IRON DEFICIENCY

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IRON DEFICIENCY IDA

• Abdelaziz Elamin
• MD, PhD, FRCPCH
• Professor of Child Health
• College of Medicine
• Sultan Qaboos University
• Muscat, Oman
• azizmin_at_hotmail.com

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HIDDEN HUNGER

• The term was coined by WHO in 1986 refers to
  the problems associated with the deficiency of 3
  essential micronutrients
• Iron
• Iodine
• Vitamin A

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LEARNING OBJECTIVES

• At the end of the lecture you will be able to
• Discuss iron absorption, transport stores
• Know the burden of IDA in the world
• Identify the causes consequences of IDA
• Know how to diagnose IDA
• Recognize the strategies for control prevention
  of IDA

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IRON IN NATURE

• Iron is among the abundant minerals on earth.
• Of the 87 elements in the earths crust, Iron
  constitutes 5.6 and ranks fourth behind Oxygen
  (46.4), Silicon (28.4) and Aluminum (8.3).
• In soil, Iron is 100 times more than Ca, Na Mg
  and1000 times more than Zinc and 100,000 times
  more than Iodine.

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IRON DEFICIENCY

• Iron deficiency is the most common micronutrient
  deficiency in the world affecting 1.3 billion
  people i.e. 24 of the world population.
• In comparison only 275 million are iodine
  deficient and 45 million children below age 5
  years are Vitamin A deficient.

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IRON DEFICIENCY /2

• Iron deficiency can range from sub-clinical state
  to severe iron deficiency anemia.
• Different stages are identified by clinical
  findings lab tests.
• Anemia is defined as a hemoglobin below the 5th
  percentile of healthy population.
• Most studies showed this cutoff point to be
  around 11 g/dl (-2SD below the mean).

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HB IN IDA
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AT RISK GROUPS

• Infants
• Under 5 children
• Children of school age
• Women of child bearing age

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PREVALENCE OF ID

• Region 0-4yr 5-12yr Women
• South Asia 56 50 58
• Africa 56 49 44
• Latin Am 26 26 17
• Gulf Arabs 40 36 38
• Developed 12 7 11
• World 43 37 35

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ETIOLOGY

• Inadequate intake of iron of food, which
  enhances iron absorption.
• High intake of inhibitors of iron absorption
• Hookworm infestation.
• Blood loss (heavy menses use of aspirin
  NSAID).
• High fertility rate in womem.
• Low iron stores in newborns.

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DIETARY IRON

• There are 2 types of iron in the diet haem iron
  and non-haem iron
• Haem iron is present in Hb containing animal food
  like meat, liver spleen
• Non-haem iron is obtained from cereals,
  vegetables beans
• Milk is a poor source of iron, hence breast-fed
  babies need iron supplements

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IRON ABSORPTION

• Haem iron is not affected by ingestion of
• other food items.
• It has constant absorption rate of 20-30
• which is little affected by the iron balance
• of the subject.
• The haem molecule is absorbed intact and the iron
  is released in the mucosal cells.

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IRON ABSORPTION (2)

• The absorption of non-haem iron varies greatly
  from 2 to 100 because it is strongly influenced
  by
• The iron status of the body
• The solubility of iron salts
• Integrity of gut mucosa
• Presence of absorption inhibitors or facilitators

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INHIBITORS OF IRON ABSORPTION

• Food with polyphenol compounds
• Cereals like sorghum oats
• Vegetables such as spinach and spices
• Beverages like tea, coffee, cocoa and wine.
• A single cup of tea taken with meal reduces iron
  absorption by up to 11.

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OTHER INHIBITORS

• Food containing phytic acid i.e. Bran, cereals
  like wheat, rice, maize barely. Legumes like
  soya beans, black beans peas.
• Cows milk due to its high calcium casein
  contents.

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INHIBITION-HOW?

• The dietary phenols phytic acids
• compounds bind with iron decreasing
• free iron in the gut forming
• complexes that are not absorbed.
• Cereal milling to remove bran reduces
• its phytic acid content by 50.

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Promoters of Iron Absorption

• Foods containing ascorbic acid like citrus
  fruits, broccoli other dark green vegetables
  because ascorbic acid reduces iron from ferric to
  ferrous forms, which increases its absorption.
• Foods containing muscle protein enhance iron
  absorption due to the effect of cysteine
  containing peptides released from partially
  digested meat, which reduces ferric to ferrous
  salts and form soluble iron complexes.

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IRON ABSORPTION (3)

• Some fruits inhibit the absorption of iron
  although they are rich in ascorbic acid because
  of their high phenol content e.g strawberry
  banana and melon.
• Food fermentation aids iron absorption by
  reducing the phytate content of diet

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IRON TRANSPORT

• Transferrin is the major protein responsible for
  transporting iron in the body.
• Transferrin receptors, located in almost all
  cells of the body, can bind two molecules of
  transferrin.
• Both transferrin concentration transferrin
  receptors are important in assessing iron status.

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STORAGE OF IRON

• Tissues with higher requirement for iron
• ( bone marrow, liver placenta) contain more
  transferrin receptors.
• Once in tissues, iron is stored as ferritin
  hemosiderin compounds, which are present in the
  liver, RE cells bone marrow.
• The amount of iron in the storage compartment
  depends on iron balance (positive or negative).
• Ferritin level reflects amount of stored iron in
  the body is important in assessing ID.

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IRON CYCLE IN THE BODY
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ROLE OF IRON IN THE BODY

• Iron have several vital functions
• Carrier of oxygen from lung to tissues
• Transport of electrons within cells
• Co-factor of essential enzymatic reactions
• Neurotransmission
• Synthesis of steroid hormones
• Synthesis of bile salts
• Detoxification processes in the liver

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DIAGNOSIS OF IDA

• Clinical symptoms (fatigue, dizziness ,
  palpitations..etc) signs (pallor, smooth
  tongue, Koilonychia, splenomegaly dysphagia in
  elderly women).
• Laboratory
• Stainable iron in bone marrow
• Response to iron supplements

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LAB FINDINGS IN IDA

• Microcytic hypochromic anaemia
• Low Hb level (lt 11.0 g/dl)
• Low MCV, MCH, MCHC
• Low serum ferritin
• High RWD
• High iron binding capacity
• High erythrocyte protoporphyrin

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Normal Blood Film
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MICROCYTES
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HYPOCHROMIA
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Consequences of Iron Deficiency

• Increase maternal fetal mortality.
• Increase risk of premature delivery and LBW.
• Learning disabilities delayed psychomotor
  development.
• Reduced work capacity.
• Impaired immunity (high risk of infection).
• Inability to maintain body temperature.
• Associated risk of lead poisoning because of
  pica.

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MANAGEMENT OF IDA

• Blood transfusion if heart failure is eminent
• IV or IM iron in pregnant women
• Oral iron 3-5 mg Fe/kg/day
• Treat underlying cause
• Dietary education

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PREVENTION OF IDA

• Dietary modification
• Food fortification
• Iron supplementation

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PREVENTION OF IDA /2

• Diet nutrition education
• eat more fruits and vegetable
• no coffee or tea with meals
• programmes should be targeted to
• at risk groups
• reduce phytic content of cereals and
• legumes by fermentation

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PREVENTION OF IDA /3

• Short term approach
• supplementation with iron tablets.
• Long-term approach
• food fortification with iron either for the whole
  population (blanket fortification) or for
  specific target groups like infants. It requires
  no cooperation from users unlike taking iron
  supplements.

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FOOD FORTIFICATION

• Iron compounds used in food fortification can be
  divided into 4 groups
• Freely water soluble (ferrous sulphate,
  gluconate, lactate ferric ammonium citrate).
• Poorly water soluble (ferrous fumarate, succinate
• saccharate).
• Water insoluble (ferric pyrophosphate, ferric
  orthophosphate elemental iron).
• Experimental (sodium-iron EDTA bovine Hb
  concentrate).

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Which iron form to use?

• The major factors governing the choice of iron
  compound include
• Bioavailability
• Organoleptic problems
• Cost
• Safety
• Ideally we should go for a safe, cheap, highly
  bioavailable iron, which causes no organoleptic
  side-effects

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Which iron form to use?

• Freely water soluble iron are the most
  bio-available, but causes unacceptable colour
  flavour change in many foods.
• Insoluble iron compounds are inert with no
  organoleptic effects but it is poorly absorbed
• Cost-wise elemental iron is the cheapest, ferrous
  sulphate costs 10 times more, but most expensive
  is EDTA
• Safety is of concern with EDTA Bovine Hb only
  because of potential problems

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COMMON PRACTICE

• Ferrous sulphate is commonly used in Rx
  prevention of IDA because of good absorption
  high bioavailability, but it has its drawbacks
• GIT disturbances staining of teeth are frequent
• Effects on fortified foods may include
• Fat oxidation rancidity
• Colour changes
• Metallic taste
• Precipitation

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EXPERIMENTAL COMPOUNDS

• EDTA (Ethylene Diamine Tetra-Acetate) molecule
  has 4 negative charges to which any metal can be
  attached to form stable complex. The metal
  incorporated into EDTA can be replaced by a metal
  of higher affinity or released at a certain PH.
• Food is usually fortified by both Fe-EDTA Na or
  Ca EDTA.

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HOW EDTA ACTS?

• Fe EDTA is stable in the acidic PH of the
  stomach, but dissociate in the alkaline PH of the
  duodenum releasing ferrous ions ready to be
  absorbed. while the Na-Ca EDTA dissociate in the
  stomach releasing Na Ca and taking iron from
  the food instead to form Fe EDTA which dissociate
  in the duodenum.

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ADVANTAGES OF USING EDTA

• Iron absorption is 6 times greater than with
  ordinary methods even in the presence of
  inhibitors.
• No need to add vitamin C or other promoters to
  enhance iron absorption.
• No change in colour or flavour of food with EDTA
  even when stored for long time.

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LIMITATIONS of EDTA USE

• EDTA fortification is 7 times more expensive than
  ordinary fortification using iron salts.
• Health care providers have little experience with
  this new technique.