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OriginalArticle
NutritionalStatusinPatientswithThalassemiaIntermedia
*
PhuritaThongkijpreecha,OranongKangsadalampai,BunchooPongtanakul ,andKulwaraMeksawan
Department of Food and Pharmaceutical Chemistry, Faculty of Pharmaceutical Sciences, Chulalongkorn University;
*Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Siriraj Hospital, Mahidol University.
Abstract: Malnutrition affects growth pattern, learning, treatment and quality of life in children with thalassemia.
This study aimed to assess nutritional status in patients with thalassemia intermedia. Mothods: Nutritional
status was evaluated by subjective global assessment (SGA) and anthropometric measurements. Dietary intake
was assessed by 24-hour recall. Serum total protein and albumin levels were also determined. Results: Thirty
patients with thalassemia intermedia aged between 5-15 years (12 males and 18 females) were enrolled in this
study. The results showed that these patients had normal nutrition evaluated by SGA and their serum levels of
total protein and albumin were normal. However, the anthropometric measurements including the percentages
of weight for age, weight for height, height for age, triceps skinfold thickness, and mid-arm circumference, and
body mass index for age demonstrated that these patients were both underweight and stunting. It was found
that they had average total energy intake lower than the dietary reference intake.Conclusion: The results of
anthropometric measurements in this study indicated that patients with thalassemia intermedia had growth
impairment. Although the SGA and biochemical parameters appeared normal in these patients, their dietary intakes
were apparently inappropriate. Therefore, the nutritional assessment and appropriate nutritional interventions
should be incorporated into therapeutic plans for these patients to improve growth status and clinical outcomes.
Key Words : l Nutritional status l Malnutrition l Thalassemia intermedia l Anthropometry
l Dietary intake
J Hematol Transfus Med 2011;21:167-76.
Introduction maintain normal erythropoiesis.3,4 It was reported that
Thalassemia is a hereditary disorder of hemoglobin thalassemic children had increased energy expenditure
synthesis commonly found in Mediterranean and Southeast and protein turnover,3,4 while they had the average
Asian countries, especially in Thailand. Approximately energy intake lower than the recommended daily dietary
30-40% of Thai people have thalassemia traits (20-30% allowances.5 These patients also had multiple deficiencies
with alpha-thalassemia trait and 3-9% with beta- of vitamins and minerals such as vitamin A, vitamin E,
1 4,6
thalassemia trait). Thalassemic patients have ineffective folate, vitamin B12, and zinc. Therefore, thalassemic
erythropoiesis and accelerated red cell turnover owing children are at risk of energy and nutrient deficiencies.
2 The results of malnutrition can affect the maturation
to the short life span of red blood cell, which results
in increased body demand of energy and nutrients to and growth of the children. Previous studies showed
that thalassemic patients had growth failure, delayed
rd th 7,8
Received April 23 , 2011. Accepted May 24 , 2011. puberty and underweight. Nutritional statuses in
Requests for reprints should be addressed to Kulwara Meksawan thalssemic patients should thus be evaluated.
Department of Food and Pharmaceutical Chemistry, Faculty of Phar- From the past, several techniques have been used
maceutical Sciences, Chulalongkorn University Tel. +662 218 8294 to determine nutritional status in thalassemic patients.
email: Kulwara.M@chula.ac.th
วารสารโลหิตวิทยาและเวชศาสตรบริการโลหิต ป ที่ 21 ฉบับ ที่ 3 กรกฎาคม-กันยายน 2554
168 Phurita Thongkijpreecha, et al
However, no studies proved which method was the subject was evaluated by SGA and anthropometric
best in providing information about nutritional status measurements. Blood biochemical parameters were
of these patients. In addition, most of the studies also determined.
involving nutritional status in thalassemic patients were
generally conducted for the patients who had severe Anthropometric measurements
conditions and received regular blood transfusion. There Anthropometric assessments included weight, height,
are still limited studies of nutritional status in patients, body mass index (BMI), triceps skinfold thickness
especially children, with mild to moderate conditions. (TSF), mid-arm circumference (MAC), mid-arm muscle
Therefore, this study focused on nutritional status in circumference (MAMC), arm muscle area (AMA), and
children with thalassemia intermedia who did not require arm fat area (AFA). The percentages of weight for
regular blood transfusion. The relationships of nutritional age (%W/A), weight for height (%W/H), height for age
parameters were also evaluated. The information gained (%H/A), triceps skinfold thickness (%TSF), mid-arm
from this study is beneficial in developing nutrition circumference (%MAC) were calculated based on the
recommendation to improve nutritional status, growth, reference values for children aged 1 day - 19 years old
quality of life and treatment in the children patients of Department of Health, Ministry of Public Health,
9
with thalassemia intermedia. Thailand. The percentages of TSF and MAC and the
percentiles of BMI for age were calculated based on the
SubjectsandMethods reference values of anthropometric reference data for
10
This study was conducted in 30 patients (12 girls children and adults, United States. Nutritional status
and 18 boys) from Pediatric Hematology Clinic, Siriraj of the subjects was classified by %W/A, as described
11
Hospital during the period of March to September 2010. in the Gomez’s classification, and %W/H and %H/A
The subjects who were diagnosed with thalassemia was categorized by the Waterlow’s classification.12,13
intermedia, aged between 5 - 15 years old, and had baseline Nutritional status was also evaluated by the percentages
hemoglobin between 7 - 9 g/dL were recruited into this of TSF, and MAC14 and the percentiles of BMI for age.15
study. None of them received blood transfusion and iron
chelation therapy within 3 months before enrollment. Subjective global assessment
They had no history of infection (either acute or chronic) Nutritional status of subjects was classified by SGA.
and surgical operation within 1 month before enrollment. The history of patients including weight change (during
The subjects who received medicines affecting growth 6 months and 2 weeks before participating in the study),
and nutritional status such as growth hormones and dietary intake, frequency and duration of gastrointestinal
glucocorticoid therapy were excluded from the study. symptoms (nausea, vomiting, diarrhea, constipation
Experimental protocols were explained to the subjects and loss of appetite), and functional capacity were
and their parents. The protocol was approved by the recorded. The physical examination was performed to
Siriraj Institutional Review Board (SIRB), Faculty of investigate the loss of subcutaneous fat, muscle wasting
Medicine, Siriraj Hospital, Mahidol University. The and the presence of edema of the sacral area and lower
written informed consents were obtained before the extremities. A score was assigned to each evaluation,
beginning of the study. Then, the subjects did the and nutritional status was determined based on the
questionnaires involving demographic characteristics SGA score as followed:
and a 24-hour dietary recall. Nutrition status of each
JournalofHematologyandTransfusionMedicine Vol. 21 No. 3 July-September 2011
Nutritional Status in Patients with Thalassemia Intermedia 169
SGAscore Nutritionalstatus b-thalassemia/Hb E and the others had Hb AE Bart’s
1 - 14 Normal nutrition disease (3.3%), Hb H disease (3.3%) and Hb H with
15 - 35 Mild-moderately malnourished Constant Spring (3.3%). It was found that the subjects
36 - 49 Severely malnourished were taking folic acid (100%), multivitamin (66.7%),
Determination of biochemical parameters vitamin E (63.3%) and cucurmin (13.3%). Nineteen
Venous blood sample was drawn from each subject subjects (63.3%) received the nutrition counseling for
for measuring serum albumin and total protein. thalassemic patients before participating in this study.
The results of anthropometric measurement are shown
Statistical analysis in Table 1. It was found that the mean %W/A, %H/A,
%TSF and %MAC in males were lower than the normal
Data were expressed as means ± standard errors of ranges, but the mean %W/H was in the normal range.
the mean (SEM). Correlations of nutritional parameters In females, the mean %W/A, %TSF and %MAC were
were reported as the Pearson’s correlation coefficient. lower than the normal ranges, but the mean %W/H
The significant level was set at p < 0.05. and %H/A were in the normal ranges. According to
SGA scores, most of the subjects had scores ranging
Results from 7 - 8. Only 2 persons had score of 14. Based on
The results showed that the average age of the the SGA scores, the subjects appeared to have normal
subjects was 11.9 ± 0.4 years. Most of them (90%) had nutritional status. The laboratory data of the subjects
a
Table1Anthropometric measurement of the subjects
Parameters Normalrange Males(n=12) Females(n=18)
Weight (kg) - 30.1 ± 1.8 36.5 ± 2.8
Height (cm) - 137.5 ± 3.5 146.3 ± 3.7
%W/A 90% - 110%b 82.3 ± 2.6 88.9 ± 4.6
%W/H More than 90%c 95.6 ± 2.6 92.5 ± 3.2
%H/A More than 95%c 94.2 ± 1.3 98.5 ± 1.2
TSF (mm) - 9.5 ± 0.8 12.8 ± 1.1
%TSF More than 85%d 80.8 ± 7.0 78.4 ± 5.8
MAC (cm) - 18.9 ± 0.6 20.3 ± 0.8
%MAC More than 85%d 79.6 ± 2.2 81.4 ± 2.2
MAMC (cm) - 15.9 ± 0.6 16.3 ± 0.5
2
AMA (cm) - 20.4 ± 1.6 21.4 ± 1.3
2
AFA (cm) - 8.3 ± 0.8 12.1 ± 1.3
2
BMI (kg/m ) - 15.8 ± 0.4 16.5 ± 0.7
a b 11
Values are expressed as mean ± SEM; Normal ranges were obtained from Cogill, 2003 ;
c 13 d 14
Normal ranges were obtained from Waterlow, 1972 ; Normal ranges were obtained from Ekvall et al, 2005 ;
%W/A = percentage of weight for age; %W/H = percentage of weight for height; %H/A = percentage of height
for age; TSF = triceps skinfold thickness; %TSF = percentage of triceps skinfold thickness; MAC = mid-arm
circumference; %MAC = percentage of mid-arm circumference; MAMC = mid-arm muscle circumference;
AMA = arm muscle area; AFA = arm fat area; BMI = body mass index
วารสารโลหิตวิทยาและเวชศาสตรบริการโลหิต ป ที่ 21 ฉบับ ที่ 3 กรกฎาคม-กันยายน 2554
170 Phurita Thongkijpreecha, et al
Table2Biochemical parameters of the subjectsa
b
Parameters Normalrange Males(n=12) Females(n=18)
Serum total protein (g/dL) 6.6 – 8.7 7.5 ± 0.1 8.1 ± 0.1
Serum albumin (g/dL) 3.5 – 5.5 4.8 ± 0.1 4.7 ± 0.1
a b
Values are expressed as mean ± SEM; Normal ranges were obtained from laboratory unit, Siriraj Hospital.
are presented in Table 2. The results showed that the range, while that in males was in the range. In both
subjects had the mean serum levels of total protein and genders, the percentages of energy distribution from
albumin in the normal ranges. protein were higher than the recommended ranges. The
The results of nutritional status classified by %W/A, percentage of energy distribution from fat in male was
%W/H and %H/A are presented in Table 3. According in the recommended range whereas that in female was
to %W/A, 11 subjects (36.7%) were well nourished, higher than the recommendation. The results showed
12 subjects (40.0%) were mildly malnourished and 7 that protein intake in both males and females were
subjects (23.3%) were moderately malnourished. Based higher than the recommendation.
on %W/H, 50% of the subjects were well nourished, and The correlations of nutritional parameters are presented
mild malnutrition was found in 46.7% of the subjects. in Table 6. It was found that %W/A of the subjects
According to %H/A, 63.3% of the subjects were well was significantly correlated with weight (R = 0.755, p
nourished, 26.7% and 10.0% of the subjects were classified < 0.001), height (R = 0.492, p = 0.006), BMI (R = 0.824,
as mild and moderate malnutrition respectively. No p < 0.001) and TSF (R = 0.703, p < 0.001). Moreover,
subject was in severely malnourished state when the it was significantly correlated with MAC (R = 0.774,
evaluations were made by %W/A, %W/H and %H/A. p < 0.001), MAMC (R = 0.639, p < 0.001), AMA (R =
In this study, nutritional status of subjects classified by 0.657, p < 0.001) and AFA (R = 0.802, p < 0.001). The
%TSF and %MAC are presented in Table 4. According results showed that %W/H was correlated with BMI (R
to %TSF, 40% of the subjects were in normal nutrition, = 0.803, p < 0.01), TSF (R = 0.500, p = 0.005), and MAC
but 46.7% of the subjects were classified as severe (R = 0.555, p = 0.01). In addition, it was significantly
malnutrition. The remaining subjects were malnourished correlated with MAMC (R = 0.461, p < 0.01), AMA (R =
in different degrees. Based on %MAC, 30% of the subjects 0.483, p = 0.007) and AFA (R = 0.580, p = 0.001). This
had normal nutrition whereas 26.7% of the subjects were study found the correlations between %H/A and weight
severely malnourished. According to the percentiles (R = 0.648, p < 0.001), height (R = 0.708, p < 0.001), TSF
of BMI for age, 50% of the subjects were underweight. (R = 0.471, p = 0.019) and MAC (R = 0.481, p = 0.007).
Only 1 male subject was overweight. The study also found the correlations between %H/A
The dietary intakes of the subject were assessed and MAMC (R = 0.376, p = 0.041), AMA (R = 0.373, p
by 24-hour recall. In this study, the results of average = 0.042), and AFA (R = 0.501, p = 0.005).
dietary intakes of the subjects are shown in Table 5. It Based on the results, %TSF showed significant
was found that average total energy intake in males and correlations with weight (R = 0.439, p = 0.015), BMI
females were lower than the dietary reference intake (R = 0.611, p < 0.001) and TSF (R = 0.812, p < 0.001).
for Thais 2003 recommended by Department of Health, It appeared that %TSF was also correlated with MAC
Ministry of Public Health, Thailand.16 According to the (R = 0.533, p = 0.002) and AFA (R = 0.745, p < 0.001).
results, the percentage of energy distribution obtained from According to %MAC, it was correlated with weight (R
carbohydrate in females was lower than the recommended = 0.624, p = 0.001), BMI (R = 0.853, p < 0.001), TSF (R
JournalofHematologyandTransfusionMedicine Vol. 21 No. 3 July-September 2011
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