Iron def.ninad final


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Iron def.ninad final

  1. 1. IRON IN NATURE <ul><li>Iron is among the abundant minerals on earth. </li></ul><ul><li>Of the 87 elements in the earth’s crust, Iron constitutes 5.6% and ranks fourth behind Oxygen (46.4%), Silicon (28.4%) and Aluminum (8.3%). </li></ul><ul><li>In soil, Iron is 100 times more than Ca, Na & Mg and 1000 times more than Zinc and 100 , 000 times more than Iodine. </li></ul>
  2. 2. DIETARY IRON <ul><li>There are 2 types of iron in the diet; haem iron and non-haem iron </li></ul><ul><li>Haem iron is present in Hb containing animal food like meat, liver & spleen </li></ul><ul><li>Non-haem iron is obtained from cereals, vegetables & beans </li></ul><ul><li>Milk is a poor source of iron, hence breast-fed babies need iron supplements </li></ul>
  3. 3. Daily Iron Requirement <ul><li>Male 1mg/day of elemental iron. </li></ul><ul><li>Absorption 6% </li></ul><ul><li>Daily intake 15mg </li></ul><ul><li>Female 1.4mg /day of elemental iron. </li></ul><ul><li>Absorption 12% </li></ul><ul><li>Daily intake 11mg </li></ul><ul><li>Pregnancy 5 to 6 mg/day </li></ul>
  4. 4. IRON ABSORPTION <ul><li>Site: - Duodenum & Jejunum </li></ul><ul><li>Haem iron is not affected by ingestion of </li></ul><ul><li>other food items. </li></ul><ul><li>It has constant absorption rate of 20-30% </li></ul><ul><li>which is little affected by the iron balance </li></ul><ul><li>of the subject. </li></ul><ul><li>The haem molecule is absorbed intact and the iron is released in the mucosal cells. </li></ul>
  5. 5. IRON ABSORPTION (2) <ul><li>The absorption of non-haem iron varies greatly from 2% to 100% because it is strongly influenced by: </li></ul><ul><ul><ul><li>The iron status of the body </li></ul></ul></ul><ul><ul><ul><li>The solubility of iron salts </li></ul></ul></ul><ul><ul><ul><li>Integrity of gut mucosa </li></ul></ul></ul><ul><ul><ul><li>Presence of absorption inhibitors or facilitators </li></ul></ul></ul>
  6. 6. INHIBITORS OF IRON ABSORPTION <ul><li>Food with polyphenol compounds </li></ul><ul><ul><li>Cereals like sorghum & oats </li></ul></ul><ul><ul><li>V egetables such as spinach and spices </li></ul></ul><ul><ul><li>Beverages like tea, coffee, cocoa and wine. </li></ul></ul><ul><ul><li>A single cup of tea taken with meal reduces iron absorption by up to 11%. </li></ul></ul>
  7. 7. OTHER INHIBITORS <ul><li>Food containing phytic acid i.e. Bran, cereals like wheat, rice, maize & barely. Legumes like soya beans, black beans & peas. </li></ul><ul><li>Cow’s milk due to its high calcium & casein contents. </li></ul>
  8. 8. INHIBITION-HOW? <ul><li>The dietary phenols & phytic acids </li></ul><ul><li>compounds bind with iron decreasing </li></ul><ul><li>free iron in the gut & forming </li></ul><ul><li>complexes that are not absorbed. </li></ul><ul><li>Cereal milling to remove bran reduces </li></ul><ul><li>its phytic acid content by 50% . </li></ul>
  9. 9. Promoters of Iron Absorption <ul><li>Foods containing ascorbic acid like citrus fruits, broccoli & other dark green vegetables because a scorbic acid reduces iron from ferric to ferrous forms, which increase s its absorption . </li></ul><ul><li>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. </li></ul>
  10. 10. IRON ABSORPTION (3) <ul><li>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. </li></ul><ul><li>Food fermentation aids iron absorption by reducing the phytate content of diet </li></ul>
  11. 11. IRON TRANSPORT <ul><li>Transferrin is the major protein responsible for transporting iron in the body. </li></ul><ul><li>Transferrin receptors, located in almost all cells of the body, can bind two molecules of transferrin. </li></ul><ul><li>Both transferrin concentration & transferrin receptors are important in assessing iron status. </li></ul>
  12. 12. STORAGE OF IRON <ul><li>Tissues with higher requirement for iron </li></ul><ul><li>( bone marrow, liver & placenta) contain more transferrin receptors. </li></ul><ul><li>Once in tissues, iron is stored as ferritin & hemosiderin compounds, which are present in the liver, RE cells & bone marrow. </li></ul><ul><li>The amount of iron in the storage compartment depends on iron balance (positive or negative). </li></ul><ul><li>Ferritin level reflects amount of stored iron in the body & is important in assessing ID. </li></ul>
  14. 14. Body Iron Distribution Adult Female Wt. 60kg Adult Male Wt. 80kg 0-300mg 600-1000mg Iron stores 3 3 Transferrin iron 300mg 500mg Myoglobin /enzyme 1700mg 2500mg Hemoglobin
  15. 15. ROLE OF IRON IN THE BODY <ul><li>Iron have several vital functions </li></ul><ul><li>Carrier of oxygen from lung to tissues </li></ul><ul><li>Transport of electrons within cells </li></ul><ul><li>Co-factor of essential enzymatic reactions: </li></ul><ul><ul><li>Neurotransmission </li></ul></ul><ul><ul><li>Synthesis of steroid hormones </li></ul></ul><ul><ul><li>Synthesis of bile salts </li></ul></ul><ul><ul><li>Detoxification processes in the liver </li></ul></ul>
  16. 16. IRON DEFICIENCY <ul><li>Iron deficiency is the most common micronutrient deficiency in the world affecting 1.3 billion people i.e. 24% of the world population. </li></ul><ul><li>In India 20% Adult male </li></ul><ul><li>40% Children </li></ul><ul><li>40% Non pregnant women </li></ul><ul><li>80% Pregnant women </li></ul>
  17. 17. IRON DEFICIENCY /2 <ul><li>Iron deficiency can range from sub-clinical state to severe iron deficiency anemia. </li></ul><ul><li>Different stages are identified by clinical findings & lab tests. </li></ul><ul><li>Anemia is defined as Hb less than12 g/dl (-2SD below the mean). </li></ul><ul><li>Mild 10-12 g/dl </li></ul><ul><li>Moderate 5-10 g/dl </li></ul><ul><li>Sever <5 g/dl </li></ul>
  18. 18. AT RISK GROUPS <ul><ul><ul><li>Infants </li></ul></ul></ul><ul><ul><ul><li>Under 5 children </li></ul></ul></ul><ul><ul><ul><li>Children of school age </li></ul></ul></ul><ul><ul><ul><li>Women of child bearing age </li></ul></ul></ul>
  19. 19. ETIOLOGY <ul><li>Increased Iron Demand/ Hematopoiesis </li></ul><ul><li>-Infancy / Adolescence </li></ul><ul><li>-Pregnancy </li></ul><ul><li>-Erythropoietin </li></ul><ul><li>Increase Iron loss </li></ul><ul><li>-Acute blood loss (Trauma, surgery) </li></ul><ul><li>-Chronic blood loss </li></ul><ul><li>(Hookworm inf., Menses) </li></ul><ul><li>-Blood donation / Phlebotomy as </li></ul><ul><li>treatment for polycythemia </li></ul>
  20. 20. Continued…. <ul><li>Decreased iron intake / Absorption </li></ul><ul><li>-Inadequate Diet </li></ul><ul><li>-Malabsorption Disease </li></ul><ul><li>(Sprue, Crohn’s disease) </li></ul><ul><li>-Post-gastrectomy </li></ul><ul><li>-Acute/ Chronic Inflamation </li></ul>
  21. 21. Clinical Presentation <ul><li>Asymptomatic </li></ul><ul><li>Pallor </li></ul><ul><li>Irritability, exercise intolerance, fatigue, and tachycardia, palpitation, </li></ul><ul><li>Weakness, giddiness </li></ul><ul><li>Koilonychia </li></ul><ul><li>“ Beeturia” </li></ul>
  22. 22. Investigations <ul><li>Hb: - </li></ul><ul><li>Low MCV (78-100 μ m3) </li></ul><ul><li>Low MCH (26-34pg/cell) </li></ul><ul><li>Low MCHC (31-37g/dl) </li></ul><ul><li>Microcytic hypochromic anaemia </li></ul>
  23. 23. Normal Blood Film
  24. 24. MICROCYTES
  26. 26. Continued .. <ul><li>Low serum ferritin </li></ul><ul><li>Male- (30-300 μ g/dl) </li></ul><ul><li>Female (10-200 μ g/dl) </li></ul><ul><li>Low serum iron (30-160 μ g/dl) </li></ul><ul><li>High iron binding capacity (228-428 μ g/dl) </li></ul><ul><li>High erythrocyte protoporphyrin(16-36 μ g/dl) </li></ul><ul><li>High RWD (Red cell Distribution Width) </li></ul><ul><li>(11.5-14.5%) </li></ul><ul><li>Stool for occult blood </li></ul><ul><li>Helminthes inf. </li></ul>
  27. 27. Consequences of Iron Deficiency <ul><li>Increase maternal & fetal mortality . </li></ul><ul><li>Increase risk of premature delivery and LBW . </li></ul><ul><li>Learning disabilities & d elayed psychomotor development . </li></ul><ul><li>Reduced work capacity . </li></ul><ul><li>Impaired immunity (high risk of infection ). </li></ul><ul><li>Inability to maintain body temperature. </li></ul><ul><li>Associated risk of lead poisoning because of pica. </li></ul>
  28. 28. MANAGEMENT OF IDA <ul><li>Oral Iron Therapy </li></ul><ul><li>Parenteral Iron Therapy </li></ul><ul><li>Red cell transfusion </li></ul>
  29. 29. ORAL IRON THERAPY <ul><li>Dose: - 3-6mg/kg of elemental iron in 3 doses </li></ul><ul><li>Hb is raised by 1g/dl with 7-10 days of oral treatment </li></ul><ul><li>As the Hb level rises, erythropoietin stimulation decrease and </li></ul><ul><li>Hence iron absorption is reduced </li></ul><ul><li>6-8 weeks requires to normalize Hb </li></ul><ul><li>At least 6 months therapy should be given </li></ul>
  30. 30. Continued… <ul><li>Ferrous sulphate (37%) </li></ul><ul><li>Ferrous fumarate (33%) </li></ul><ul><li>Ferrous succinate (23%) </li></ul><ul><li>Ferrous gluconate (12%) </li></ul><ul><li>Ferrous carbonate (16%) </li></ul><ul><li>Ferrous Lactate (19%) </li></ul>
  31. 31. Side Effects of Oral Therapy <ul><li>Abdominal discomforts </li></ul><ul><li>Abd. Pain, constipation, nausea,cramps </li></ul><ul><li>Teeth staining </li></ul><ul><li>Failure of therapy </li></ul><ul><li>Non compliance </li></ul><ul><li>Poor absorption </li></ul>
  32. 32. PARENTERAL IRON THEROPY <ul><li>Indications </li></ul><ul><li>-Oral iron intolerance </li></ul><ul><li>-Non compliance </li></ul><ul><li>-Acute need ( Erythropoietin therapy) </li></ul><ul><li>-Chronic GI blood loss </li></ul><ul><li>Iron Req .= 2.3 x Body Wt. x Hb deficit </li></ul><ul><li>+ 500 to 1000mg(for stores) </li></ul>
  33. 33. Continued…. <ul><li>Iron dextran (I.V. I.M.) </li></ul><ul><li>Iron gluconate (I.V.) </li></ul><ul><li>Iron sorbitol (I.M.) </li></ul><ul><li>Large dose (>100mg) should be given in </li></ul><ul><li>100 ml of NS or 5% D after test dose (I.V.) </li></ul><ul><li>Side effects: - Hypersensitivity, Anaphylaxis </li></ul><ul><li>Arthralgia, Skin Rash, low </li></ul><ul><li>grade fever </li></ul>
  34. 34. Red Cell Transfusion <ul><li>Indications </li></ul><ul><li>- Symptomatic Anemia </li></ul><ul><li>-Excessive bleeding </li></ul><ul><li>-Immediate Intervention </li></ul><ul><li>One packed cell volume increases appr. 1g/dl of Hb </li></ul>
  35. 35. PREVENTION OF IDA <ul><li>Dietary modification </li></ul><ul><li>Food fortification </li></ul><ul><li>Iron supplementation </li></ul>
  36. 36. PREVENTION OF IDA /2 <ul><li>Diet & nutrition education </li></ul><ul><ul><ul><li>eat more fruits and vegetable </li></ul></ul></ul><ul><ul><ul><li>no coffee or tea with meals </li></ul></ul></ul><ul><ul><ul><li>programmes should be targeted to </li></ul></ul></ul><ul><ul><ul><li>at risk groups </li></ul></ul></ul><ul><ul><ul><li>reduce phytic content of cereals and </li></ul></ul></ul><ul><ul><ul><li>legumes by fermentation </li></ul></ul></ul>
  37. 37. PREVENTION OF IDA /3 <ul><li>S hort term approach : </li></ul><ul><ul><li>s upplementation with iron tablets . </li></ul></ul><ul><li>L ong-term approach : </li></ul><ul><ul><li>f ood 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. </li></ul></ul>
  38. 38. Which iron form to use? <ul><li>Freely water soluble iron are the most bio-available, but causes unacceptable colour & flavour change in many foods. </li></ul><ul><li>Insoluble iron compounds are inert with no organoleptic effects but it is poorly absorbed </li></ul><ul><li>Cost-wise elemental iron is the cheapest, ferrous sulphate costs 10 times more, but most expensive is EDTA </li></ul><ul><li>Safety is of concern with EDTA & Bovine Hb only because of potential problems </li></ul>
  39. 39. COMMON PRACTICE <ul><li>Ferrous sulphate is commonly used in Rx & prevention of IDA because of good absorption & high bioavailability, but it has its drawbacks </li></ul><ul><li>GIT disturbances & staining of teeth are frequent </li></ul><ul><li>Effects on fortified foods may include: </li></ul><ul><ul><li>Fat oxidation & rancidity </li></ul></ul><ul><ul><li>Colour changes </li></ul></ul><ul><ul><li>Metallic taste </li></ul></ul><ul><ul><li>Precipitation </li></ul></ul>
  40. 40. EXPERIMENTAL COMPOUNDS <ul><li>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. </li></ul><ul><li>Food is usually fortified by both Fe-EDTA & Na or Ca EDTA. </li></ul>
  41. 41. HOW EDTA ACTS? <ul><li>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. w hile 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. </li></ul>
  42. 42. ADVANTAGES OF USING EDTA <ul><li>Iron absorption is 6 times greater than with ordinary methods even in the presence of inhibitors. </li></ul><ul><li>No need to add vitamin C or other promoters to enhance iron absorption. </li></ul><ul><li>No change in colour or flavour of food with EDTA even when stored for long time . </li></ul>
  43. 43. LIMITATIONS of EDTA USE <ul><li>EDTA fortification is 7 times more expensive than ordinary fortification using iron salts. </li></ul><ul><li>Health care providers have little experience with this new technique. </li></ul>
  44. 44. Confusing Chart
  45. 45. Thank You