NUTRITIONAL ANEMIA

Nurpudji Astuti. MD, MPH, Sp.GK

Nutrition Department School of Medicine Hasanuddin University

Anemia gizi
Anemia 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 Anemia
Keadaan 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 GIZI

BERDASARKAN PEMERIKSAAN HEMATOLOGIK
Anemia mikrositik hipokromik

disebabkan 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

KELOMPOK UMUR Anak 6 bln -6 th Anak 6 th 14 Laki2 dewasa
Hb g/100ml Ht atau PVC (%) MCHC

11 12 13

33 36 39

34 34 34

Wanita dewasa
Bumil

12
11

36
33

34
34

GEJALA KLINIK ANEMIA GIZI

GEJALA KLINIK ANEMIA AKAN

MEMBERIKAN GAMBARAN SERUPA APAPUN PENYEBABNYA

DEFISIENSI ZAT BESI PADA ANAK

DITEMUKAN PADA NEGARA MAJU DAN

BERKEMBANG
PADA ANAK

Cadangan besi yang terbatas Pertumbuhan yang cepat Variasi makanan yang terbatas Makanan tambahan yang terlambat Metabolisme yang meningkat Absorbsi yang berkurang

ETIOLOGI ANEMIA PADA ANAK

Bayi < 6 bulan
Cadangan

besi tidak adekuat Makanan tambahan terlambat

Umur 1 - 2 tahun
Infeksi

sal. cerna dan nafas Diet tidak adekuat

5 tahun
Infeksi

parasit ( ankylostomiasis, trichuris, amubiasis )

ANEMIA PADA WANITA DEWASA

Keperluan yang meningkat pada masa

menstruasi
Kehamilan Laktasi

Pada saat menstruasi

Rata-rata kehilangan darah 30 ml/hari
Dibutuhkan 0,1 mg Fe Absorbsi dalam makanan 20%, untuk itu

dibutuhkan asupan zat besi sebanyak 10 mg dalam makanan Absorbsi makanan akan ditingkatkan oleh protein hewani Akan dihambat oleh kandungan pytat dari tumbuh2an

KEHAMILAN DAN LAKTASI

Kehilangan besi pada kehamilan normal
Fe

foetus Persalinan Laktasi

400 mg 325 mg 175 mg

900 mg

Total

Untuk periode selama 460 hari

membutuhkan tambahan 2mg Fe/hari

Patogenesis terjadinya defisiensi zat besi pada wanita

Perubahan metabolisme zat besi selama

kehamilan Faktor lain

Perubahan

komposisi darah Perubahan pada sumsum tulang Pertumbuhan dan perkembangan foetus Intake yang kurang Absorbsi meningkat 20-40% ( ibu anemi) Pool bumil yang rendah (jarak hamil dekat)

Total zat besi dalam tubuh

4-5gr (dewasa) & 400mg (Bayi)
RBC yang beredar Ferritin & hemosiderin 60% 30%

Myoglobin
Enzym2 haem Fe plasma

5-10%
<1% 0.1%

KEHILANGAN BESI DARI TUBUH

Bayi
Anak umur 4 12 th

0.3-0.4mg/hr
0.4-1.0/hr

Laki2 dewasa
Wanita dewasa bumil

1.0-1.5/hr
1.0-2.5/hr 2.7mg/hr

IRON
Human body contains 3 to 5 g iron Approximately 2 g as Hemoglobin and 8 mg as

enzymes Well 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 BODY

METABOLIC PROTEIN

Heme Proteins

Hemoglobin Myoglobin
cytochromes Cytochrom P-450 Catalase

Oxygen transport from lungs to tissues Transport & store Oxygen in muscle
Enzymes - Heme Electron transport Oxidative degradation of drugs Convert hydrogen peroxide to oxygen and water Enzymes-Nonheme

Iron sulfur & metalloproteins

Oxidative metabolism

Enzymes-iron dependent Tryptophan pirrolase Oxidation of tryptophan

IRON COMPOUND IN THE BODY, cont..

TRANSPORT AND STORAGE PROTEINS

Transferrin
Ferritin Hemosiderin

transport of iron and other minerals Storage Storage

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 cont
95% is associated with proteins e.g hemoglobin & myoglobin Functions: Respiratory transport of O2 & CO2 (Oxygen binding component of hemoglobin and myoglobin) Co-factor for enzymes Involved in the immune function and cognitive performance

Absorption
Transported Sources

: : :

Well regulated Transferrin Meat, seafood, some vegetables

Iron Absorption
Healthy Individuals: 5-10% absorbed Iron deficiency : Up to 40% absorbed Factors that affect absorption:

enhancing factors:

acid in the stomach

heme iron high body demand low body stores meat protein factor vitamin C

Iron Absorption, cont.

Inhibiting factors

dietary 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 body

Most iron is recycled.

Some lost with body tissues and must be replaced by eating ironcontaining food Intestinal 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 haemosiderin Liver/lien; Dismantle red blood cells and package Fe into transferrin, stores excess as ferritin / haemosiderin

Iron Deficiency and Toxicity

Deficiency:

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 Iron
Adequate diet contains no more than

6mg/1000kcal of iron RDA 12mg/day Dried beans and vegetables are the best plant sources Best sources dietary iron

Liver, heart, kidney, lean meat oysters, shellfish Fish Poultry

COPPER
COMPONENT 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 Copper
Most diet provide 2mg/day RDA 1.5 - 3mg/day Food high in copper Oysters, shellfish Liver, Kidneys Chocolate Nuts Dried legumes, Dried foods Cereals Poultry

Cobalt
A component of vitamin B12 (cobalamin) This vitamin is essential for maturation of red

blood cells and normal functioning of all cells Requirement expressed in terms of Vit B12 : 1.4-2 ug daily Toxicity : intake of 10 to 20 ug/kg Body weight : high intake cobalt in animal diet produce polycytemia, bone marrow hyperplasia, reticulocytosis, and increased blood volume Deficiency: related to Vit B12 deficiency --macrocytic anemia

Source of Cobalt
RDA 1.4 - 2.0 ug/day Liver, kidney,

Oysters, clams
Poultry Milk

FOLIC ACID
RDA

Male Female

200ug 180ug

Functions

Essential for bio-synthesis of nucleic acids. Essential for normal maturation of RBC Functions as co-enzyme: tetrahydro-folic acid

Source of Folic acid

Green leafy vegetable,
Organ meats (liver), lean beef,

Wheat, dry beans,

lentils, cowpeas Asparagus, broccoli,

collards, yeast
Synthesized by intestinal tract

B12 Vitamin
Involved in the metabolism of single

carbon fragment Essential for biosynthesis of nucleic acid and nucleoproteins Role in metabolism of nervous tissue Involved with folate metabolism Related to growth

B12 Vitamin cont.

RDA 2ug
Liver, kidney Eggs, fish

Milk and dairy product

Vegans require supplement

Contoh soal
Seorang 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 Fe Total kebutuhan Fe= 510gr el. Fe + 205gr el.Fe = 715 el.Fe Terapi dilanjutkan selama 6 bulan