ANEMIA GIZI

Agussalim Bukhari
Bagian Ilmu Gizi
Fak.Kedokteran Unhas
SEVERE PROTEIN ENERGY MALNUTRITION (PEM)

MARASMUS

KWASHIORKOR
Types of Malnutrition

• Marasmus
• Kwashiorkor
• Mixed

Because this is a disease with multiple etiologies, the

best terminology would probably be polydeficient
malnutrition.

Green CJ. Clin Nutr 1999;18(s):3-28

 Definition

 Anemia: A deficit of circulating RBC

associated with diminished oxygen-
carrying capacity of the blood
 Hb < 12 g/dL or Ht < 36% in adult
females
 Hb < 14 g/dL or Ht < 42% in adult males
 Signs and Symptoms

• Depend less on its severity than on the

pace of its development
• Pallor of skin and mucous membrane
• Easily fatique or poor exercise tolerance
• Resting tachycardia, Palpitations
• Dizziness, Syncope
• Amenorrhea
• Systolic ejection murmur
 Signs & Symptoms

 Nutritional anemias often accompanied by

vitamins and minerals deficiency
 Vit C and folic acid coexist in many foods -
-- anemia + scurvy
 Anemia not usually an isolate finding ---
limits RBC production usually affect other
high turnover cells such as leukocytes,
platelets, and enterocytes
Anemia yang disebabkan oleh defisiensi
nutrisi yang merupakan faktor eritropoesis
pembentukan darah merah seperti : Fe, B12,
C, Folic Acid, Protein, B6, CU, CO.

Tipe :
1. Mikrositik hipokremik ---- defisiensi Fe
2. Makrositis hiperkromik = megaloblastik
anemia--- defisiensi vitamin B12, Folic
acid
 Etiologies

 1. diminished erythropoiesis due to

nutritional def or BM failure
 2. Blood loss
 3. Increased hemolysis, hereditary or
acquired
PENYEBAB DEFISIENSI
1. Asupan tidak adekuat
2. Absorpsi tidak adekuat
3. Utilisasi tidak adekuat---gangguan
enzim
4. Keperluan meningkat ( Bumil )
5. Eksresi Meningkat ( Penyakit Hati )
6. Mobilisasi dari penyimpanan (Ferritin)
terganggu---penyakit infeksi/
inflamasi
 Etiologies
Category (MCV) Nutritional causes Other causes

Microcytic (<80 u3) Iron deficiency (common), Chronic diseases,

Pyridoxine def (uncommon), thalassemias,
Copper def (uncommon) hemoglobin E disorders,
sideroblastic anemia
(Lead toxicity)

Normocytic (80-100 PEM Chronic diseases

u3 )

Macrocytic (>100 u3) Folic acid def, Vit B12 Def Alcoholism. Liver disease,
hemolysis
 etiologies
• Microcytic and macrocytic can coexist;
patient can have both iron and folic acid
def.
• In these case MCV may normal and
suggest a normocytic anemia but the
blood smear shows dimorphic RBCs
• Nutritional def anemia may occur in
normal intake if there are increased
requirements, inadequate ingestion,
malabsorption, impaired utilization,
elevated requirements, increased
excretion, or increased destruction
 Diagnostic steps

 Patient history
 Physical examination
 Lab: blood smear, blood count, Ht, MCV,
BM
 Microcytic anemia

 Common cause is iron def

 Iron def: inadequate intake, absorption,
excessive loss/bleeding
 Iron def is the most common nutritional
anemia and the most common nutritional
deficiency.
 Pathophysiology

 Iron in the body: functional and storage

form
 Iron incorporated into heme and
myoglobin
 Part of enzymes : COX, catalase,
peroxidase
 Storage form: ferritin and hemosiderin
 Dietary iron: heme iron from animal/meat
and nonheme iron from vegetables and
• Heme iron 20% bioavailable, nonheme
iron 3% available
• Net absorption of the two forms combined
is 10%
• Each day, about 1 % RBC is destroyed
releasing about 30 mg of Iron into RES
and circulation
• Of 30 mg released, about 29 mg salvaged
and only 1 mg must be replaced
 Premenopausal women need additional
0.5 mg/day to compensate menstrual loss-
---1.5 mg ---15 mg RDA
 The group with greatest risk: (1) 6 mo---4
y.o(2) early adolescence (3) menstrual
women (4) pregnant women
 Lab
Lab finding Injury, infection, Iron deficiency PEM
chronic
inflammation

Serum iron Low Low Generally Low

Serum TIBC Normal or Low High Low

Serum Ferritin Normal or slightly Low Generally Low

high

Marrow and liver Present Absent Low to absent

iron store
 Treatment

 Fe sulfate 325 mg (60 mg elemental iron)

1-3 x/d with meals
 Theraphy should be continued for 4 to 6
mo to restore normal Hb and iron stores.
 Iv injection can be given as iron dextran
provides 50 mg/ml (Imferon) when oral
th/ is ineffective
 Macrocytic anemia

 When caused by defic. of Folic acid or vit

B12----megaloblastic anemias because
large, immature RBC precursors
(megaloblasts) accumulate in the BM
 Not all macrocytic anemias are
megaloblastic; anemias in alcoholism, liver
disease, and hemolysis, the RBCs are
large but megaloblasts are not present in
the BM.
 Anemia of Chronic Diseases

 The most common Anemia in hospitalized

patients due to inflammation, infection,
and malignancy occurs because there is
decreased RBC production, possibly as a
result of disordered iron metabolism
 It may be due to the presence of
Inflammatory cytokines such as IL-1 and
TNF-alpha which decrease Iron absorption
and erythroblast activity, inadequate
 Ferritin levels are normal or increased, but
serum iron levels and TIBC are low
 In arthritis, depletion of stored iron
develops partly because of reduced iron
absorption from the gut
 Recombinant erythropoetin therapy
usually corrects this anemia
 TNFa increases expression of hepcidin, a
protein which inhibits ferroportin (iron
membrane transporter)
 TNFa decreases expression of ferroportin
NILAI HEMOGLOBIN WHO 1968 DAN 1972

KADAR
UMUR Ht MCHC
Hb
6 Bl – 6 Th 11 33 34
6 Th – 14 th 12 36 34
Laki dewasa 13 39 334
Wanita dewasa 12 36 34
Bumil 11 33 34
 ANEMIA DEFISIENSI BESI
 Anak :
1. Pada bayi karena cadangan Fe rendah
2. Pertumbuhan cepat
3. Variasi makanan yang terbatas
4. PMT terlambat
5. Infeksi – metabolisme meningkat
6. Absorbsi berkurang – infeksi TGI
7. Kehilangan darah kronis – ankylostomiasis
８. Obesitas----inflamasi----gangguan mobilisasi
Fe dari ferritin dan gangguan absorpsi
 Dewasa :
- Wanita haid --- kehilangan 30 mg --- butuh
1 mg Fe / hari
- Bumil --- 900 mg untuk cadangan foetus,
persalinan dan laktasi, butuh 2 mg Fe / hari

 Pencegahan :
1. Fe prophylaxis
2. Perbaikan pola makan
3. Keluarga berencana
4. Fortifikasi makanan
5. Eradikasi infeksi dan infestasi parasit
 Sumber Fe

 Meat and alternative

 Liver ( 300 mg) : 5.3 ug
 Hamburger : 2.3
 Soybean (2 cups) : 2.9
 Fish 300 mg : 0.3
 Chicken 300 mg : 0.9
Vegetables
 Spinach 1 cup : 1.7 ug
 Asparagus 1 cup : 1.2 ug
ANEMIA MEGALOBLASTIK ANAK
FOLIC ACID – Sintesis RNA dan DNA
 Penyebab :
1. Asupan tidak adekuat
2. Gangguan absorbsi : stetoroe idiopatik, tropical
sprue, celiac disease, kelainan TGI lain
3. Antagonis folic acid : metotrexate, primetamin

 Pengobatan :
1. Terapi penyebab dan asupan makanan
2. Pemberian folic acid 3 x 5 mg/hr atau 3 x 2,5
mg pada bayi
3. Tranfusi darah bila diperlukan
ANEMIA MEGALOBLASTIK DEWASA

= An Perniciosa Addison

 Penyebab :

Gangguan absorbsi vitamin B12 akibat

defisiensi faktor intrinsik pada mukosa
lambung
 ANEMIA MEGALOBLASTIK GIZI

1. Primer : asupan B12 dan Folic acid makanan

2. Sekunder :
a. Gangguan absorbsi ; sindroma
malabsorbsi, oral kontrasepsi – mengganggu
abs folic acid
b. Kebutuhan meningkat ; Hb-nopati,
hemolitik, antikonvulsan
Diagnosis
= anemia lainnya
 Pengobatan
1. Folic acid 5-10 mg/hr
2. Cyanocobalamine 1000 ug 2 x
seminggu – 250 ug/mgg-normal
 Pada kehamilan diberikan :
1. Folic acid 10 mg/hr
2. Anemia hebat ---- transfusi
3. Pemberian preparat Fe
 Pencegahan pada Bumil
1. 300-500 ug folic acid bersama-sama
2. 60 mg elemental Fe / hr pada trisemester
III kehamilan
 Folate (Vit B-9)
 Group of compounds. Active form is tetrahydrofolate (THF)
 Source : intestine: small amount produced by
bacteria
 Animal food: absorbed unaltered
 Plant food: conjugated with glutamic acid
 One of the most unstable vitamins
 Functions:
 Coenzymes in transport of carbon atoms in the synthesis of:
 - purine nucleotide, thymine involved in DNA
synthesis
 - convert B12 to coenzyme form
 - other enzymatic reaction
 Sumber Folat

 Sayuran: (dalam 100 g)

 Asparagus 265 ug
 Bayam 130 ug
 Broccoli 160
Buah
Orange juice 75 ug
Nasi 20 u9
Sources of folate
 Folate : deficiency/toxicity
 Deficiency : the most common vitamin deficiency in Australia
 Causes: low dietary intake
 Destruction in food preparation
 Poor intestinal absorption
 Effects: shortage of nucleotide
 Impairment of DNA replication
 Immature RBC cannot divide and become megaloblasts
 Symptoms: megaloblastic (macrocytic) anemia
 At risk: pregnant women, elderly, alcoholics,
 (is linked with neural tube defect in foetus)
 Vitamin B12 (cobalamin)
 Group of compounds that contain cobalt
 Source : synthezised only by microorganisms
 Found in food of animal origin
 Not in plants
 Functions: coenzyme in only 2 reactions:
 Isomerisation of methylmalonyl CoA --- succinyl
CoA
 Methylation of homocysteine --- methionine
 Converts folate to active form
 Maintains sheath that surrounds nerve fibres
 Vitamin B12-deficiency
 rare in developed countries except among
strict vegetarians
 Pernicious anemia: megaloblastic
(macrocytic anemia) and neurological
disturbances
Causes:
 Malabsorption

 Lack of intrinsic factor (in stomach)

 Inadequate intake (vegans, alcoholics)

 Sumber B12

 Meats / 300 g
Liver : 6.8 ug
Beef : 2.2
Lamb : 1.8
Tuna : 1.8
hamburger :1.5
telur (1 butir) : 0.6
 Sumber B12

 Milk and Milk products

Skim milk (1 cup) : 1.0 ug
Whole milk (1 cup) : 0.9
yogurt : 0.8
Cheese : 0.2-0.5
Tabel Angka Kecukupan Gizi (AKG) bagi orang Indonesia 2004