Zoe’s Nutrition Corner

Nutrition can play a vital role for people who have Thalassaemia.

Although nutritional interventions will not cure the condition of the comorbidities that come along with it, it can help to manage the symptoms and prevent them becoming worse.

This article will cover:

What should I eat more of & what nutrients should I focus on?

  • What should be eaten less often (for non-transfused patients)?
  • Should I take supplements?
  • Diabetes Nutrition
  • Healthy food swaps and tips
  • Meal ideas

1. What should I eat more of & What nutrients should I focus on?

IRON

WHAT IS IRON?

Iron is essential for the formation of Haemoglobin in red blood cells; Haemoglobin binds oxygen and transports it around the body. Iron is also an essential component in many enzyme reactions and has an important role in the immune system.

IRON FOR PATIENTS WITH THALASSAEMIA?

Blood transfusions leave patients with progressive iron deposition in body tissues that can result in organ injury due to iron overload. People with Thalassaemia that do not have transfusions, can also develop iron overload due to increased intestinal dietary iron and this can accumulate to levels comparable with transfusion-dependent patients. For those that are transfused with chelation therapy, a low iron diet is unnecessary and may decrease the quality of life for some patients; so, it is ideal for these patients to eat a moderate iron diet. It is recommended for non-transfused patients to have a low iron diet and have a lower intake of foods that are high in iron, iron supplemented foods and foods high in vitamin C as this increases iron absorption.

Iron has two forms; haem iron which is found in meat and meat products e.g. milk and non-haem iron which is found in non-meat foods e.g. leafy green vegetables. Haem iron is more easily absorbed compared to non-haem iron as non-haem iron needs to be dissolved before uptake. 

In general, a low iron diet would contain cereals (maize, whole-grain flour, beans) and root vegetables with little meat, fish or foods rich in vitamin C. A moderate iron diet would consist of cereals and root vegetables but would also contain some vitamin C-rich foods and meat. High iron diets contain generous quantities of meat, poultry and fish.

However, it is important for non-transfused patients to not avoid iron rich foods completely as this can affect the intake of other nutrients such as zinc.

Foods that decrease non-haem iron absorption and should be consuming more Why?
Dairy products High in calcium

Reduces haem iron absorption

Tea Contain tannins which reduce iron absorption
Cereals-Wheat bran, maize, oats, rice and soy (which are in most foods) Decrease the iron absorbed into our body and fight the effect of vitamin C which aids iron absorption
Plant based foods such as dark chocolate, peanut butter, hemp seeds, artichoke High Iron

HOW DO I KOW HOW MUCH IRON IS IN FOODS?

Check food labels as they might state that the food product/ingredients are high in iron. The nutritional information does not usually tell you how much iron is in the product/ food, but you can use the app ‘MyFitnessPal’ to scan the food and it will break down the nutritional value of the food for you of google it.

The following table can give you can idea of the foods that have more and less iron.

Food Milligrams of iron
per serving
Breakfast cereals, fortified with 100% of the DV for iron, 1 serving 18
Oysters, eastern, cooked with moist heat, 3 ounces 8
White beans, canned, 1 cup 8
Chocolate, dark, 45%–69% cacao solids, 3 ounces 7
Beef liver, pan fried, 3 ounces 5
Lentils, boiled and drained, ½ cup 3
Spinach, boiled and drained, ½ cup 3
Tofu, firm, ½ cup 3
Kidney beans, canned, ½ cup 2
Sardines, Atlantic, canned in oil, drained solids with bone, 3 ounces 2
Chickpeas, boiled and drained, ½ cup 2
Tomatoes, canned, stewed, ½ cup 2
Beef, braised bottom round, trimmed to 1/8” fat, 3 ounces 2
Potato, baked, flesh and skin, 1 medium potato 2
Cashew nuts, oil roasted, 1 ounce (18 nuts) 2
Green peas, boiled, ½ cup 1
Chicken, roasted, meat and skin, 3 ounces 1
Rice, white, long grain, enriched, parboiled, drained, ½ cup 1
Bread, whole wheat, 1 slice 1
Bread, white, 1 slice 1
Raisins, seedless, ¼ cup 1
Spaghetti, whole wheat, cooked, 1 cup 1
Tuna, light, canned in water, 3 ounces 1
Turkey, roasted, breast meat and skin, 3 ounces 1
Nuts, pistachio, dry roasted, 1 ounce (49 nuts) 1
Broccoli, boiled and drained, ½ cup 1
Egg, hard boiled, 1 large 1
Rice, brown, long or medium grain, cooked, 1 cup 1
Cheese, cheddar, 1.5 ounces 0
Cantaloupe, diced, ½ cup 0
Mushrooms, white, sliced and stir-fried, ½ cup 0
Cheese, cottage, 2% milk fat, ½ cup 0
Milk, 1 cup 0

SUMMARY:

  • Dietary iron should be monitored by all patients
  • Drinking tea with meals helps to reduce iron absorption
  • Check labels and nutritional content of foods before consumption

IRON SUPPLEMENTS SHOULD NOT BE TAKEN BY ANYONE WITH THALASSAEMIA!

CALCIUM

 HOW DOES CALCIUM HELP?

Foods high in calcium should be incorporated in the diet as it is important for bone development and management. It strengthens bones by aiding its structure and rigidity and enables bones to store minerals for the body to use which is particularly important for children and their development. Calcium also reduces haem iron absorption and it can be useful to try to have a glass of milk with meals or incorporate milk into cooking.

Osteoporosis can be an issue some people with Thalassaemia therefore calcium is a crucial component in the diet to strengthens bones and improve bone health. Vitamin D works alongside calcium to ensure calcium is absorbed by the body and is essential for efficient calcium utilisation by the body, therefore it is recommended to take supplements. For those that are lactose intolerant, there are lots of lactose free options that are still high in calcium.

FOOD SOURCES OF CALCIUM?

Foods high in calcium: Milk, cheese and other dairy products provide about half of the calcium in the UK diet. Bread is also an important source in the UK because most bread flour (though not whole meal) is fortified with calcium by law. Calcium is also provided by some green leafy vegetables such as broccoli and cabbage (but not spinach but these should be minimized as they are high in iron), fortified soya products and fish eaten with the bones such as sardines, salmon and whitebait. If you are lactose intolerant, lactose free foods are still high in calcium.

ZINC

 WHY IS ZINC IMPORTANT FOR PEOPLE WITH THALASSAEMIA?

Zinc, unlike iron, is not stored in the body, therefore it must be consumed as part of the diet. It is essential for optimal immune function, optimal growth, bone health / bone density, pubertal development and glucose homeostasis which is useful for those with diabetes. From research, it is found that a lot of people with Thalassaemia are deficient in Zinc and it is particularly important in patients receiving transfusions; a Zinc supplement is an option, however, please consult with your GP before intake as Zinc can affect the absorption of other nutrients.

FOODS SOURCES OF ZINC?

Foods that are high in zinc: Mainly found in meat and present in milk, cheese, eggs, shellfish, wholegrain cereals, nuts and pulses. For cereals and pulses, zinc’s availability is limited by phytates.

Phytate (in cereals and pulses), fibre, tannins (in tea) and calcium can all bind to non-haem iron in the intestine, which reduces iron absorption.

The following table can give you can idea of the foods that have more and less Zinc.

Food Milligrams (mg)
per serving
Oysters, cooked, breaded and fried, 3 ounces 74.0
Beef chuck roast, braised, 3 ounces 7.0
Crab, Alaska king, cooked, 3 ounces 6.5
Beef patty, broiled, 3 ounces 5.3
Pork chop, loin, cooked, 3 ounces 2.9
Baked beans, canned, plain or vegetarian, ½ cup 2.9
Breakfast cereal, fortified with 25% of the DV for zinc, 1 serving 2.8
Chicken, dark meat, cooked, 3 ounces 2.4
Pumpkin seeds, dried, 1 ounce 2.2
Yogurt, fruit, low fat, 8 ounces 1.7
Cashews, dry roasted, 1 ounce 1.6
Chickpeas, cooked, ½ cup 1.3
Cheese, Swiss, 1 ounce 1.2
Oatmeal, instant, plain, prepared with water, 1 packet 1.1
Milk, low-fat or non-fat, 1 cup 1.0
Almonds, dry roasted, 1 ounce 0.9
Kidney beans, cooked, ½ cup 0.9
Chicken breast, roasted, skin removed, ½ breast 0.9
Cheese, cheddar or mozzarella, 1 ounce 0.9
Peas, green, frozen, cooked, ½ cup 0.5

VITAMIN E

Paradoxically, oxygen is essential for life but is also lethal! This is because normal oxygen molecules can convert into different chemical forms known as ‘free radicals. When the activity of free radicals is harnessed and controlled, they have important uses in the body. Uncontrolled free radical reactions, however, can do great damage and lead to disease.

Antioxidants are important in any diet, because as their name suggests, they prevent oxidative damage in the body. In doing so, they play an important role in the prevention of diseases such as coronary heart disease and cancer. In Thalassaemia, because of the excess iron in the body, there is a higher risk of oxidative damage.

Vitamin E is an important antioxidant and has a role in immune function.

SOURCES OF VITAMIN E

Vitamin E is mainly found in vegetable oils such as olive oil and safflower oil. The best one to use is probably olive oil because it can help to protect against heart disease. Add it towards the end of cooking, after the food is cooked or on raw vegetables because heating can destroy the vitamin.

The following table can give you can idea of the foods that have more and less Vitamin E.

Food Milligrams (mg)
per serving
Wheat germ oil, 1 tablespoon 20.3
Sunflower seeds, dry roasted, 1 ounce 7.4
Almonds, dry roasted, 1 ounce 6.8
Sunflower oil, 1 tablespoon 5.6
Safflower oil, 1 tablespoon 4.6
Hazelnuts, dry roasted, 1 ounce 4.3
Peanut butter, 2 tablespoons 2.9
Peanuts, dry roasted, 1 ounce 2.2
Corn oil, 1 tablespoon 1.9
Spinach, boiled, ½ cup 1.9
Broccoli, chopped, boiled, ½ cup 1.2
Soybean oil, 1 tablespoon 1.1
Kiwifruit, 1 medium 1.1
Mango, sliced, ½ cup 0.7
Tomato, raw, 1 medium 0.7
Spinach, raw, 1 cup 0.6

2. What should be eaten less often for non-transfused patients?

 

Foods that increase non-haem iron absorption and should be consumed less Why?
Meat (poultry, red meat, fish) and grain products (quinoa), liver, oysters, liver, pork, beans, beef, peanut butter, tofu High in haem iron and increase absorption iron
Juice, fruit (citrus fruits have the most vitamin C e.g. oranges, grapefruit) and vegetables High in vitamin C which increases iron absorption
Sauerkraut, pickled onions, turnips and carrots as well as fermented soy products (e.g. miso and soy sauce) and alcohol Increases iron absorption
Flour tortillas, infant cereal, cream of wheat, cereals: All Bran, Life, Raisin Bran, Special K, 100% Bran, Rice Krispies, Cornflakes, Shreddies Increases iron absorption and fortified with iron

 

3. Should I take supplements?

 *Ensure to check with your GP before intake*

  • Folic acid: this will help with anaemia and it is also important for women to supplement folic acid to prevent developmental abnormalities of babies in the womb.
  • Vitamin D: Vitamin D is mainly absorbed from the sun, so since the UK weather is not as sunny and holidays are unlikely this year, it is recommended for all to take a vitamin D supplement. Vitamin D is also essential for calcium absorption which is vital for bone health and strength
  • Multivitamin is suggested (without iron is suggested) but it is more important to get nutrients from food

HOWEVER, I cannot stress this enough, this is so important to get your vitamins and minerals through the diet itself first and use supplements if you are struggling to meet the recommended intake as suggested by your haematology team.

4. Diabetes Nutrition

People with Diabetes should be eating a healthy balanced diet; this means that you should eat from all the food groups including carbohydrates, protein and fat. But of course, the diet must be in line with the other requirements specific for those with Thalassaemia.

Macronutrient Examples
Carbohydrates Bread, pasta, cereal, potatoes
Fat Egg yolk, nuts, dark chocolate, avocado
Protein Chicken, salmon, pork, tuna

Type 1 Diabetes:

  • Regulate amount dietary carbohydrates

Type 2 diabetes:

  • Moderate fat intake is recommended
  • Diets rich carbohydrates that have a low glycaemic index which include soy products,beans, fruit, milk, pasta, grainy bread, porridge (oats) and lentils.
  • Replace butters with margarines and limit use of coconut oil
  • Weight control is also important

5. Healthy food swaps and tips

 Changing habits such as the foods you normally eat can be difficult. However, by making small changes and replacing some of the foods you normally eat with the foods that are recommended, it can make a big difference. 

Food that should be moderated Replacement
Beef mince Turkey mince
Fruits that are high in Vitamin C e.g. oranges, grapefruit, cantaloupe, watermelon, pineapple, mango, berries Cherries, apples, plums, apricots
Vegetables that are high in Vitamin C e.g. broccoli, spinach, peppers, potatoes, watercress, tomatoes, carrots and avocado Mushrooms, cucumber, celery and beetroot
Darker parts of chicken White parts of chicken
Alcohol Non- alcoholic cocktails, diet fizzy drinks etc
Full fat milk and dairy products Reduced fat options
Fruit Juice Squash
Cereals Oats

Easy tips to incorporate in your daily routine

  • Drink tea with most meals (coffee should be limited to one a day as the caffeine can thin bones as it interferes with calcium absorption)
  • Add milk or dairy products into your meals e.g. lasagna, moussaka
  • Season your food with oregano and turmeric
  • If you can sit in the sun for around 20 minutes, this will help your Vitamin D intakes as the sun is the main source

  6. Meal ideas

 Breakfast:

 

Lunch

Dinner