Biochemical correlates of anemia in
Cambodian women of reproductive age
Crystal Karakochuk1,2, Kyly Whitfield1,2, Aminuzza...
The Fish on Farms project is being jointly conducted by the University of
British Columbia (UBC) and Helen Keller Internat...
University of British Columbia Ministry of Health, Cambodia
Dr. Tim Green, Associate Professor, Human Nutrition Ministry o...
Global Prevalence of Anemia
Iron and Hemoglobin
 Iron: a natural metal found in the environment and in food
 Primarily important for the synthesis o...
Potential Causes of Anemia in Cambodia
disease
blood loss
inflammation
Anemia
micronutrient genetic hemoglobin
deficiencie...
Potential Causes of Anemia in Cambodia
disease
blood loss
inflammation
Anemia
micronutrient genetic hemoglobin
deficiencie...
Potential Causes of Anemia in Cambodia
disease
blood loss
inflammation
Anemia
micronutrient genetic hemoglobin
deficiencie...
Potential Causes of Anemia in Cambodia
disease
blood loss
inflammation
Anemia
micronutrient genetic hemoglobin
deficiencie...
Potential Causes of Anemia in Cambodia
disease
blood loss
inflammation
Anemia
micronutrient genetic hemoglobin
deficiencie...
Autosomal Recessive Disorder
Audience Poll
What is the prevalence of genetic hemoglobin disorders in
Cambodia?
a) 5%
b) 10%
c) 20%
d) >50%
Audience Poll
What is the prevalence of genetic hemoglobin disorders in
Cambodia?
a) 5%
b) 10%
c) 20%
d) >50% *majority ar...
Structural hemoglobin variants Thalassemias
-result from amino acid
substitutions in the globin chain of
hemoglobin
-resul...
Objectives
1. To explore the correlates of anemia in Cambodian
women of reproductive age
2. To estimate the proportion of ...
Study Design & Methods
Cross sectional survey design:
 Baseline data from ongoing RCT in Cambodia
Participants:
 450 Cam...
Prevalence of Genetic Hemoglobin Disorders
*underestimated due to incomplete data for α-thalassemias (trait,
co-inherited)...
Micronutrients & Inflammation
Table 2: Micronutrients and inflammation characteristics (n=450)
Cut off n %
Ferritin1, iron...
Anemia
Table 3: Anemia (n=420 non-pregnant women)
n %
Anemia total, Hb <120 g/L
Mild anemia, >110 to <120 g/L
Moderate ane...
Hemoglobin, Ferritin & sTfR by Hb Variant
Table 4: Hemoglobin, ferritin and sTfR by hemoglobin variant (n=420
non-pregnant...
Anemia & Iron Deficiency by Hb Variant
Table 5: Anemia and iron deficiency by hemoglobin variant (n=420
non-pregnant women...
Conclusions
1. Genetic Hb disorders cannot be ignored in South East Asia;
more than just assessment of Hb is required for ...
Next Steps & Future Research
1. Complete PCR analysis for α-thalassemia analysis
2. Multivariate logistic regression
3. In...
Acknowledgements
Dr. Angela Devlin
Dr. Susan Barr
Dr. Suzanne Vercauteren
HKI Cambodia research team
Green-McLean lab
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Nutrition: Biochemical correlates of anemia in Cambodian women of reproductive age

  1. 1. Biochemical correlates of anemia in Cambodian women of reproductive age Crystal Karakochuk1,2, Kyly Whitfield1,2, Aminuzzaman Talukder3, Suzanne Vercauteren4, Judy McLean1, Tim Green1,2 1University of British Columbia, Vancouver; 2Child and Family Research Institute, Vancouver; 3Helen Keller International, Phnom Penh; 4BC Children’s Hospital, Vancouver International Food Security Dialogue 2014 Enhancing Food Production, Gender Equity and Nutritional Security in a Changing World
  2. 2. The Fish on Farms project is being jointly conducted by the University of British Columbia (UBC) and Helen Keller International (HKI), with technical assistance from World Fish, in Prey Veng Province, Cambodia. This randomized control trial investigates an integrated Homestead Food Production models in relation to poverty, gender empowerment, and food and nutrition security, particularly among women and children. This is the first project known to rigorously measure the effectiveness of different models of Homestead Food Production at reducing undernutrition using biochemical and anthropometric measurements.
  3. 3. University of British Columbia Ministry of Health, Cambodia Dr. Tim Green, Associate Professor, Human Nutrition Ministry of Planning, Cambodia Dr. Judy McLean, Assistant Professor, Human Nutrition Dr. Susan Barr, Professor, Human Nutrition Dr. Larry Lynd, Professor & Director, Collaboration for Outcomes Research & Evaluation Dr. Tony Farrell, Professor, Centre for Aquaculture and Environmental Research Dr. David Kitts, Professor, Food Science & Associate Dean of Research Dr. Ian Forster, Centre for Aquaculture and Environmental Research Jen Foley, Fish on Farms Program Coordinator Helen Keller International - Cambodia Graduate Students Dr. Zaman Talukder Kyly Whitfield (PhD, Nutrition) Mr. Hou Kroeun Crystal Karakochuk (PhD, Nutrition) Ms. Ly Sokhoing Vashti Verbowski (MSc, Nutrition) Field Research Team Pardis Lakzadeh (MSc, Public Health Jeff Tang (BSc, Science) World Fish
  4. 4. Global Prevalence of Anemia
  5. 5. Iron and Hemoglobin  Iron: a natural metal found in the environment and in food  Primarily important for the synthesis of Hemoglobin (Hb) in red blood cells which is essential for oxygen transport  Anemia in women of reproductive age: defined as Hb <120 g/L Image courtesy of antranik.org
  6. 6. Potential Causes of Anemia in Cambodia disease blood loss inflammation Anemia micronutrient genetic hemoglobin deficiencies disorders iron, vitamin A, folate & vitamin B12
  7. 7. Potential Causes of Anemia in Cambodia disease blood loss inflammation Anemia micronutrient genetic hemoglobin deficiencies disorders induces hepcidin = anemia of chronic inflammation
  8. 8. Potential Causes of Anemia in Cambodia disease blood loss inflammation Anemia micronutrient genetic hemoglobin deficiencies disorders hookworm, parasites, malaria
  9. 9. Potential Causes of Anemia in Cambodia disease blood loss inflammation Anemia micronutrient genetic hemoglobin deficiencies disorders menses, losses from childbirth
  10. 10. Potential Causes of Anemia in Cambodia disease blood loss inflammation Anemia micronutrient genetic hemoglobin deficiencies disorders Inherited disorders that result in a defective hemoglobin
  11. 11. Autosomal Recessive Disorder
  12. 12. Audience Poll What is the prevalence of genetic hemoglobin disorders in Cambodia? a) 5% b) 10% c) 20% d) >50%
  13. 13. Audience Poll What is the prevalence of genetic hemoglobin disorders in Cambodia? a) 5% b) 10% c) 20% d) >50% *majority are heterozygous traits that are asymptomatic, but serious risk of homozygous form inherited by offspring (Carnley et al, 2006; George et al, 2012)
  14. 14. Structural hemoglobin variants Thalassemias -result from amino acid substitutions in the globin chain of hemoglobin -result from an amino acid deletion causing impaired synthesis of the globin chains (α- or β) Examples: Hb AE (heterozygous), EE (homozygous), Constant Spring (CS) Examples: α- or β thalassemias (α-3.7 most common) Diagnostic method: Hb gel electrophoresis (% of Hb variants of total Hb) Diagnostic method: Polymerase Chain Reaction (PCR) for DNA typing Genetic Hemoglobin Disorders (Bain, 2006)
  15. 15. Objectives 1. To explore the correlates of anemia in Cambodian women of reproductive age 2. To estimate the proportion of anemia associated with iron deficiency using biochemical indicators
  16. 16. Study Design & Methods Cross sectional survey design:  Baseline data from ongoing RCT in Cambodia Participants:  450 Cambodian women 18-45 yrs of age from poor households in rural Prey Veng province Data collected in June 2012:  Venous blood sample collected  Complete blood count (CBC) and serum analyses
  17. 17. Prevalence of Genetic Hemoglobin Disorders *underestimated due to incomplete data for α-thalassemias (trait, co-inherited) Table 1: Prevalence of genetic hemoglobin disorders (n=450) Hemoglobin n % Normal hemoglobin AA 249 59% Hemoglobin variant Any variant 171 41%* Heterozygous E trait AE 99 24% Homozygous E EE 31 7% Constant spring CS 17 4% β -thalassemia trait β 11 3% Other - 13 3%
  18. 18. Micronutrients & Inflammation Table 2: Micronutrients and inflammation characteristics (n=450) Cut off n % Ferritin1, iron stores deficiency <15 ug/L 13 2.8 sTfR, tissue iron deficiency >8.3 mg/L 84 18.7 Vitamin B12 <150 pmol/L 7 1.6 Folate <3 ng/mL 11 2.4 RBP1 (Vitamin A) <0.7 mmol/L 0 0 CRP (acute inflammation) >5 mg/L 39 8.7 AGP (chronic inflammation) >1 g/L 113 25.1 1Ferritin and RBP corrected for inflammation by methods proposed by Thurnham et al (Lancet 2003, AJCN 2010). sTfR, serum transferrin receptor; RBP, retinol binding protein; CRP, c-reactive protein; AGP, alpha-1 acid glycoprotein
  19. 19. Anemia Table 3: Anemia (n=420 non-pregnant women) n % Anemia total, Hb <120 g/L Mild anemia, >110 to <120 g/L Moderate anemia, 90-110 g/L Severe anemia, <90 g/L Microcytic anemia, MCV <80 fL Normocytic anemia, MCV 80-95 fL Macrocytic, anemia, MCV >95 fL 124 85 39 0 78 45 1 29.5 69 31 0 63 36 <1 MCV; mean corpuscular volume
  20. 20. Hemoglobin, Ferritin & sTfR by Hb Variant Table 4: Hemoglobin, ferritin and sTfR by hemoglobin variant (n=420 non-pregnant women) AA (No variant) AE Heterozygous (trait) EE Homozygous CS Constant spring Total, n (%) 249 (59%) 99 (24%) 31 (7.4%) 17 (4%) Hb, g/L 128.1 ± 9.71 123.3 ± 9.32 108.5 ± 7.32 119.6 ± 8.22 Ferritin, ug/L 93.5 ± 54.8 88.5 ± 47.7 129.0 ± 90.62 93.8 ± 36.9 sTfR, mg/L 6.4 ± 1.9 6.8 ± 2.2 9.5 ± 3.62 9.6 ± 3.02 1Mean±SD. 2pairwise comparisons showed significant differences (p<0.0001) compared to women with a normal hemoglobin (AA)
  21. 21. Anemia & Iron Deficiency by Hb Variant Table 5: Anemia and iron deficiency by hemoglobin variant (n=420 non-pregnant women) Without Hb Variant n=249 With Hb Variant n=171 Anemia prevalence, Hb <120 g/L 15.3% 50.3% Ferritin, Iron stores deficiency, <15 ug/L 2.8% 1.2% sTfR, Tissue iron deficiency, >8.3 mg/L 11.2% 30.4% IDA, Hb <120g/L & Ferritin <15 ug/L <1% <1% IDA, Hb <120g/L & sTfR >8.3 mg/L <1% 7%
  22. 22. Conclusions 1. Genetic Hb disorders cannot be ignored in South East Asia; more than just assessment of Hb is required for anemia 2. More research is warranted on hemoglobin disorders and anemia; low-cost methods for testing for genetic disorders 3. No biochemical evidence of B12, folate or vitamin A deficiencies in Cambodian women in our study 4. Iron deficiency? Ferritin & sTfR likely confounded in those with Hb disorders. However, even in those with no Hb disorder, anemia is only 15% and IDA is <1%
  23. 23. Next Steps & Future Research 1. Complete PCR analysis for α-thalassemia analysis 2. Multivariate logistic regression 3. Investigate potential deficiency of riboflavin, B6 and zinc as contributors to anemia in this population (May survey) 4. Further investigation of potential iron sources in diet • Dietary intake of iron (24-hr recalls) • Assessment of ground well water for iron content • Iron supplementation trial
  24. 24. Acknowledgements Dr. Angela Devlin Dr. Susan Barr Dr. Suzanne Vercauteren HKI Cambodia research team Green-McLean lab

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