NUTRITIONAL

ANEMIA
Dr. Naveed Akthar

NUTRITIONAL ANEMIA

ANEMIA IS
NEVER

NORMAL

NUTRITIONAL ANEMIA
Anemia is the most common Nutritional
Disorder.
Nutritional anemiarefers to a type
ofanemiathat can be directly attributed
to nutritional causes.
Iron deficiency Anemia is the most
common and widespread form of Anemia
accounting for about 95% of anemia cases.

Who is Aneamic ?

why

Causes of Anemia
Decreased
Increased

red blood cell production

red blood cell destruction

Red

blood cell loss

Red

blood cell sequestration

Nutritional anaemia
reduced

red blood cell count due to a

poor diet which is deficient in iron,
folate and/or Vitamin B12.
Iron deficiency and B12/folate
deficiency can present with normocytic
anemia esp. if both deficiencies are
present together.

Nutritional requirements for RBC

formation

Iron for Hb synthesis

Vitamin B12 and folate for normal DNA

synthesis

Other vitamines ? B6(pyridoxine), thiamin,

riboflavin and vitamins C & E

Trace metals such as copper, cobalt

Categories of Nutritional Anaemia

Iron deficiency

B12 and Folic acid deficiency

Other deficiencies
Copper deficiency anemia
protein-energy malnutrition Anemia
Sideroblastic (pyridoxine-responsive) anemia
Vitamin Eresponsive (hemolytic) anemia

Causes of iron deficiency

Inadequate iron for haemoglobin synthesis
resulting in microcytic hypochromic anaemia.

Causes of iron deficiency Blood loss

hookworm infestation,
bleeding haemarroids,
Menorrhagia

Increased demand
Pregnancy
Decreased absorption
Poor intake

Sign and symptoms

Tachycardia,

tachypnea
Pallor, Jaundice
Murmur
Koilonychia or Spoon nails
Splenomegaly, lymphadenopathy
Petechiae, ecchymoses
Atrophy of tongue papillae

Sign and symptoms

Daily Iron
Requirements(mg/day)
Age (years)

Male

Female

0 - 0.5 -----------6
6
0.5 - 10 -----------10
10
11 18 -----------12
15
19 -- 50 ---------- 10
15
50+---------- 10
10
Pregnant
30
Lactating 15

Sources of Iron
Haem iron
Fish, meat and chicken
Non-haem iron
vegetables cereals,
beans
and grains
When iron storage is full in body, it
automatically reduces the further iron
absorption
Liver reduces apotransferrin formation
Transferrin decrease release of iron so
that, transferrin is completely saturated
with iron and further absorption is
prevented.

Iron
haem iron : not affected by ingestion of
other food items.
non-haem iron Inhibitors :
Food

with

polyphenol

compounds;

oats

spinach, spices , tea, coffee, cocoa and

wine.
Food with phytic acid i.e. Bran, cereals like
wheat, rice, maize & barely. Legumes like
soya beans, black beans & peas.

Iron
Absorption

- mainly from the small intestine

Transportation

- in the form of transferrin

(iron + apotransferrin)
Storage

- in the form of ferritin mainly in the

cells of RES and hepatocytes.

Loss of iron
In

males, about 1 mg is excreted

every day through feces

In

females,About 50 ml of blood is
lost during menstruation and it
contains about 25 mg of iron.

Lab results
Decreased

serum iron
Increased TIBC
Decreased serum ferritin levels
-Reflect iron stores.
Decreased transferrin saturation
Micro, Hypo, Aniso, target cells and
pencil cells

Microscopy/Morphology
Microcytosis
Hypochromia
Anisocytosis
Target cells
Pencil cells
Reactive thrombocytosis

Microscopy/Morphology

Iron stain: (bone marrow aspirate):

Prussian blue stain for iron in bone marrow of a
patient with iron deficiency anemia. Note absence of
any blue stain.

Treatment
Iron

supplementation therapy

Oral

and

i/v

Part -2
MEGALOBLASTIC ANEMIA
Dr. Naveed Akhtar

MEGALOBLASTIC
ANEMIA
Requirements for Red Blood Cell
Production
Erythropoeitin
Proteins, required for globin synthesis
Iron
Vitamin B12 and folic acid
Vitamin B6
Vitamin C
Thyroid hormones, estrogens and
androgens

MEGALOBLASTIC
ANEMIA
Megaloblastic Anemia is a
condition in which the
bone marrow produces
unusually large,
structurally
abnormal, immature red
blood cells (megaloblasts).

Results of Megaloblastic Anemia

Defect

in nuclear replication and

division

Myeloid

, Erythroid and Megakaryocytic

series are affected
HB production is normal

Results of Megaloblastic
Anemia
Megaloblastosis can be associated with
severe anemia
pancytopenia
gastrointestinal dysfunction
glossitis
personality changes
psychosis, and
neurological disorders.

Types of Megaloblastic
Anemia
Vitamin
Folic

B12 deficiency

Acid deficiency

Vit. B12 and folate deficiency are the most

common causes of megaloblastic anemia.
Morphologically both have same features on
blood smear and bone marrow

Vit. B12 Deficiency Megaloblastic

Anemia
Vitamin

B12 Deficiency anemia is

characterized by very large and oval red
blood cells, the inner contents of each
cell are not completely developed

VitaminB12

or Cobalamin is
coenzyme in the body

Vit. B12 Deficiency Megaloblastic

Anemia
VitaminB12 or Cobalamin
Produced by Microorganism and gained by
eating bacterial contaminated food
Sources of Vitamin B12
Liver, Meat,Fish ,Egg,
Seafood, Milk , Cheese
and other Dairy Products

Plants are not sources of Vit.B12

Vit. B12 Deficiency Megaloblastic Anemia

Absorption Vitamin B12
B12 combine with Intrinsic factor
IF-B12 bind to Cubilin receptor
IF-B12-cubilin bind to
Amnionless Protein
Endocytosis of IF-B12-cubilin
result in absoption of B12

Vit. B12 Deficiency Megaloblastic

Anemia
Transport
From portal blood it is transported by
trnascobalamin to bone marrow and
other tissues.
Heptocorrin also transport B12

Vit. B12 Deficiency Megaloblastic

Anemia
daily Requirment
1-2 ug
Daily intake
7-30 ug
Body stores
2-3 mg (2-4 years). No chances of deficiency

Vit. B12 Deficiency Megaloblastic

Anemia

Causes of vitamin B12 deficinecy

dietary factors
Eating a vegetarian diet
Poor diet in infants
Poor nutrition during pregnancy
Malabsorptions
Pernicious anemia,
Congenital Lack or Abnormal IF
Total or Partial Gastrectomy, such as some weightloss surgeries
Crohn disease, celiac disease
infection with the fish tapeworm,

Pernicious anemia
Autoimmune

destrution of parietal cell

Antibodies VS Parietal cells, intrinsic
factor
Achlorhydria is universal
2-3 % incidence of gastric cancer
Often associated with other
autoimmune diseases

Pernicious anemia

Vitiligo

 1-Oral

radiolabelled B12 +i/m injection of

B12 after 1 hour---urine 24 collection
2- Oral radiolabelled B12 with IF24 h urine
Abnormal stage one and normal stage
two indicates intrinsic factor deficiency.
3-if abnormal stage two 2 wk antibiotic
b4 test---- due to bacteria
4- Pacreatic enzyme+Radio VitB12------------

Schilling Test

Folic acid Sources

Produced by plants and some microorganisms

Folate rich foods;
vegetables (Green leaf),
Liver and kidney (parenchymal organs)
Molds.

Folic acid or Folate

Daily requirements
Age

0 - 10
3.6g /kg
> 10
3g /kg
Pregnants 500 g
Lactation
+100 g
Diet contains 100 - 500 g folate/day.

Symptoms
Numbness

and
tingling in the hands
and feet.
Diarrhea or
constipation
Muscle weakness.
Irritability.
Memory loss.
Dementia.
Depression.
Psychosis.

grey hair
Weakness, tiredness, or
light-headedness
Rapid heartbeat and
breathing
Pale skin
Sore tongue
Easy bruising or bleeding,
including bleeding gums
Stomach upset and
weight loss

Lab tests

The CBC will show

Decreased

RBC count and HB levels

Increased MCV, >95 fl and MCH
Normal MCHC, 3236 g/dL
The reticulocyte count is decreased due
to destruction of fragile and abnormal
megaloblastic erythroid precursor.
The platelet count may be reduced.

Blood Film
Hypersegmented nuclei ("senile neutrophil").
Anisocytosis (increased variation in RBC size)
and
poikilocytosis (abnormally shaped RBCs).
Macrocytes (larger than normal RBCs) are
present.
Ovalocytes macrocytes (oval-shaped RBCs) are
present.
Howell-Jolly bodies (chromosomal remnant) also
present.

Blood chemisty
increased LDH level. is LDH-2 more
specific.
Holotranscobalamin (HoloTC), the
active fraction of plasma cobalamin
Increased homocysteine and
methylmalonic acid in Vit. B12 deficiency
Increased homocysteine in folate
deficiency
Bone marrow shows megaloblastic
hyperplasia.

Bone Marrow
Bone marrow shows
megaloblastic hyperplasia.
Erythroid hyperplasia
nuclear-cytoplasmic
asynchrony.
Giant Myelo and
Metamyelcytes
bands and hypersegmented
polymorphonuclear neutrophils

Bone Marrow

Special tests

Treatment Vit.B12 def.

Give

Hydroycobalmin by i/m injection1mg 3

times for 2 weeks then every 2-3 months.
Review every 3rd month.

Give

Hydroycobalmin/ Methyl cobalamin by

i/m injection1mg on atlernate days till no
further neuropsychiatric in mprovement then
every 1-2 months. Review every 3 rd month.

Treatment Vit.B12 def.

0.8

mgdaily doses or more of folic acid

are typically required to have maximal
reduction in plasma homocysteine
concentrations

Thank You