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 Table of Contents  
Year : 2017  |  Volume : 6  |  Issue : 1  |  Page : 26-29

Impact of diet counseling in thalassemic children and its response on nutritional status

1 Department of Pediatrics, JSS Hospital, JSS Medical College, Mysore, Karnataka, India
2 Department of Pediatrics, JSS Hospital, Mysore, Karnataka, India

Date of Web Publication15-Feb-2017

Correspondence Address:
Pavana Sreenivasan
Flat No 504, Block 2, Skyline City Apartments, Nagarbhavi, Bengaluru - 560 072, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijhas.IJHAS_71_16

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OBJECTIVE: The objective of this study is to identify some nutritional deficiencies in thalassemic patients on regular transfusion therapy and to assess the improvement after dietetic modification.
MATERIALS AND METHODS: This cross-sectional hospital-based study was conducted in thalassemia patients admitted to the Pediatric Ward of JSS Hospital, Mysore for 6 months. Those with any concurrent illnesses that could interfere with dietary intake were excluded. Dietary data were collected by 24 h recall method. The total amount of energy, protein, fat, calcium, iron, phosphorus, fiber, and carbohydrates consumed was estimated. Dietary counseling was then done to meet the recommended daily allowance of deficient nutrients for that specific age group during the next follow-up to the hospital. Using the similar 24-h recall method, the total amount of energy, protein, fat, calcium, iron, phosphorus, fiber, and carbohydrates consumed was again estimated and assessed after 6 months.
ETHICAL CLEARANCE: Institutional Ethical Clearance was taken from the ethics committee before commencing the study. An informed written consent was taken from the parents before starting data collection.
RESULTS: Before diet counseling, the study showed that all children consuming iron deficient diet suffered from deficiencies of calories, fiber, calcium, and phosphorus. All children seemed to consume adequate levels of protein, fat, and carbohydrates. On the 6-month review, these deficiencies continued to persist, but the nutritional value of the diet seemed to show an improvement when compared to their pre-counseled values.
CONCLUSION: The emphasis on iron deficient diets in thalassemic children causes associated deficiencies. Emphasis on diet rich in these elements with follow-up dietary counseling during each visit is required to maintain a balanced nutrition.

Keywords: Diet, iron overload, nutrition, thalassemia

How to cite this article:
Sreenivasan P, Mahtani AU, Ravi M D, Gowda K. Impact of diet counseling in thalassemic children and its response on nutritional status. Int J Health Allied Sci 2017;6:26-9

How to cite this URL:
Sreenivasan P, Mahtani AU, Ravi M D, Gowda K. Impact of diet counseling in thalassemic children and its response on nutritional status. Int J Health Allied Sci [serial online] 2017 [cited 2022 Jun 27];6:26-9. Available from: https://www.ijhas.in/text.asp?2017/6/1/26/200201

Thalassemia is an inherited autosomal recessive disorder of hemoglobin synthesis resulting from an alteration in the globin chain production due to a defect in intron/exon splicing or missense/nonsense mutation. It can either cause a decrease in the production (thalassemia minor) or a total absence of globin chain synthesis (thalassemia major), the latter being more severe.[1] It is diagnosed in early life when children present with anemia, hepatosplenomegaly, jaundice, and bone changes as described originally by Cooley and Lee.[2] With transfusion therapy, they achieve adulthood but suffer its consequences of chronic iron overload.[3] Because the body lacks any effective means for excreting excess iron, transfusion therapy results in a progressive accumulation of iron, which may be augmented by its absorption from diet as a result of increased ineffective erythropoiesis. Eventually, liver, pancreas, heart and other organs develop an extensive iron injury. The severity of toxicity seems to be related to magnitude of the body iron burden.[4] Hence, without treatment or dietary modification, toxic levels are reached easily. Therefore, in addition to chelation therapy, they are advised iron deficient diet. How these modifications impact other nutrient intake, is not clear. The present study was geared to look at this issue.

  Materials and Methods Top

This cross-sectional hospital-based study was conducted in thalassemia patients admitted to Pediatric Department of JSS Hospital, Mysore. The study was carried out for the duration of 6 months. Thirty children belonging to various age groups were chosen starting from 6 months to 18 years.

Ethical clearance

Institutional Ethical Committee clearance was taken before the commencement of the study. Informed written consent was obtained from one of the parents/guardians before collecting the data.

Thalassemia patients with comorbidities such as diabetes mellitus, sepsis, nephrotic syndrome, cirrhosis, and sideroblastic anemia that can modify the iron deficient diet were excluded from the study. Anthropometric measurements such as height, weight, head, and mid-arm circumferences were measured using standard methods.[5]


Height was measured in the Pediatric Ward of JSS Hospital. A standard height chart was used and was measured in centimeters.


Weight was measured using a standard weighing scale and was measured in kilograms.

Head circumference

Head circumference was measured using a standard measuring tape. It was only done for children until age 5 years and was measured in centimeters.

Mid arm circumference

Mid-arm circumference was measured using a standard measuring tape. It was done for children only until the age of 5 years and was measured in centimeters.

Body mass index

Body mass index (BMI) was calculated and compared with the standard BMI chart to assess the nutritional status of the child.

Calculation of calories and other parameters

Intake of food items was measured using different sized bowls which had milliliter and ounces as their unit of measurement. If chapatis or paranthas was also included in the list then big was classified as 6 inches, and small was classified as 4 inches. This was compared to a food chart which was procured from the dietician at JSS Hospital.

Data collection

The dietary data were collected by 24-h recall method. Dietary counseling with the dietician was done to ensure consumption of iron deficient diet and also to educate the child's parents/guardians about intake of food rich in other essential nutrients. The total amount of calories, protein, fat, carbohydrate, fiber, calcium, phosphorous, and iron consumed was estimated. The diet was evaluated based on the reference ranges listed in [Table 1], and the excess/deficit of nutrients consumed was estimated [6],[7] After a month, when the patient came for regular follow-up, dietary data were collected employing the same 24 h recall method, and the two data were compared to check for improvement in nutritional status. Statistical analysis was not done for the study, as the statistician did not feel the need for it.
Table 1: Required nutrition for children of various age groups

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  Results Top

Before diet counseling, it was seen that there was a deficit in calories, calcium, fiber, phosphorus in the iron deficient diet of all children, indicated by the negative values in [Table 2]. All children consumed diet with adequate levels of protein, fat and carbohydrates. After diet counseling, the deficit in calories was −397.37 as opposed to −54.34 before counseling. The deficit in calcium was seen to be −271.05, improved from −319.15 before counseling. A similar trend is seen in fiber and phosphorus levels as well. These children seemed to consume adequate levels of protein, fat, and carbohydrates.
Table 2: Dietary nutrients calculated from thalassemic children before and after dietary counseling

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  Discussion Top

Iron overload is a major problem in thalassemics on transfusion therapy. To prevent iron from accumulating, these patients are advised an iron free diet and are given chelators such as deferasirox to bind to free iron and prevent toxicity.

Administration of an iron free diet also has an effect on the nutritional status of these patients.[8] Adhering to this diet will not only decrease iron levels in the body but will also decrease levels of other essential nutrients which will be required by the body to carry out various functions. For example, avoiding spinach in the diet, not only decreases dietary iron, but also other essential nutrients such as Vitamin K, Vitamin A, calcium, potassium, Vitamin C, dietary fiber, protein, and zinc.[9]

Nutritional deficiency is considered as a red flag for the child as it is closely linked with growth and development delay. Zinc playing an important role, whose deficiency leads to stunted growth, is highly required by thalassemic children. This deficit is seen to be more prevalent in these children. An additional zinc supplementation in their diet is thus a necessity, which ends up improving bone mineral content as well.[10] In thalassemic children, the amounts of nutrients that need to be consumed are on a higher side when compared to a normal healthy child. This could be attributed to the continuous source of energy requiring to be supplied for effective hemoglobin and red blood cell turnover. Short stature and malnutrition are highly prevalent among these children and adolescents up to 18 years, more so malnutrition and stunted growth sets in much earlier if transfusion and chelation therapy was started at a younger age.[11] We observed a similar trend in our study as energy and protein deficits were higher among the older age group who received transfusion therapy for a longer time.

Journal of the Academy of Nutrition and Dietetics published a paper back in January 2012, which shed light on inadequate dietary intake in thalassemic children. They found that 30% of the subjects were deficient in Vitamins A, D, E, and K along with deficiencies in micronutrients such as calcium, magnesium, and folate. Furthermore, the deficiencies and dietary inadequacy increased with an increase in age group.[12] Our study also reflects similar findings and showed that the mean energy, phosphorus, and calcium intake were deficient when calculated among all children. Thus, from the above findings, we can conclude that to lower the burden of nutritional deficiencies in thalassemic children it is important to address the issue as early as possible and tackle it by ensuring adequate diet counseling along with appropriate nutritional supplementation.

On the initial assessment of the diet, it was found that thalassemic children were deficient in most of the nutrients and minerals required for healthy growth and development. These included calcium, calories, fiber, and phosphorus. Diet counseling was provided for these patients when they came for regular follow-up/blood transfusions. The diet counseling done was to attempt to increase essential nutrients intake as well as to keep the iron levels low.

On comparing the data before and after the intervention, it was found that there was an improvement in the nutritional status of the patients, but the required daily allowance was not met. The mean calorie intake was however found to be more prominent before and after counseling, showing the need for continuous dietary monitoring. Dietetic manipulation may, therefore, be inadequate to correct nutritional deficiencies in this population. The importance of nutritional assessment and correction of deficiencies with appropriate supplementation may, therefore, be a requirement in these children.

  Conclusion Top

Emphasis on iron restriction normally dominates diet counseling in thalassemic children. It is possible that other nutrients become deficient in this process. The present study demonstrated a lack of attainment of required nutrients by the thalassemic children and the need for continuous dietary assessment and counseling to attain a balanced nutrition.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Ghai OP, Paul VK, Bagga A. Textbook of Essential Pediatrics. 7th ed. New Delhi: Satish Kumar Jain; 2009.  Back to cited text no. 1
Cooley TB, Lee P. A series of cases of splenomegaly in children with anemia and peculiar bone changes. Trans Am Pediatr Soc 1925;37:29-30.  Back to cited text no. 2
Lassman MN, O'Brien RT, Pearson HA, Wise JK, Donabedian RK, Felig P, et al. Endocrine Evaluation in Thalassemia Major. New Haven, Connecticut: Department of Pediatrics, Medicine and Laboratory Medicine, Yale University School of Medicine; 2005.  Back to cited text no. 3
Brittenham GM, Griffith PM, Nienhuis AW, McLaren CE, Young NS, Tucker EE, et al. Efficacy of deferoxamine in preventing complications of iron overload in patients with thalassemia major. N Engl J Med 1994;331:567-73.  Back to cited text no. 4
WHO Expert Committee on Physical Status: The Use and Interpretation of Anthropometry. Geneva; 1993. Available from: http://www.who.int/childgrowth/publications/physical_status/en/.  Back to cited text no. 5
Chheda MK. Practical Aspects of Pediatrics. 5th ed. Bhalani Publishers; 2009.  Back to cited text no. 6
Kleinman RE, editor. Pediatric Nutrition Handbook. 6th ed. USA: American Academy of Pediatrics Committee on Nutrition; 2009.  Back to cited text no. 7
UCSF Benioff Children's Hospital, Oakland, Northern California Comprehensive Thalassemia Center. Living with Thalassemia; Nutrition and Diet. 2012. Available from: http://www.thalassemia.com/nutrition-and-diet.aspx#gsc.tab=0.  Back to cited text no. 8
Available from: http://nutritiondata.self.com/facts/vegetables-and-vegetable-products/2626/2. [Last accessed on 2014].  Back to cited text no. 9
Fung EB, Kwiatkowski JL, Huang JN, Gildengorin G, King JC, Vichinsky EP. Zinc supplementation improves bone density in patients with thalassemia: A double-blind, randomized, placebo-controlled trial. Am J Clin Nutr 2013;98:960-71.  Back to cited text no. 10
Mirhosseini N, Shahar S, Ghayour-Mobarhan M, Tavallaei S. Factors affecting nutritional status among pediatric patients with transfusion-dependent beta thalassemia. Mediterranean J Nutr Metab 2013;6.  Back to cited text no. 11
Fung EB, Xu Y, Trachtenberg F, Odame I, Kwiatkowski JL, Neufeld EJ, et al. Inadequate dietary intake in patients with thalassemia. J Acad Nutr Diet 2012;112:980-90.  Back to cited text no. 12


  [Table 1], [Table 2]


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