Establishing rapport
Assessment of individual medical history, pregnancy history, family medical history, dietary history.
Identify point for assessment
- Problem identified after assessment of medical and dietary assessment include:-
- I. Anaemia
- Medical history- hemoglobin level status was less than 11.0g/dl
- Dietary history-Following analysis of daily food records and 24 hour recall method, client daily food intake lack foods that are rich in iron source.
- II. Food allergy
Goal
To improve and maintain the iron status of pregnant mother involves changes in behavior, leading to an increase in the selection of iron containing foods and meal pattern favourable to increased bioavailability.
Objective
To improve dietary consumption of iron food by 50% within 3 months.
Health Education of anemia deficiency
Iron deficiency is defined as a condition in which there are no mobilizable iron stores and in which signs of a compromised supply of iron to tissues, including the erythron, are noted. The more severe stages of iron deficiency are associated with anaemiaIron deficiency is defined as a condition in which there are no mobilizable iron stores and in which signs of a compromised supply of iron to tissues, including the erythron, are noted. The more severe stages of iron deficiency are associated with anaemia
In anemia, there are a low number of red blood cells in the blood. Red blood cells contain the protein hemoglobin, which is vital to carrying oxygen to the cells of the body. Symptoms of anemia can be vague and include feelings of sluggishness, tiredness, weariness, fatigue, exhaustion, weakness, or low energy due to a general lack of oxygen that is available to the cells.
Shortness of breath can occur due to a low amount of hemoglobin that is available to carry oxygen from the lungs to the cells of the body. Low blood pressure (hypotension) can also result from anemia due to a lack of a sufficient amount of red blood cells in the blood to create enough blood volume to maintain normal blood pressure.
This can lead to sensations of palpitations, due to a lack of oxygen that can be delivered to the heart, resulting in a rapid heart rate. When the brain does not receive enough oxygen due to anemia, a person can experience vertigo or a feeling of faintness. Fainting (syncope), falls, and injuries can occur. There can also be difficulties with concentration and problems with memory. Serious life-threatening complications of severe anemia include shock, stroke, coma and death.
Other symptoms of anemia can include bleeding, vomiting blood, black tarry stools (melana), fever, severe bone pain, abdominal pain, weight loss, loss of appetite, and depression. Symptoms can also include flu-like symptoms, muscle aches, vomiting, and diarrhea.
How to control Anemia.
The following food sources should be taken in daily dietary intake.
Iron
Pregnancy increases the need for iron in the diet. The developing foetus draws enough iron from the mother to last it through the first five or six months after birth so a woman has an increased need for iron during pregnancy.
Iron losses are reduced during pregnancy because the woman is no longer menstruating and so loses less iron from menstrual blood loss. It is useful to include foods that are good sources of iron in the diet every day (for example red meat) and to have foods that are good sources of vitamin C (like oranges) to help absorb the iron.
The recommended daily intake (RDI) of iron during pregnancy is 27mg per day (9mg per day more than that for non-pregnant women). The amount needed depends on the amount of iron the woman has ‘stored’ in her body prior to pregnancy. If your iron stores are very low, you may need to get more from supplements. It is important to discuss your need for supplements with your doctor, as iron can be toxic in large amounts.
Iron
Pregnancy increases the need for iron in the diet. The developing foetus draws enough iron from the mother to last it through the first five or six months after birth so a woman has an increased need for iron during pregnancy.
Iron losses are reduced during pregnancy because the woman is no longer menstruating and so loses less iron from menstrual blood loss. It is useful to include foods that are good sources of iron in the diet every day (for example red meat) and to have foods that are good sources of vitamin C (like oranges) to help absorb the iron.
The recommended daily intake (RDI) of iron during pregnancy is 27mg per day (9mg per day more than that for non-pregnant women). The amount needed depends on the amount of iron the woman has ‘stored’ in her body prior to pregnancy. If your iron stores are very low, you may need to get more from supplements. It is important to discuss your need for supplements with your doctor, as iron can be toxic in large amounts.
Folic acid (folate)
Folate (known as folic acid when added to foods) is a B-group vitamin found in a variety of foods. Some breakfast cereals, breads and juices are fortified with folic acid. This will be listed on the nutrition label of these products.
As well as a healthy diet, it is recommended that women planning a pregnancy take a folic acid supplement prior to conception and for the first three months of pregnancy to reduce the risk of neural tube defects such as spina bifida. Folate taken over this period can prevent up to seven out of 10 cases of neural tube defects.
If you are planning a pregnancy or are in the early stages of pregnancy, you should increase your folate intake by an additional 0.4mg (400µg) per day above the recommended daily intake (RDI) of 0.6mg (600µg) per day for pregnancy.
Folate in your diet
Excellent food sources of folate include:
- Broccoli
- Brussels sprouts
- Chick peas
- Dried beans
- Lentils
- Spinach.
Very good food sources of folate include:
- Cabbage
- Oranges
- Peas
- Wheat germ
- Wholegrain bread.
Although liver is high in folate, it is not recommended to women who are, or could be pregnant, because of its high vitamin A content.
Iodine
Iodine is an important mineral needed for the production of thyroid hormone, which is important for growth and development. Inadequate iodine intake during pregnancy increases the risk of mental impairment and cretinism in the newborn baby.
Foods that are good sources of iodine include seafood and seaweed, eggs, meat and dairy products. Women who are pregnant should also use iodised table salt when cooking or adding salt to food.
Vitamin A
Although vitamin A requirements do increase during pregnancy, vitamin A supplements are rarely recommended for pregnant women. This is because an excessive intake of vitamin A may cause birth deformities.
The best way to increase your intake of vitamin A, if it is low, is through food sources like milk, fish, eggs and margarine.
Multivitamin supplements
Multivitamin supplements may be recommended for the following groups of pregnant women:
- Vegetarians
- Teenagers who may have an inadequate food intake
- Substance misusers (of drugs, tobacco and alcohol)
- Obese pregnant women who are restricting their energy intake to prevent large weight gains.
Dietary fiber
How to stop constipation
- Eat insoluble fibre, contained in foods such as raw vegetables and fruit, dried fruit, wholemeal dark bread, whole-grain cereals, nuts and seeds.
- Eat frequent and small meals regularly throughout the day.
- Drink plenty of fluids throughout the day.
- Be active and exercise regularly to stimulate bowel movement and improve digestion.
In counseling session, counselor should learn the client performance by assisting in planning a menu and applying the skill at home during meal preparation.
Giving assignments than include filling the daily food record intake and nutritional questions on the effects of taking foods that are rich and poor in iron sources.
Handouts and references that contain lists of food that are rich in iron, folates, iodine and vitamin A.
Anemia handout and References
IRON DEFICIENCY ANAEMIA
Iron status can be considered as a continuum from iron deficiency with anaemia, to iron deficiency with no anaemia, to normal iron status with varying amounts of stored iron, and finally to iron overload – which can cause organ damage when severe. Iron deficiency is the result of long-term negative iron balance.
Iron stores in the form of haemosiderin and ferritin are progressively diminished and no longer meet the needs of normal iron turnover.
From this critical point onward, the supply of iron to the transport protein apotransferrin is compromised. This condition results in a decrease in transferrin saturation and an increase in transferrin receptors in the circulation and on the surface of cells, including the erythron.
Iron deficiency is defined as a condition in which there are no mobilizable iron stores and in which signs of a compromised supply of iron to tissues, including the erythron, are noted. The more severe stages of iron deficiency are associated with anaemia.
Functional consequences of iron deficiency
The pallor of anaemia was associated with weakness and tiredness long before its cause was known. Now it is recognized that even without anaemia, mild to moderate iron deficiency has adverse functional consequences.
Iron deficiency adversely affects
- the cognitive performance, behaviour, and physical growth of infants, preschool and school-aged children;
- the immune status and morbidity from infections of all age groups; and
- the use of energy sources by muscles and thus the physical capacity and work performance of adolescents and adults of all age groups.
Specifically, iron deficiency anaemia during pregnancy
- increases perinatal risks for mothers and neonates; and
- increases overall infant mortality.
Moreover, iron-deficient humans have impaired gastrointestinal
functions and altered patterns of hormone production and metabolism.
The latter include those for neurotransmitters and thyroidal hormones which are associated with neurological, muscular, and temperature-regulatory alterations that limit the capacity of individuals exposed to the cold to maintain their body temperature. In addition, DNA replication and repair involve iron-dependent enzymes.
Bioavailability of food iron is strongly influenced by enhancers and inhibitors in the diet. Presently, there is no satisfactory in vitro method for predicting the bioavailability of iron in a meal.
Iron absorption can vary from 1% to 40%, depending on the mix of enhancers and inhibitors in the meal. Therefore, the adequacy – i. e. bioavailability – of iron in usual diets can be improved by altering meal patterns to favour enhancers, lower inhibitors, or both.
Enhancers of iron absorption include:
- haem iron, present in meat, poultry, fish, and seafood;
- ascorbic acid or vitamin C, present in fruits, juices, potatoes and some other tubers, and other vegetables such as green leaves, cauliflower, and cabbage; and
- some fermented or germinated food and condiments, such as sauerkraut and soy sauce (note that cooking, fermentation, or germination of food reduces the amountof phytates).
Inhibitors of iron absorption include:
- phytates, present in cereal bran, cereal grains, high-extraction flour, legumes, nuts, and seeds;
- food with high inositol content;
- iron-binding phenolic compounds (tannins); foods that contain the most potent inhibitors resistant to the influence of enhancers include tea, coffee, cocoa, herbal infusions in general, certain spices (e.g. oregano), and some vegetables; and
- calcium, particularly from milk and milk products.
IRON DEFICIENCY ANAEMIA
Examples of simple but effective alterations in meal patterns that
enhance iron absorption might include:
- separate tea drinking from mealtime – one or two hours later, the tea will not inhibit iron absorption because most of the food will have left the stomach;
- include in the meal fruit juices such as orange juice, or another source of ascorbic acid such as tubers, cabbage, carrots, or cauliflower;
- consume milk, cheese, and other dairy products as a between-meal snack, rather than at mealtime; and
- consume foods containing inhibitors at meals lowest in iron content, e.g. a breakfast of a low-iron cereal (bread or corn tortilla) consumed with tea or milk products; this meal pattern can provide adequate calcium without hampering iron nutrition.
Other actions that indirectly affect iron status might include:
- parasitic disease control programmes, in particular those directed to hookworm, schistosomiasis and malaria control; these programmes can enhance iron deficiency anaemia control programme effectiveness in a population with moderate to severe levels of infection; and
- incentive policies and improved farming systems that favour the development, availability, distribution, and use of foods that enhance iron absorption.
Food fortification
Several iron fortificants have been used successfully. Examples are as follows.
- Rice is fortified with a standard ferrous sulphate mix.
- Where bread and pasta are abundantly consumed, and flour is milled in only a few places, several iron fortificants have been added successfully during the milling process. Ferrous sulphate is adequate if the turnaround time between milling and bread consumption is relatively short (3 to 4 months).
.
- If flour (wheat or maize) is stored for a long time, metallic iron or ferrous fumarate have been used. When flour is used as a vehicle, the general population is the target group, but this approach does not reach infants and young children, who usually consume little bread.
Supplementation
Dosage schedules for iron supplementation
Low-birth-weight infants
A daily dosage of 2 mg iron/kg of body weight in the form of a liquid preparation
should be given to all low-birth-weight infants, starting at 2 months and
continuing to 23 months of age (universal supplementation).
Infants and children below 2 years of age
Where the diet does not include fortified foods, or prevalence of anaemia in
children approximately 1 year of age is severe (above 40%), supplements of
iron at a dosage of 2 mg/kg of body weight/day should be given to all children
between 6 and 23 months of age. There have been some reports of stained
teeth after iron supplementation with some solutions. Good oral hygiene and
the use of ferrous carbonate can prevent this condition. Ferrous carbonate is
not soluble, but present as a suspension or a solution of iron-EDTA (118).
Children above 2 years of age
The recommended WHO regimen (4) – based on daily supplementation as
summarized in Table 10 – should be followed. However, supervised weekly,
or biweekly supplementation of preschool and school-aged children and
adolescent girls has been reported to be effective in several countries
(115,119,120).
Women of childbearing age: pregnant women
A total amount of about 700-850 mg of iron is needed to meet the iron
requirements of a mother and fetus during pregnancy, at delivery, and during
the perinatal period. Iron needs during the first trimester are lower than
pre-pregnancy needs; they increase the most during the second half of the
pregnancy and especially during the last trimester. For unknown reasons,
dietary iron absorption in iron-sufficient women is reduced during the first
trimester and increased in the second half of pregnancy.
The average woman of reproductive-age needs about 350-500 mg additional
iron to maintain iron balance during pregnancy. Potentially, this iron could
be provided either from the mother’s iron stores or from iron supplements.
However, it is not reasonable to expect that this additional iron can come from
iron stores, since they very seldom reach this level in women in either
developed or developing countries (the mean iron content of the body
reserves – ferritin and haemosiderin – is often only around 200-250 mg).
Possible side-effects associated with iron medication
- Epigastric discomfort, nausea, diarrhoea, or constipation may appear with a daily dose of 60 mg or more. If these symptoms occur, supplement should be taken with meals.
- Faeces may turn black, which is not harmful. Treatment should continue.
- All iron preparations inhibit the absorption of tetracyclines, sulphonamides, and trimethoprim. Thus, iron should not be given together with these agents.
- High-dose vitamin C supplements should not be taken with iron tablets, because this would likely cause epigastric pain.
References
1. WHO/UNICEF/ICCIDD. Indicators for assessing iodine deficiency
disorders and their control through salt iodization. Geneva,
World Health Organization,1994 (unpublished document WHO/NUT/94.6;
available on request from Department of Nutrition for Health and
Development, World Health Organization, 1211 Geneva 27, Switzerland).
2. Indicators for assessing vitamin A deficiency and their application in
monitoring and evaluating intervention programmes. Geneva,
World Health Organization, 1996 (unpublished document WHO/NUT/96.10;
available on request from Department of Nutrition for Health and
Development, World Health Organization, 1211 Geneva 27, Switzerland).
3. National strategies for prevention and control of micronutrient
malnutrition. Geneva, World Health Organization, 1992
(WHA45/1992/REC/1).
4. De Maeyer EM et al. Preventing and controlling iron deficiency anaemia
through primary health care. Geneva, World Health Organization, 1989.
5. Yip R. Iron nutritional status defined. In: Filer IJ, ed. Dietary iron: birth to
two years. New York, Raven Press Ltd., 1989:19-36.
6. Scrimshaw NS. Functional significance of iron deficiency: an overview.
In: Enwonwu CO, ed. Annual Nutrition Workshop Series, Vol. III.
Functional significance of iron deficiency. Nashville, TN, Meharry Medical
College, 1990:1-13.
7. Walter T, Kovalsys J, Stekel A. Effect of mild iron deficiency on infant
mental development scores. Journal of Pediatrics, 1983, 102:519-522.
8. Lozoff B. Methodologic issues in studying behavioral effects of infant
iron-deficiency anemia. American Journal of Clinical Nutrition, 1989,
50:641-654.
9. Lozoff B et al. Behavioural abnormalities with iron deficiency. In: Pollitt E,
Leibel RL, eds. Iron deficiency: brain biochemistry and behavior. New York,
Raven Press Ltd., 1982:183-194.
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