTEINHeme Proteins Hemoglobin Oxygen transport from lungs to tissues Myoglobin Transport & store Oxygen in muscle Enzymes - Heme cytochromes Electron transport Cytochrom P-450 Oxidative degradation of drugs Catalase Convert hydrogen peroxide to oxygen and water Enzymes-Nonheme Iron sulfur & metalloproteins Oxidative metabolismEnzymes-iron dependent Tryptophan pirrolase Oxidation of tryptophan

IRON COMPOUND IN THE BODY, cont..

TRANSPORT AND STORAGE PROTEINS Transferrin transport of iron and other minerals FerritinStorage HemosiderinStorage

Two Types IRON in Food:

Heme-Iron: In animals product (hemoglobin & myoglobin)Well absorbed About 90% of iron consumed

Nonheme-iron : Mainly in plants Main source of iron in the diet (~10%)Absorption variable affected by other factors

Iron cont95% is associated with proteins e.g hemoglobin & myoglobin

Functions: Respiratory transport of O2 & CO2 (Oxygen binding component of hemoglobin and myoglobin) Co-factor for enzymesInvolved in the immune function and cognitive performance

Absorption: Well regulatedTransported: TransferrinSources: Meat, seafood, some vegetables

Iron AbsorptionHealthy Individuals: 5-10% absorbedIron deficiency : Up to 40% absorbedFactors that affect absorption:enhancing factors:acid in the stomachheme ironhigh body demand low body storesmeat protein factorvitamin C

Iron Absorption, cont.Inhibiting factorsdietary fiber (phytate)tannin in tea

Calcium helps to remove phosphate, oxalate and phytate that would combine with iron and inhibit its absorption

Iron routes in bodyMost iron is recycled. Some lost with body tissues and must be replaced by eating iron-containing foodIntestinal cells: store excess in ferritin; if body no need iron-----some losses in shed intestinal cells; package iron in transferrin (transport protein)Blood: transferrin carries Fe in blood; some losses via urine, sweat, skin; some Fe delivered to myoglobin of muscle cells; bone marrow puts Fe into haemoglobin of red blood cells; stores excess in ferritin and haemosiderinLiver/lien; Dismantle red blood cells and package Fe into transferrin, stores excess as ferritin / haemosiderin

Iron Deficiency and ToxicityDeficiency:decreased blood hemoglobin (anemia) Low plasma iron increased transferrin and reduction in tissue iron lethargy

Toxicity Not common, usually due to a genetic disorder

Source of IronAdequate diet contains no more than 6mg/1000kcal of ironRDA 12mg/dayDried beans and vegetables are the best plant sourcesBest sources dietary ironLiver, heart, kidney, lean meat oysters, shellfish FishPoultry

COPPERCOMPONENT OF MANY ENZYMES

OXIDIZING IRON BEFORE IT IS TRANSPORTED ( ceruloplasmin, copper containing protein, required for normal mobilization of iron from its storage site to the plasma)

PLAYS ROLE IN MITOCHONDRIAL ENERGY PRODUCTION, PROTECTION FROM OXIDANTS, AND SYNTHESIS PF MELANINE AND CATHECOLAMINE

Source of CopperMost diet provide 2mg/dayRDA 1.5 - 3mg/dayFood high in copperOysters, shellfishLiver, KidneysChocolateNutsDried legumes, Dried foodsCerealsPoultry

CobaltA component of vitamin B12 (cobalamin)This vitamin is essential for maturation of red blood cells and normal functioning of all cellsRequirement expressed in terms of Vit B12 : 1.4-2 ug dailyToxicity : intake of 10 to 20 ug/kg Body weight : high intake cobalt in animal diet produce polycytemia, bone marrow hyperplasia, reticulocytosis, and increased blood volumeDeficiency: related to Vit B12 deficiency --- macrocytic anemia

Source of CobaltRDA 1.4 - 2.0 ug/dayLiver, kidney,Oysters, clamsPoultryMilk

FOLIC ACIDRDAMale200ugFemale180ugFunctionsEssential for bio-synthesis of nucleic acids.Essential for normal maturation of RBCFunctions as co-enzyme: tetrahydro-folic acid

Source of Folic acidGreen leafy vegetable,Organ meats (liver), lean beef, Wheat, dry beans, lentils, cowpeasAsparagus, broccoli, collards, yeastSynthesized by intestinal tract

B12 VitaminInvolved in the metabolism of single carbon fragmentEssential for biosynthesis of nucleic acid and nucleoproteinsRole in metabolism of nervous tissueInvolved with folate metabolismRelated to growth

B12 Vitamin cont.RDA 2ugLiver, kidneyEggs, fishMilk and dairy productVegans require supplement

Contoh soalSeorang wanita yg menderita anemia dengan kadar Hb 9 gr%. Berapa kebutuhan Fe yang harus diberikan untuk menaikkan Hb menjadi 12, jika setiap kenaikan 0.5 gr Hb/100 ml dibutuhkan 85 mg elemental diet?Dari 9 gr jadi 12 = 6 x 85 mg elemental Fe, plus 50% untuk pool FeTotal kebutuhan Fe= 510gr el. Fe + 205gr el.Fe = 715 el.FeTerapi dilanjutkan selama 6 bulan