A Look At Anemia Related To Nutritional

Issues Essay, Research Paper

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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International Nutritional Anemia Consultative Grou