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Clinical Nutrition Notes Za Wizara Cmt Nta 4 Clinical Medicine First Year

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Introduction

Micronutrient disorders occur when there are inadequacies of some important micronutrients in the body.

We will discuss the deficiencies of vitamin A, iron, folate, iodine and vitamin C in detail because these are the micronutrients that people are most likely to lack.

We will also briefly discuss thiamine, niacin and vitamin D deficiencies because these deficiencies occur occasionally

 

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Classification of Nutritional Anaemia

Micronutrient disorders occur when there are inadequacies of some important micronutrients in the body.

We will discuss the deficiencies of vitamin A, iron, folate, iodine and vitamin C in detail because these are the micronutrients that people are most likely to lack.

We will also briefly discuss thiamine, niacin and vitamin D deficiencies because these deficiencies occur occasionally

 

Anaemia

Anaemia is a pathological condition arising as a result of low level of haemoglobin in the body. Reduction in haemoglobin impairs oxygen transport to the tissues – the basis for the clinical features of anaemia.

Anaemia is classified according to causes and mechanism of its development:

i. Haemorrhagic anaemia develops due to various forms of bleeding (trauma,excessive menses, bleeding associated with pregnancy and childbirth, and parasitic infestations

ii. Haemolytic anaemia, due to massive destruction of red blood cells, as occurs in malaria and sickle cell disease

iii. Hypoplastic/Aplastic anaemia, due to failure of bone marrow to regenerate and produce red blood cells. When production of red blood cells is reduced it is hypoplastic anaemia; when it is severely curtailed, it is aplastic anaemia.

iv. Bone marrow depression may be caused by diseases, intake of some drugs and other factors.

v. Nutritional anaemia, due to deficiency of nutrients that are needed for the synthesis of red blood cells, iron, folic acid and vitamin B12.

Thus nutritional anaemia includes:

a. Iron deficiency anaemia

b. Folic acid deficiency anaemia

c. Vitamin B12 deficiency anaemia


Haemoglobin in the red blood cells is necessary to carry oxygen and many of the symptoms and signs of anaemia result from the reduced capacity of the blood to transport oxygen.

The commonest cause of anaemia is iron deficiency or lack of the nutrient iron

 

Symptoms and Signs Iron Deficiency Anaemia (IDA)

Tiredness and fatigue

Dizziness and/or headaches

Palpitations

Difficulty in breathing on exertion

Inadequate temperature regulations because iron play a role in regulating body temperature.

 

In addition, the deficiency of folate and vitamin B12 (megaloblastic anaemia) may cause:

i. Glossitis (tongue inflammation)

ii. Sometimes stomatitis(inflammation of the mouth and lips)

iii. Hyper pigmentation of skin and mucosa(skin become darker in color than normal)

iv. Peripheral neuropathy(pain from nerve damage usually in the hand and feet)

v. Dementia

In children, severe Vitamin B12 deficiency may produce mental regression,convulsions, coma and ultimate death

Note: The symptoms are quite variable, and they can be caused by other conditions. The only sign you can look for is paleness, which is not very reliable.

So to know whether a person is anaemic or not, you need to measure the amount of haemoglobin in the blood.

 

Complications of Anaemia

The following are the major complications of anaemia.

i. Heart failure

ii. Reduced mental capacity.

iii. Anaemia negatively affects school performance

 

Reduced immune competence, leading to high incidences of diseases

a) Poor pregnancy outcomes (low birth weight, spontaneous abortion, premature delivery)

b) Failure of mothers to withstand blood loss at delivery and hence increased risk of maternal deaths.

 

Groups who are at Risk of Nutritional Anaemia

i. Women, especially during pregnancy or soon after delivery

ii. Babies who are low birth weight or not breast fed

iii. Premature babies

iv. Young children especially if they are malnourished

v. Sickle cell disease patients

vi. Adolescents, who are growing fast, especially girls

vii. Older men and women, especially if they are poor

 
Strategies for Prevention and Control of Anaemia

i. Promotion of consumption of iron- and vitamin-rich foods

ii. Prevention and treatment of anaemia-related diseases (malaria, worm infestation)

iii. Iron and folic acid supplementation to the most at risk groups (children, pregnant women, sickle cell disease patients)

iv. Fortification of foods with relevant nutrients (iron, folic acid)

 

Introduction to Iodine Deficiency Disorders

Deficiency of iodine in the body leads to conditions termed iodine deficiency disorders (IDD).

Iodine is found in the soil and is picked up by different foods (plants, animals, water) obtainable in the area.

The human body gets iodine from the variety of foods they eat.

The major cause of iodine deficiency is its loss from the soil through leaching.

For very long, since the primordial formation of the earth crust, iodine has leached and been carried away by water (rains, streams, floods) to lowland areas and the sea.

Thus highland and mountainous areas are devoid of iodine while lowland areas are relatively rich in iodine.

Iodine deficiency manifests as goitre as well as a variety of conditions termed hypothyroidism. The type and severity of the illness depends on the period of life when deficiency of iodine occurs.

 

How to Examine and Classify Goitre

a) Stand or sit facing the person

b) Place your two thumbs on either side of the persons trachea, several centimetres below the larynx (voice box)

c) Roll your thumbs gently over the thyroid (which lies next to the trachea).

d) This is called palpation.

 

If each lobe of the thyroid is smaller than the end joint of the persons thumb, there is no goitre.

If one or both lobes are larger than the end joint of the persons thumb, then there is goitre.

Ask the person to bend their head back and look upward. Try to see the goitre

Ask the person to look straight forward, and try to see the goitre again.

Note whether you can see the goitre from a distance of about 10 meters or only up close.

 

Symptoms and Signs of Iodine Deficiency Disorders

i. Goitre

ii. Hypothyroidism

iii. A person who is hypothyroid:

iv. Feels cold easily

v. Moves slowly and lacks energy

vi. Think slowly and appear unconcerned

vii. May be sleepy

viii. Has a dry skin

ix. May be constipated

 

A child who is hypothyroid

i. Also grows slowly, and may be very short

ii. May not do well in school

iii. Women who are hypothyroid during pregnancy may also have;

iv. Miscarriage or still birth

v. Low birth weight babies

vi. Babies with congenital deformities,

vii. Babies with cretinism

 

Cretinism: There are two type of cretinism

a. Neurological

b. Hypothyroid

 

 

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Neurological Cretinism

Is likely if the mother is iodine deficient in the early part of pregnancy, when the baby’s brain and nervous system are developing. Neurological cretinism cannot be treated. So giving iodine does not help.

 

The effect may include

i. Deafness and mutism (the child cannot speak)

ii. Squint (eyes are not held straight)

iii. Weakness and stiffness especially of the legs

iv. Severe mental handicap

 

Hypothyroid Cretinism

The baby has signs which are similar to those listed under hypothyroidism in older people.

Hypothyroid cretinism is likely if the mother is iodine deficient in later pregnancy.

Breast feeding may partly protect the baby. Effects of iodine deficiency may become worse after weaning. So it is important to try to find and treat hypothyroid babies as early (before one year of age) as possible.

 

Deficiency during pregnancy may lead to;

a) Spontaneous Abortion

b) Low birth weight

c) Stillbirth

d) Impaired foetal brain development

 

In older children deficiency causes

a. Delayed physical and mental growth

b. Learning problems

c. For adolescents and adults

d. Lack of energy and vigour

e. Goitre becomes the main visible manifestation of iodine deficiency

 

Strategies for Control of Iodine Deficiency

Various medicinal preparations are administered, such as:

i. Injectable iodized oil

ii. Iodinated oil capsules

iii. Salt iodations: emphasis should be on salt iodation only because currently other strategies are less commonly used

iv. Injectable iodized oil that is administered as an intra-muscular injection.

 

Advantages

a. The iodine is retained in the body tissues for a long period (three to five years) and helps to maintain thyroid hormones at normal levels.

b. It is applicable to remote or isolated locations such as mountain areas where food items like salt have difficulty reaching.

 

Disadvantages

a. High costs involved - syringes, needles and trained personnel.

b. Lack of sterility and low levels of hygiene pose risk to the population in terms of HIV, hepatitis B and other infections.

 

Iodinated oil capsules that are administered orally. The body tissue takes up the iodine and releases it slowly, over many months.

Advantage

a. The easiness of administration and the long retention period – one to two years.

Disadvantage

a. Absorption of the capsules may be impaired in presence of intestinal parasites.

 

In undernourished population, the low fat stores would reduce the retention period.

In many countries capsule distribution is applied as interim measure while still in the process of setting up mechanism and structure for universal salt iodation.

 

Salt iodation is considered the most feasible long-term approach to the prevention and control of iodine deficiency.

In many countries there is a legislation that forbids trading non-iodated salt that is earmarked for human consumption.

According to the WHO a salt iodation programme is considered performing adequately when 90 percent or more households consume iodated salt.

 

Advantage

i. It is able to achieve the wide coverage for, most communities and people consume salt irrespective of social or economic status

ii. Iodated salt is readily accepted as it is taken as food, not as medicine.

iii. It is consumed at roughly the same level all the time (without the worry of underor overdose)

iv. Production of iodated salt can be confined to few centres with controlled conditions

v. Also the mixing of salt with the iodine compound (potassium iodate or iodide) is a physical reaction and a simple one- there are no adverse chemical reactions involved.

 

Disadvantages

i. Salt producers can be quite numerous in the country, hence difficult to monitor and enforce the salt regulation. Some of them, particularly small scale holders; find it difficult to acquire equipment, the iodine compound and other supplies

ii. Another constraint is that iodine is slowly lost as the salt stays long and in unfavourable conditions such as heat, moisture and dust.

 

 

Groups at Risk of Iodine Deficiency

a) Women of child bearing age (including lactating women)

b) Child age 0-15 years

c) Men aged 45 years

 

IMPORATANT CONCEPT

Common signs and symptoms of anaemia include tiredness, dizziness and paleness.

Anaemia affects mostly women and children.

The commonest cause of anaemia is iron deficiency (lack of the nutrient iron).

Iodine deficiency manifests as goitre as well as a variety of ill conditions termed hypothyroidism.

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