Nurpudji A Taslim Nutrition Department School of Medicine Hasanuddin University @2010
Nurpudji A TaslimNutrition Department School of Medicine
Hasanuddin University@2010
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 HEMATOLOGIK
Anemia 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
KELOMPOK UMUR Hb
g/100ml
Ht atau PVC (%)
MCHC
Anak 6 bln -6 th 11 33 34
Anak 6 th – 14 12 36 34
Laki2 dewasa 13 39 34
Wanita dewasa 12 36 34
Bumil 11 33 34
GEJALA KLINIK ANEMIA GIZI
GEJALA KLINIK ANEMIA AKAN
MEMBERIKAN GAMBARAN SERUPA
APAPUN PENYEBABNYA
DEFISIENSI ZAT BESI PADA ANAKDITEMUKAN PADA NEGARA MAJU DAN BERKEMBANG
PADA ANAK
Cadangan besi yang terbatasPertumbuhan yang cepatVariasi makanan yang terbatasMakanan tambahan yang terlambatMetabolisme yang meningkatAbsorbsi yang berkurang
ETIOLOGIANEMIA PADA ANAKBayi < 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 menstruasiRata-rata kehilangan darah 30 ml/hariDibutuhkan 0,1 mg FeAbsorbsi 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 LAKTASIKehilangan besi pada kehamilan normal
Fe foetus 400 mg Persalinan 325 mg Laktasi 175 mg
Total 900 mg
Untuk perode selama 460 hari membutuhkan tambahan 2mg Fe/hari
Patogenesis terjadinya defisiensi zat besi pada wanitaPerubahan metabolisme zat besi selama
kehamilanFaktor 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 tubuh4-5gr (dewasa) & 400mg (Bayi)
RBC yang beredar 60%
Ferritin & hemosiderin 30%
Myoglobin 5-10%
Enzym2 haem <1%
Fe plasma 0.1%
KEHILANGAN BESI DARI TUBUH
Bayi 0.3-0.4mg/hr
Anak umur 4 – 12 th 0.4-1.0/hr
Laki2 dewasa 1.0-1.5/hr
Wanita dewasa 1.0-2.5/hr
bumil 2.7mg/hr
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 PROTEIN
Heme 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 metabolism
Enzymes-iron dependent Tryptophan pirrolase Oxidation of tryptophan
IRON COMPOUND IN THE BODY, cont…..
TRANSPORT AND STORAGE PROTEINS Transferrin transport of iron and other minerals Ferritin Storage 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 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 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 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 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 iron
Liver, 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 copper
Oysters, 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 volume
Deficiency: related to Vit B12 deficiency --- macrocytic anemia
Source of CobaltRDA 1.4 - 2.0 ug/dayLiver, kidney,Oysters, clamsPoultryMilk
FOLIC ACIDRDA
Male 200ugFemale 180ug
FunctionsEssential 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
Vitamin CNormal kebutuhan 60mgHamil 90mgKeadaan luka atau infeksi kebutuhan
meningkatSumber dari buah2an Fungsi Membantu absorbsi zat besi
CLASSIFICATION OF SOME ANEMIAS
Test B12 Deficiency Folate Deficiency Iron Deficiency Anemia of Chronic Disease
RBC count D D D D
Hemoglobin D D D Slight D
Hematocrit D D D D
MCV I I D N
MCH I I D N
MCHC N N D N
Reticulocyte count N or D N or D N or D N or D
RDW N or I N or I I N
Serum ferritin I I D N or I
TIBC N N N or I N or D
Transferrin N N N or I N or D
Transferrin saturation (%)
N N D N or D
Serum iron N N D D
Serum folate N or I D N N
Red cell folate D D N N
Vitamin B12 D N N N
Red blood cells Normochromic, macrocytic
Normochromic, macrocytic
Hypochromic, microcytic
Hypochromic, microcytic (both mild)
Other Hypersegmented neutrophils, macro-ovalocytes
Hypersegmented neutrophils, macro-ovalocytes
Anisocytosis Poikilocytosis (slight), anisocytosis (moderate)
I = increased; N = normal; D = decreased; TIBC = total iron-binding capacity
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 Fe
Total kebutuhan Fe= 510gr el. Fe + 205gr el.Fe
= 715 el.FeTerapi dilanjutkan selama 6 bulan