Microminerals

Prof. Chandrani Liyanage

Objectives

Sources
Body pools
Prevalence of deficiency
Clinical features in deficiency
Absorption
Requirements and recommendations
Deleterious effects
Implications
National plan to combat the deficiency

Iron

Iron deficiency is the most

common nutritional disorder in
the world
Affects
- women of reproductive age (15-49y)
- young children in tropical and
subtropical regions

Has the greatest overall effect in terms of premature

death, ill-health and lost earnings

Metabolism and physiology

Iron in human body - about 2.3g in adult women
3.5g in men
Of which 73% haemoglobin (2-2.5g of iron)
10% myoglobin (130mg of iron)
3% active iron containing heme and flavin
enzymes and transport iron (labile Fe
80- 90mg, tissue Fe 6-8mg, trans Fe 3mg)
Remainder 14% in women and children in storage SF &
haemosiderin (0.3g)
25% in men in storage (1.0g)

Childhood & adolescence

ID less common as rate of growth
decreases
During adolescence prevalence rises
again as iron needs increase with
adolescent growth spurt
More common among pregnant
adolescents

Iron needs
Pregnancy imposes increased needs.
At risk of developing an iron responsive
depression in Hb conn in the 3rd Trimester
Infancy - needs are primarily for growth.
High Hb conn and abundant neonatal iron stores
protect until 4 months (stores deminish by 4th month).
Term infants at a greater risk of developing ID
between 4-12 months and after.
In infants absn is 4 times greater than excretion
and the difference is used for growth. Risk
largely depends on the complementary feeding.

Iron deficiency
Is rare in formula fed infants
Is common in unfortified formula or cow milk
fed
Exclusively breastfed infants develop after 6
months
Low birth infants develop after 2 months
need iron supplements
Fe needs are greater due to low neo stores
and rapid relative growth rate
A dose of 2-3mg elemental iron/kg /day
recommended

Deficiency - Definitions
Anaemia
Hb conn or Hct <95% range for healthy well
nourished individuals of the same age,sex, and
stage of pregnancy
Iron deficiency anaemia
Anaemia associated with additional laboratory
evidence of iron depletion (low SF, Trf, MCV,
elevation of Erythrocyte protopophyrin or Trf
receptor levels

 Iron deficiency
Lack of iron that is severe enough to impair
the production of RBC, but not necessarily to the
extent that Hb falls <normal. Can progress to
iron deficiency anaemia
Iron deficiency without anaemia
Relatively mild iron deficiency diagnosed on
impaired iron status (combination of 2 or more
Bio-chemical indicators), but Hb remains in
normal range

Prevalence of anaemia

Global in 2005
47.4% in preschool children
25.4% in school children
41.8% in pregnant women
30.2% in non-pregnant women
2.7% in men
23.9% in elderly

SEAsia
65.5% in preschoolers
48.2% in preg. Women
45.7% in non-preg, women

In Sri Lanka

1973

38% men
68% women
78 primary schoolers
1996
15% preschoolers
58% children of 6-11y
36% adolescents
45% nonpreg. Women
56-78% preg. women
2001
29.9% preschool
29.3% pregnant
21.6 nonpregnant
2006/07
20.3% prelimenary school
40% pregnant
35% nonpregnant (15-49)

WHO recommended standards below

which anaemia is likely to be present

Cut-off level of haemoglobin

Up to 6 years 110g/l
6-14 years
120g/l
15-74 years
120g/l
Pregnancy
110g/l (100g/l in 2 nd Trime)
Adults (male) 130g/l

Classification of anaemia
as a problem of public health
significance
Prevalence % < 4.9

no PH problem

5-19.9 -

20-39.9 - moderate PH

> 40

mild PH pr..

- severe PH

Iron loss
Loss primarily through faeces in healthy individuals
(0.6mg/day)
And, bile and desquamated cells & through blood in minute
quantities
In women through menstruation (30ml/month) (additional
req 0.5mg/day)
About 10% women loose more than 30ml, likely anaemic
and, need additional iron each day
If total loss > 1.5mg/d positive balance not maintained
Losses occur due to aspirin intake, bleeding tumours &
ulcers, diahorreal diseases , chronic malaria, parasitic
infections
Method of contraception pill decreases to and IUCD
doubles the bleeding

Iron absorption
Chemical form of Fe
more important than the amount
determines the potentially available Fe for abs n
Heme Fe is absorbed more than twice as
effeciently as nonheme Fe
Low pH helps in dissolving ingested Fe and
facilitates enzyme reduction of ferric to ferrous by
a brush-border ferrireductase.
Duodenal crypt cells mature into absorptive
enterocytes for absn of Fe

Factors determine absorption

1. Enhancers vit C, foods rich in vit C
meat factor
animal proteins
2. Inhibitors - phytates and phytic acid
polyphenols
high Ca and Mg intake
tea, coffee, fiber, non-albuminous
part of egg
soy protein

3. Physiological factors
Low stores increases
Good stores decreases
4. Fe losses from the body
5. Increased requirements during
infancy, pregnancy, adolescence
after surgery

Absorption of Fe from iron

fortified foods and supplements
Eg. Cereals, milk powders, vitamin drops,
sauces, complementary foods, sugar etc.
Ferrous sulphate is usually used. (not good for
long term storage due to soluble form of Fe
promote fat oxidation and rancidity)
Influenced by the dose (<120mg/day), iron
stores, take in between meals, alone or as part
of vitamin-mineral supplement

Slow-release Fe preparations better

Absn of Fe from multi mineral

supp & fortified foods
Less is absorbed from certain MMSs than
when given alone (CaCO3 and MgO are
inhibitory). If the dose is reduced to 250mg
and 25mg the absn is almost double.
The Ca level should not go beyond 250mg
in a MMS.

Clinical features
Due to low Hb shortness of breath lead by physical
exertion
Increasing lethargy and fatigue
Headache, tinnitus and taste disturbances
Pallor of conjunctiva, tongue, nails beds (and soft palate as
severity increases)
Long term IDA papillary atrophy of the tongue and spoon
shaped nails
Enlargement of spleen
Behavioral changes in children, impaired cognition
Short attention spans, poor learning ability

Deleterious effects of IDA

In children
Impairment in neuronal growth and brain function
Become irritable and apathetic
Impaired mental and physical development
Permanent neurological damage
Hinders defense against infection and temp regulation
Increased attacks of malaria, angular stomatitis,
glossitis

Contd
In pregnant women
Increased risk of maternal morbidity and mortality
- premature delivery
- foetal morbidity and mortality
Milder degrees of anaemia assocoated with LBW
Placental hypertrophy
Low stores of Fe and folate in the new born
Poor maternal weight gain

Contd..
In adults
Reduced work capacity (related to Hb)
Work out put is significantly less
Reaching socio-economic consequences
Increased lactic acid levels and tachycardia
with exercise
Reduced activity of intestinal enzymes
Reduced growth rate
Impaired bodily functions

Estimated dietary requirement (EDR)

and RDA of iron mg/day.
EDR
0-1yr
1-2
2-6
6-12
boys 12-16
girls 12-16
men >16
women(menstruating)
(postmenopausal)
(pregnant)
(lactating)

21
12
14
23
36
40
23
48
19
30-60
26

RDA, 2001 (US-FNB)

4-8yr
9-13yr
14-18yr
14-18 yr
>18yr
>51yr
<18yr

11
07
10
08
11
15
08
18
08
27
10

Public health implications of IDA

Associated with poor reproductive performance
Higher proportion of maternal deaths (10-20% of total
deaths)
Higher incidence of LBW
Higher incidence of IUM
Impairs scholastic performance
Impaired psychomotor devt, interlectual performance
Decreased resistance to infection
Reduced work capacity, esp with intense exercises
Reduced productivity
Increases risk of lead toxicity (due to shared absorptive
mechanism)

Risk factors for IDA

Poor iron stores at birth
Dietary inadequacy
Increased demands due to rapid growth(preg,
inf, puberty, childhood)
Malabsorption and increased losses (repeated
episodes of doarrhoea, hook worm infestation
and ascariasis, repeated attacks of malaria in
endemic areas)

Contd..
Closely spaced pregnancies, pph, poor obstetric
care, prolonged lactation, use of intra uterine
contraceptive devices
Haeglobinopathies Thalassemias and sickle
cell anaemia (abnormal formation of Hb a
nonnutritional factor)
Drugs and other factors
Radiation therapy, leukemia
Anti-cancer and anti-convulsant drugs
In chronic inflammatory conditions (arthritis)
In GI blood loss

Control of nutritional anemia

Direct intervention
a) supplementation
b) fortification
Indirect intervention
a) start breast feeding immediately and continue
b)educational programmes
c) reduction of pathological losses (control of hook worm
and malaria)
d) Regular and frequent assessment of Hb and iron
status of population
e) study the causal factors in the area
f) train field staff to identify the risk individuals
g) encourage regular ANC visits

Supplementation & Fortification

Iron pills and drops
Complementary foods and milk powders
enriched with iron
Centrally processed infant foods
Cereal-legume supplements (Thriposha)
School biscuits
Cereals (wheat flour, rice), salt, sauces,
sugar etc.

Edu programmes

Increased production and consumption of iron and folate rich foods

Include even small quantities of non-veg foods
Vit C rich foods to minimize inhibition by phytates & poly
Avoidance of tea and minimize coffee
Inclusion of yoghurt and fruit juices in the diet
Inclusion of pulses and green leaves in daily diet
Intake of supplements in between meals
Emphasize the special needs and importance of Fe
Encourage home gardening

Intake of supplemental iron helps to reduce fatigue and increase ability to

work
Introduce cheap and locally produced iron rich foods

National Plan to combat

anaemia in pregnant mothers
Advises on good iron sources (pulses & legumes, green
leafy veg in addition to meat and fish
Inclusion of vit C and rich foods, even a small amt of
animal food, not to include much tea and Ca
supplements. Promoting fermented and germinated
food.
To supplement all the preg mothers with Fe and folic acid
supplements after 12 weeks of gestation. Mothers be
made aware of side effects (vomiting, nausea, loss of
appetite etc.). Correct consumption of supplements and
regular clinic visits.

 To identify anaemic mothers by the Hb level and

report as mild, moderate and severe.
To give parenteral iron to severe anaemics. Advise
them on high protein diet.
To treat and control paracitic infections after 1st
trimester (100mg mebendazole twice daily for 3
consecutive days). To prevent worm infection, use
latrines, wearing slippers, hygeinic source of
water, good health habits etc.
To treat and prevent malaria in endemic areas
(300mg of chloroquin once a week during preg
and 42 days after delivery).

 Information, education and communication

Obtain information about anaemia from the FHWs &
people in the area
Implementation of proper health education
programes
Risk groups (young women, working women, urban
poor, estate workers & refugees) be given more
attention
Make all the health workers more concern about the
health message and find that they convey the
messages to the public
Doctors to supervise all these educational programs