_A look at anemia related to nutritional issues _
By: Stephanie Deeb
A LOOK AT ANEMIA RELATED TO NUTRITIONAL ISSUES by STEPHANIE DEEB HEALTH
SCIENCES RESEARCH METHODS HSA 4700 NOVEMBER 29, 1999 TABLE OF CONTENTS
INTRODUCTION...................................................................
......................1 REVIEW OF
LITERATURE.....................................................................
....
METHODOLOGY....................................................................
.................... PRESENTATION AND ANALYSIS OF
DATA..........................................
CONCLUSION.....................................................................
....................... WORKS
CITED..........................................................................
................. APPENDIX
A..............................................................................
................ APPENDIX
B..............................................................................
............... INTRODUCTION "Anemia can be defined as a decrease
in the oxygen-carrying capacity of the blood caused by low hemoglobin
concentration" ("A Practical Guide", 1). "Cells in the body require oxygen to
fully utilize fuels. The oxygen is transported from the lungs to tissues
throughout the body via red blood cells. Oxygen binds to hemoglobin, a
specific molecule within each red blood cell. This molecule consists of heme,
which is a red pigment, and globin, which is a protein. If the amount of
functioning hemoglobin is reduced, a condition known as anemia arises"
("Anemia", 1). "The anemia that may result can take many forms, including that
caused by a low iron level (iron deficiency anemia), a vitamin deficiency
(megaloblastic anemia), a thyroid deficiency, the premature destruction of red
blood cells (hemolytic anemia), replacement of normal bone marrow cells by
cancer cells or leukemia (myelophthisic anemia), injury to bone marrow
(aplastic anemia), and inborn structural defect in red blood cells (e.g.
sickle-cell anemia), inhibition of erythropoietin production by the immune
system (anemia of chronic disease), and a normal or high iron level but an
inability to manufacture hemoglobin or make use of the iron (sideroblastic
anemia)" ("Anemia", 2). There are also several other less common types of
anemia including: aplastic anemia, Thalassemia, acquired hemolytic anemia,
inherited hemolytic anemia, sickle cell anemia, and anemia caused by
miscellaneous factors ("Anemia", 3-4). All of these different types of anemia
can be grouped into categories according to their causes and treatments. "In
all, more than 400 different forms of anemia have been identified, many of
them rare. An anemic person often appears pale and weak and may feel
breathless, faint or unusually aware of a pounding heart. The disorder may
arise from a number of underlying conditions, some of which may be hereditary,
but in many cases poor diet is to blame. Although some forms of anemia require
supervised medical care, those stemming from improper nutrition can typically
be treated at home once a physician has determined the cause"("Anemia", 1-2).
Anemia induced by poor nutrition encompasses a large part of the disease. It
is important to investigate anemia related to nutrition, because it is a
problem that is present in our lives and there is a lot of action we can take
to prevent and treat this disease. The most common forms of nutritional anemia
are iron-deficiency anemia, folic-acid deficiency anemia, and Pernicious
anemia, which is commonly known as anemia caused by a vitamin B12 deficiency.
REVIEW OF THE LITERATURE There is an abundant amount of information
available on the various types of nutritional anemia and treatments for those
diseases. "International Nutritional Anemia Consultative Group was established
in 1977 in response to the need for developing a worldwide awareness of the
problem of nutritional anemia and the need for an infrastructure that could
assist in dealing with this problem"(ilsi.org, 1). "The International
Nutritional Anemia Consultative Group network provides consultative services
and advice to operating and donor agencies seeking to reduce nutritional
anemia and its accompanying adverse physiological consequences" (ilsi.org, 1).
"Anemia is not itself a disease, rather it is a set of signs and symptoms
which represent some other pathology. Because anemia affects oxygen transport,
fuel utilization is affected. Thus a common symptom in mild anemia is fatigue.
Other symptoms may include: shortness of breath pale skin, heart palpitations,
noises in the ear, excessive thirst, weight loss, memory problems, or even
jaundice, which is characterized by yellowish skin due to liver enzyme
problems" ("Anemia", 1)wellweb. "Because anemia is a hematologic (involving
the blood) problem, the most basic testing involves a Complete Blood Count
(CBC). This can provide much of the needed information, including: a white
blood cell count (cells important to fighting infection), and the hematocrit,
which is the ratio of volume of the red blood cells (erythrocytes) divided by
the complete blood volume. In addition, a blood smear is an important
diagnostic test. As the name implies, this involves inspection of a sample of
blood under the microscope to locate abnormalities within the structure of the
cells. To be labeled anemia, the red blood cell count must be less than 4.5
million/microliter for men, or less than 4 million/microliter for women.
Normal levels are approximately 5.4 million/microliter for men and 4.8
million/microliter for women" ("Anemia, 1)wellweb. "It's fairly easy to
recognize when a patient is anemic. Generally far more complex and
costly-though it doesn't have to be-is the task of defining precisely why the
disorder exists. Yet an accurate diagnosis is essential for specific treatment
to be started promptly" (Burns, 10). "Recent advances in blood-count
automation, however, now enable the primary care practitioner to analyze the
results of a complete blood count (CBC) and formulate a logical plan for
diagnosing the cause of anemia with only a small number of inexpensive tests"
(Burns, 10). The condition of anemia can exist in three different ways
including: decreased red-cell production, increased red-cell destruction, or
loss of blood through hemorrhage. The three forms of nutritional anemia in
this study are all a product of decreased red-cell production (Burns, 10-12).
IRON-DEFICIENCY ANEMIA "The most common type of anemia is iron-deficiency
anemia" ("Anemia", 1). "Iron-deficiency is defined as anemia with biochemical
evidence of iron deficiency" (Dreyfuss, background). "Iron deficiency anemia
is the most common micro nutrient deficiency in the world today. It impacts
the lives of millions of woman and children contributing to poor cognitive
development, increased maternal mortality and decreased work capacity. Yet
with appropriate public health action, this form of micro nutrient
malnutrition can be brought under control" (Dreyfuss, preface). "Iron
deficiency anemia significantly impairs mental and psychomotor development in
infants and children. Although iron deficiency can be reversed with treatment,
the reversibility of the mental and psychomotor impairment is not yet clearly
understood" ("Anemia and Iron status", 1). "Although nutritional
iron-deficiency has declined in industrialized nations, 500 to 600 million
people (one-sixth of the world's population) are still affected by this
problem worldwide. Even in the U.S., iron deficiency is the most prevalent
nutritional deficiency" ("Anemia, 7) webmd. Iron deficiency anemia is
characterized by an inadequate amount of red blood cells caused by a lack of
iron. It's very prevalent in less-developed countries, but is still considered
to be a problem in developed countries (Dreyfuss, background). This type of
anemia is most prevalent in young children, ages 6-24 months, and in women of
reproductive age. Older children, adolescents, adult men, and the elderly have
also been found to have iron deficiency anemia (Dreyfuss, background). "Iron
deficiency generally develops slowly and is not clinically apparent until
anemia is severe even though functional consequences already exist" (Dreyfuss,
background). "There are several main causes of the deficiency, including
insufficient consumption of iron-containing foods, poor absorption of iron by
the body, and loss of blood" (Mayo, 957). Poverty, abuse, and living in a home
with poor household conditions also place children at risk for iron deficiency
anemia" ("Anemia and iron status", 1). Iron-deficiency anemia is suspected to
exist when blood smears show pale-colored and extremely small cells that are
uneven in shape. After a blood smear yields these results, iron levels are
checked. If they are low, physicians measure ferritin, which is a protein that
binds iron. If ferritin levels are low, the diagnosis of iron-deficiency
anemia is confirmed ("Anemia, 11)webmd. Treatment "A varied array of
interventions exist that are designed to prevent and correct iron deficiency
anemia. These include dietary improvement, fortification of foods with iron,
iron supplementation, and other public health measures, such as helminth
control" (Dreyfuss, 4). Supplementation of iron is one approach to treating
this disease. "In many populations, the amount of iron absorbed from the diet
is not sufficient to meet many individuals' requirements. This is especially
likely to be true during infancy and pregnancy, when physiological iron
requirements are the highest. If the amount of absorbable iron in the diet
cannot be immediately improved, iron supplementation will be a necessary
component of programs to control iron deficiency anemia" (Dreyfuss, 4). "Iron
supplements are essential for the rapid treatment of severe iron deficiency
anemia in all sex and age groups" (Dreyfuss, 4). "A daily protocol of iron
supplementation is recommended for treatment and prevention in the priority
target groups. Numerous studies have evaluated whether the frequency of iron
supplementation can be reduced from daily to twice or once per week without
compromising the efficacy of supplementation. The efficacy of once-or
twice-weekly supplementation in school-age children, adolescents, and
nonpregnant women is promising, and the operational efficiency of intermittent
dosing regimens if being evaluated. While research is ongoing to evaluate
these regimens in different population groups, the current recommendation
remains daily supplementation for young children and pregnant women"
(Dreyfuss, 5). "In industrialized countries nutritional anemias have been
reduced dramatically. Food fortification is the most beneficial preferred way
of preventing nutritional anemia. In developing countries food fortification
programs have been demonstrated to be efficient, yet the incidence of
nutritional anemia is high. Inadequate and poor quality of the diet, in
conjunction with the high incidence of infection, are the most common
immediate causes of nutritional anemias. These factors are linked to
socioeconomic development. Long term reduction in the prevalence of
nutritional anemias will not occur unless direct methods of control are
complemented by improvements in socioeconomic conditions" (Haschke, 18-20).
"Fortification of suitable food vehicles with absorbable forms of iron is a
highly desirable approach to controlling iron deficiency. If a fortifiable
food exists that is consumed by many people at risk of iron deficiency,
fortification is likely to be the most cost-effective component of its
control" (Dreyfuss, 5). "There are many possible strategies for iron
fortification. One approach is to fortify a staple food that is consumed in
significant quantities by most of the population" (Dreyfuss, 5). In the
Caribbean, South America, North America, and Great Britain this approach has
been a success using wheat flour (Dreyfuss, 5-6). A second approach that has
been a success, using fish sauce, curry powder, salt, and sugar, is the
fortification of condiments that are frequently used (Dreyfuss, 6). Another
method used to combat this type of anemia is diet improvement. "The amount of
iron absorbed from the diet is highly dependent on the composition of the
diet, namely, the quantities of substances that enhance or inhibit dietary
iron absorption" (Dreyfuss, 6). "Foods rich in iron that your body can readily
absorb include meats (especially liver), fish, poultry, eggs, legumes (peas
and beans), potatoes, and rice" (Mayo, 957). "The highest sources of iron are
in red meats, but also in chicken, seafood (notably cooked clams), dried peas
and beans, dried fruits, dark leafy vegetables, molasses, wheat bran and wheat
germ, oatmeal and soybean flour" (Blood disorders, 1). These food sources,
along with Vitamin C-rich foods promote the absorption of iron (Dreyfuss, 6).
"There are also foods that reduce your body's ability to absorb iron: large
quantities in the diet of bran, calcium, tea, excessive zinc and a compound
called phytate (found in unleavened bread, unrefined cereals and soybeans)
block the entry of iron into your digestive system. Spinach and lentils
contain iron, but very little of it gets absorbed because these vegetables
also contain phytate" (intelihealth, 2). Males require approximately one gram
of iron each day. Pregnant, lactating, or menstruating women and growing
children require approximately 1.5 to 2 grams each day (Blood disorders, 1).
"However, only about 10 percent of the iron you eat is actually absorbed by
your body, so the average man would need to eat about 10 grams of iron per
day. Your body absorbs iron in different quantities from different foods"
("Blood Disorders", 1). "Eating plenty of iron-containing foods is
particularly important for people who have high iron requirements, such as
children and pregnant or menstruating women. It is also crucial for those
whose diets are low in iron, including strict vegetarians, people on
weight-reduction diets, and infants" (Mayo, 957) FOLIC-ACID DEFICIENCY
ANEMIA "Folic acid, which is also known as folate, is a member of the vitamin
B group. Lack of it causes an anemia characterized by red blood cells that are
large but few in number. Deficiency can result if you do not get enough folic
acid in your diet to meet your body's demands or if your intestines cannot
absorb it" (Mayo, 959). "Poor diet coupled with alcoholism is the most common
cause of folate deficiency. Alcohol abuse not only contributes to
malnutrition, but alcohol causes chemical changes that can result in lower
folate levels. Deficiencies can also be caused by high demand for folic acid
caused by conditions such as cancer, pregnancy, severe psoriasis, severe
hyperthyroidism, and hemolytic anemia. Some drugs, including dilantin,
methotrexate, trimethoprim, and triamterene, may also hinder folate
absorption" ("Anemia, 6) webmd. "Pregnant women who are anemic have an
increased risk for poor pregnancy outcomes, particularly if they are anemic in
the first trimester. Low levels of folic acid during pregnancy are common in
the absence of supplements, and deficiencies during the first three months
increase the risk for neural tube defects in newborns" ("Anemia", 9) webmd.
"Folic acid is critical in the body's metabolism of amino acids, as well as in
the formation of healthy red blood cells. That's why a deficiency of folic
acid may cause a form of anemia. Folic acid is a water-soluble vitamin, and
therefore cannot be stored in any great quantity in the body, and so must be
replenished by diet on a regular basis" (Intelihealth, 2). Animal organs, such
as the kidney and liver, contain the largest amounts of Folate. Other food
sources that contain abundant amounts of folic acid are green leafy
vegetables, including spinach, collards, asparagus and broccoli, orange juice,
bananas, whole wheat products, beans and peas. As with iron, the amount of
folic acid that gets absorbed depends on its source. Only 25 to 50 percent of
folic acid from foods is absorbed. Some reasons for reduced absorption of
folic acid include overcooking vegetables, leaving raw vegetables at room
temperature for more than a few days, and consuming antacids (Intelihealth,
2). "The symptoms of folic acid deficiency are similar to those of pernicious
anemia, so your physician will perform various blood tests to distinguish
between the two disorders. These include conunting the cells in your blood,
examining the cells under a microscope, and measuring the amount of folic acid
in the blood. If folic acid deficiency anemia is present, your physician may
perform more tests to look for an underlying cause" (Mayo, 959). Treatment
"Most people can prevent folic acid deficiency by eating a balanced diet,
limiting their consumption of alcohol, and taking prescribed supplements
during pregnancy. If you have folic acid deficiency, it is important to
eliminate the condition that was its underlying cause. In some cases, adequate
nutrition is the remedy. The main food sources of this vitamin are raw fruits
and vegetables, liver, and kidney. In almost all cases, supplemental folic
acid is given orally every day. It is injected only if the underlying problem
is a disorder of the intestinal tract that severely interferes with
absorption" (Mayo, 960). It is also important to stop smoking because it
increases vitamin requirements (rxmed, 2). PERNICIOUS ANEMIA "Pernicious
anemia is caused by a deficiency of vitamin B12, which is needed for normal
production of red blood cells. It is often hereditary. The term pernicious was
adopted when no effective treatment was known and the condition was inevitably
fatal. The condition is unusual. It occurs most often in older people"(Mayo,
958). This is most common in people around age 50-60. It is not common in
children" (COHIS, 1). "Men and women are affected in similar numbers. It is
most common among people of northern European descent. Those with the disorder
tend to be fair-haired" (Mayo, 958). Symptoms that appear with this disease
include weakness and faintness, shortness of breath, increased heart beat,
headaches, sore tongue, nausea, loss of appetite, dizziness, and bleeding gums
(COHIS, 2). "This chronic disease progresses slowly but steadily if not
treated. Now, replacement therapy with adequate amounts of vitamin B12
corrects the deficiency and allows a normal life. However, if the condition
progresses for a long time before detection, it may cause some damage to
certain parts of the body, primarily the nervous and digestive systems (Mayo,
959). "Vitamin B12 is only available in our diet in foods of animal origin.
Humans are one of the few mammals that cannot make Vitamin B12 in our bodies
from plant sources" (Dr. Bill, 1). "It turns out that the absorption of
Vitamin B12 from our intestine is quite complicated. It requires a protein
called intrinsic factor which is secreted by the parietal cells in the
stomach, and in most people with pernicious anemia, these cells have been
destroyed. It is believed that this destruction is brought about by an
immunologic mechanism, since people with the disease usually have antibodies
against intrinsic factor and parietal cells in their blood" (Dr.Bill, 2).
Intrinsic factor attaches itself to vitamin B12, and it is this combination
that is absorbed in the lowest portion of the small bowel enters the colon"
(Mayo, 958). Hydrochloric acid is the stomach acid which you also need to
absorb Vitamin B12" (COHIS, 1). "Recognition of the disorder's hereditary
nature makes it possible to prevent the development of symptoms. To check for
pernicious anemia, your physician can perform various blood tests. One test
measures the amount of vitamin B12 in your blood. Also, your blood is examined
under a microscope to assess the size and shape of red blood cells. If you
have pernicious anemia, your red blood cells will be enlarged and there will
be fewer of them" (Mayo, 959). Sometimes it might me necessary for the
physician to study a sample of bone marrow and determine if antibodies to
intrinsic factor are present. The physician could also perform a Schilling
test to determine whether or not the B12 deficiency exists because of a lack
of intrinsic factor (Mayo, 959). The Schilling Test involves administering an
injection of radioactive Vitamin B12. The doctor then measures how much of it
comes out in the urine to decipher if the Vitamin B12 is the cause of the
anemia (COHIS, 2). Treatment "Usually vitamin therapy is not an emergency. If
diagnostic tests indicate pernicious anemia and neurologic symptoms are
present, however, vitamin B12 therapy should begin immediately. Generally,
cyanocobalamin or hydroxocobalamin injections are given every day for up to
two weeks, followed by injections twice a week for another month. After that,
injections are usually given monthly. Vitamin B12 shots must be taken for life
when used to treat pernicious anemia or any other irreversible absorption
problems in the intestine that are causing megaloblastic anemia" ("Anemia",
16-17)webmd. "New evidence suggests that oral B12 works as well as injections,
according to a study published in the journal Blood-but high doses must be
taken. This verifies reports from Sweden dating from the 1970's that
pernicious anemia, a disease of B12 deficiency, can be controlled with oral
B12. According to recent data, 2,000 micrograms/day of oral B12 cures the
symptoms of B12 deficiency, including elevated homocysteine, neurological
problems, and methylmalonic acid ( a marker of B12 deficiency). Patients with
pernicious anemia lack intrinsic factor usually because of insufficient
stomach acid. Others may have antibodies to the factor-an inappropriate
autoimmune response to one's own proteins. Injected B12 has traditionally been
used for pernicious anemia because it bypasses the absorption problem"
(Mitchell, 34-36). If treatment for pernicious anemia is not sought early
enough, it could give rise to other problems including Congestive heart
failure, neurological problems referred to as combined systems disease, other
various infections, and impotence in males (COHIS, 2) METHODOLOGY The
methodology chosen for this study is survey research. The purpose of this
study is to gather information on nutritional anemia so it can be successfully
prevented and treated. For this to be a success, the input of experts in this
field is essential. Before this survey was sent, it was pretested on a group
of physicians in the Orlando area. These physicians helped to iron out
inadequacies in the questions. This was very helpful because it created a very
effective survey that yielded the most productive results. One hundred surveys
were sent to the International Nutritional Anemia Consultative Group(INACG).
The purpose of INACG is to guide international activities that are trying to
reduce nutritional anemia in the world. The INACG sponsors scientific reviews
and convenes task force groups to analyze issues related to etiology,
treatment, and prevention of nutritional anemia. This group gathers the most
useful, up-to-date information on nutritional anemia, therefore, their
feedback from the survey is essential to this research. One hundred experts in
the field of anemia were mailed surveys and asked to complete and return them.
These one hundred people were chosen randomly from a list of experts involved
with the International Nutritional Anemia Consultative Group. Of these one
hundred surveys, ninety-eight were returned to me in time to be included in my
study. This organization is dedicated to reducing the prevalence of
nutritional anemia, so this high response rate was to be expected.
PRESENTATION AND ANALYSIS OF RESULTS The results obtained from the survey were
very useful in the study. Out of the one hundred surveys sent out,
ninety-eight were returned. The information gained from the survey was
consistent with the other findings of this study. It clarified differences and
similarities between the different types of nutritional anemia. The importance
of performing this research has been reinforced by the information that has
been gathered. There are many problems that can arise from these diseases if
left untreated, and there are many simple things that everyone can do to
prevent these diseases from entering their lives. The following are results
from the study. The symptoms of these three forms of anemia have many
similarities. Some common symptoms include: fatigue, shortness of breath, and
sore tongue. In Iron deficiency anemia and Pernicious anemia a yellowish tinge
in the eyes and skin can be observed. The stage of life that is most affected
by each of these forms of anemia vary. In Iron deficiency anemia women of
reproductive years and children 6-24 months old are most affected. In Folic
acid deficiency anemia people over 60 are most affected. Pernicious anemia is
mostly not seen before the age of 30, and is most prevalent in people from age
50 to 60. There is a juvenile form that exists, and it's detected in children
by the age of three. The incidence of these three forms of anemia also vary.
Iron deficiency anemia has an incidence of two out of every one thousand
people. Folic acid deficiency anemia has an incidence of four out of every one
hundred thousand people. Pernicious anemia has an incidence of one out of
every one thousand people. There are various conditions that can cause a
person to get these forms of anemia. Cancer, internal blood loss, ulcers, and
lead poisoning are all conditions that could potentially cause Iron deficiency
anemia. Pregnancy, alcoholism, parasitic diseases, and cancer are some
conditions that may cause Folic acid deficiency anemia. Alcoholism, Chrohn's
disease, and malabsorption disorders could cause Pernicious anemia. There are
several treatments that have been proposed for each of these forms of anemia.
For treatment of Iron deficiency anemia, iron supplementation, food
fortification, and dietary improvement are all possible treatments. Dietary
improvement, supplementation, cessation of smoking, and cessation of alcohol
consumption are all treatments that are considered for Folic acid deficiency
anemia. For the treatment of Pernicious anemia, dietary improvement and B12
replacement are both possible methods Comparative Information on various
forms of Nutritional Anemia Nutritional Anemia Iron deficiency anemia Folic
acid deficiency anemia Pernicious anemia Symptoms Fatigue, Shortness of
breath, sore tongue, yellowish tinge in eyes and skin Fatigue, shortness of
breath, sore tongue, Fatigue, shortness of breath, sore tongue, yellowish
tinge in eyes and skin Affected age brackets Women of reproductive years and
children 6-24 months mostly seen in people over 60 Not usually seen in people
before the age of 30. There is a Juvenile form found in children by age 3.
Incidence 2 out of 1,000 4 out of 100,000 1 out of 1,000 Conditions that could
induce these diseases Cancer, internal blood loss, ulcers, lead
poisoning pregnancy, alcoholism, parasitic diseases, cancer alcoholism,
Chrohn's disease, malabsorption Proposed treatments Iron supplementation Food
fortification Dietary improvement Dietary improvement Supplementation
Cessation of smoking Cessation of alcohol consumption Dietary improvement B12
replacement CONCLUSION This study was conducted in an attempt to gather
information to evaluate the importance of investigating nutritional anemia.
The findings of this research confirm the importance of studying these forms
of anemia. These conditions are prevalent in the lives of many people in and
out of this country, and there is a lot of action we can take to prevent and
treat them. As previously noted, this research was done on the nutritional
causes of anemia. As implied in the name, these conditions have much to do
with nutrition, and there is a lot we can do ourselves to correct these
problems. Eating food rich in vitamins that we are lacking, taking
supplements, and avoiding certain behaviors that make us more susceptible to
these conditions are all simple measures that we can take to prevent these
conditions from invading our lives. There is already sufficient research done
on this subject, but I suggest that the investigation of alternative
treatments for these conditions be pursued. There are many up-and-coming
alternative ways of treating disorders that are gaining recognition. These
methods deserve a chance in this research because if they can offer additional
ways to combat theses conditions, then they are worth looking into.
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