Wednesday, 26 February 2020

Anemia -Dietary Iron & Iron salts when & how to prescribe



The unknown functions of iron:  Forget about Hb!!! We know that iron is important for synthesis of haemoglobin (haem protein).  But what are the non haemoglobin functions of iron in our system???

    Q. How can we the old clinicians forget about potential benefits of  1) myo globin ,  2) cytochrome enzyme system  & 3)  many dozens of enzymes   whose active site has  an   iron – sulfur center. , So, my dear member iron is not to be equated with Hb only. –All above quoted  enzymes are  synthesized from Fe . So such enzyme store, activity and quantum are also dependent  Fe in body. Yes, it is true that Hb , is  an  important  messenger protein which carries oxygen to different parts of body and about 70% of body Fe is utilized in Hb synthesis., But we just  can’t ignore rest 30% Fe in body.

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How many clinicians acknowledge with gratitude about  the other actions of iron which is not dependent on Hb. What I intend to highlight is that we should not equate Fe Deficincy with poor oxygen supply to peripheral tissues alone.  Such “ Nosh dependent  essential functions of Fe molecules:- are  also essential iron compounds in the body. Such nosh molecules  include 1)  Myoglobin and 2) cytochrome enzyme system .Both these  complex proteins are ,  like Hb important for life., . In addition, there   are other 3) number   of enzymes   whose active site has  an   iron – sulfur center. Admittedly, hemoglobin    is the chief function of Fe and Fe is   abundantantly seen in Hb protein and easily sampled of the heme proteins   and accounts for > 65%  of body iron. So, we come to know that  iron is not for Hb synthesis only   . Fe is an  important part of many proteins   and enzymes  that help    the human    body function  efficiently. A) It is a component of  hemoglobin the protein  involved   in the movement of oxygen   around the body. It is   also required for the B) control of the  cycle    of cell division  and C) Cell growth  and for cell   differentiation.
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What does Myoglobin acts?  Myoglobin functions   in the transport and   short term  storage  of oxygen     in muscle  cells, helping to match  the supply  of oxygen  to  the demand  of working   muscles.

What dews other Fe dependent enzymes act?? Ans:-Antioxidant   and beneficial   pro- oxidant   functions: Catalase  and peroxidase are heme   containing  enzymes   that protect cells   against the accumulation   of hydrogen   peroxide ,  a potentially   damaging    reactive oxygen   species, by catalyzing a reaction that converts hydrogen   peroxide   to water   and oxygen.


·    What we need to know about Transferrin??
·    Transferrin is synthesized   in the liver, brain   and testes as well as other tissues. The amount    of transferrin   synthesized is inversely  related  to the iron   supply.  Transferrin is the iron   transport protein   that carries ferric iron between the sites of its absorption, storage   and utilization. It   binds two atoms of ferric iron per molecule. Iron   is transferred from the intestinal mucosa to  transferrin proteins and  is carried   through   the blood   to peripheral  tissues containing receptor  sites for   transferrin. There will be more transferrin in  times  of low intake,  more serum  transferrin as such carrier proteins are  produced  so as   to optimize iron availability.

·    What is Ferritin??? Ans:-Once  iron enters the cell, it is chelated to a protein   known   as  ferritin  by the enzyme ferrochelatase.   Chelation of iron   to its  storage protein   occurs  at the outer  aspect of the mitochondrial membrane.
·    What is  Haemosiderin?? Ans:-  Hemosiderin is   a form of denatured ferritin  which   contains  significantly less iron .
·    Let us recapitulate Fe absorption:  Let not prescribe Fe salts with full meals with Phytate or brands containg Calcium ,Vit D too:
·    Do we remember that people    with a low   reserve   of iron will absorb   more iron   compared   to those with sufficient   store of iron . This is the body’s way of trying   to maintain  adequate   levels  of iron while   protecting   against   iron toxicity.
Methods  to  improve   iron absorption .      There, are however  a number of methods  to  improve   iron absorption . Enhancing   factors
1)          Ascorbic  acid 2) Meat , 3) fish 
4) Fermented vegetables 5) fermented say sauces 6) and other seafoods. In  fact the amount of dietary heme iron  is   especially   from the  meat which our Indian poor women seldom consume. But let me warn U that ingesting of calcium along with Rin is a por prescription.
Absorption inhibitors  : What are the Inhibiting   factors
 Phytate   2) Calcium 3) Soya
4)                       other lower   inositol phosphates  
5   ) Tannins  6) Tea : 7) Iron   binding  phenolic compounds 

·    So what we the treating physician do ??? One   of these methods is to include foods  rich in vitamin C in the diet. Good sources of vitamin C   include   citrus fruits   and juices, tomatoes, strawberries, melons, dark green  leafy  vegetables and potatoes. To have  an effect, these foods  must be  consumed along with   the iron  source. The   different   factors   that influence iron   absorption  
Absorption of Heme   iron   :Factors   determining   iron status   of subject :

Q.. Factors controlling “Non heme iron absorption”??
Factors    determining iron status of subjects
Amount of potentially available    non heme iron 
Satiety is important part of life but that should not compromise the Fe absorption. Balance    between the following   enhancing and inhibiting factors
  Is absorbed is meant for Hb synthesis only???  To what extent of absorbed Fe is   utilized as Hb ??  Ans:- Iron, as we understand we equate to Hb synthesis. It is far from so.  Iron   has many different   other roles   to play in the body  . Function 1:--About   65-75%     of the body’s  iron is  in the blood  in the form  of hemoglobin . Hemoglobin is a protein in  red blood   cells that transport   oxygen  to tissues  in the body. Function 2: Acts as Myoglobin,    the compound   that carries   oxygen   to the muscle cells, also requires  iron. In   addition, Function 3 : part of different enzymes;  iron  is involved   in reactions within the body that   produce  energy. Function 4(Stored Iron) :- Any excess  iron is stored  in the body   as a reserve. Don’t sit idle like Delhi Plice !!!! Identify  the Individuals who are at an  Increased   Risk of Iron Deficiency
·    Infants   and children between the ages  of 6 months  and 4 years : Iron stores  of a full – term  infant   are sufficient   to last   for 6 months. High   iron requirements  are due to  the rapid  growth rates  sustained   during this  period.
·    Adolescents: Early adolescence  is another    period of rapid  growth  . In females  the blood loss that occurs  with menstruation   adds to the  increased  iron requirement of adolescence.
·    Pregnant  women : The  iron requirement   is significantly    increased  during   pregnancy due  to increased  iron utilization by the developing   fetus and placenta , as well as blood    volume expansion.
·    Individuals with   chronic blood loss : Chronic  bleeding    or acute blood  loss may  result in iron deficiency   . A common  cause  of chronic blood loss and  iron deficiency in developing   countries  is intestinal parasitic infection. Individuals   who donate   blood   frequently, especially  menstruating women, may need to increase   their iron  intake   to prevent   deficiency  because  each 500 mL of blood donated contains between 200 and 250 mg  of iron .
·    Individuals  with celiac   disease : Celiac  disease  is an  autoimmune disorder. When people with   celiac disease  consume foods  or products  that contain   gluten, the immune system   response     damages  the  intestinal villi, which may   result  in nutrient   malabsorption  and iron   deficiency   anemia.
·    Individuals  with Helicobacter pylori infection: H. pylori   infection  is associated  with iron deficiency   anemia especially  in children, even  in the absence  of gastrointestinal   bleeding .
·    Individuals  who have   had gastric bypass surgery : Some    types   of gastric  bypass surgery  increase  the risk  of iron  deficiency by causing   malabsorption of iron   among  other  nutrients.
·    Vegetarians : Because   iron from   plants  is less efficiently absorbed than  that  from animal sources, it has  been estimated   that the  bioavailability of iron  from   a vegetarian diet  is only 10 %    while it is   18%    from a mixed diet.
·    Individuals who engage in regular   intense  exercise : Daily   iron losses    have been   found to be   greater   in athletes  involved   in intense  endurance    training   due to the    increased  microscopic     bleeding    from the  gastrointestinal tract or increased  fragility   and hemolysis   of red blood  cells,



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