Nutrition Corner

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

Hello (Welcome)

Did you know that nutrition can play a vital role for people who live with thalassaemia? Well, it can!

Advice for patients

Although, nutritional interventions will not reduce the number of blood transfusions your need or cure the condition, it can help you maintain a healthy body weight. In addition, good nutrition can help manage some of the symptoms and prevent them becoming worse, as well as reduce the risk of developing chronic diseases like diabetes etc. that can affect your overall health and well-being.

The aim of this blog is to provide nutritional advice that is tailored to the specific needs of people who live with different forms of thalassaemia. I hope this not only helps to improve your quality of life, but that it also helps to prevent/ reduce other conditions from developing.

Disclaimer- this is general nutrition advice. Everyone will have different nutritional needs that is specific for them. For nutritional advice that is tailored to you, you can request an appointment with a dietitian.

This article will include:

      • An overview of iron in patients at risk of iron overload
      • Nutrients you should be eating more of
      • Nutrients you should be eating less of
      • What supplements should I take?
      • Healthy food swaps and tips
  1. An overview of iron in patients at risk of iron overload

IRON

WHAT IS IRON?

Iron is a mineral that is essential for the formation of haemoglobin in red blood cells; haemoglobin is the oxygen carrying protein that 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 PEOPLE WITH THALASSAEMIA?

Regular long term blood transfusions can leave patients with a build-up of iron in body tissues that can result in organ injury due to iron overload. People with thalassaemia who are not transfusion dependent, can also develop iron overload due to increased intestinal dietary iron and this can accumulate to levels comparable with transfusion-dependent patients.

The need for a low iron diet:

For this reason, it is recommended that transfused and non-transfused patients to have a low iron diet. That means you have to eat less amounts of foods that are high in iron. You also have to decrease your intake of foods supplements with iron as well as food that increase iron absorption such as foods high in vitamin C. Therefore, patients who are not transfused or do not take iron chelation medication should be extra careful with the iron content in their diets.

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.

HOW DO I KNOW HOW MUCH IRON IS IN FOODS?

There are a number of ways to check for the amount of iron in foods. Reading food labels and ingredient lists may possibly give an indication of the types of food that contain iron. Do remember, that the nutritional information may not directly tell you how much iron is in the product/food, but a helpful tool is the ‘MyFitnessPal’ app that you can use to scan the food and it will break down the nutritional value of the food for you may google it.

Keep the iron under 10 mg/day for children under 10 years old, and under 18 mg/day for those who are 11 years old and older.

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

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, ingredient lists and nutritional content of foods before consumption

IRON SUPPLEMENTS SHOULD NOT BE TAKEN BY ANYONE WITH THALASSAEMIA!

  1. Nutrients you should be eating more of:

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 (strength) 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, for this reason, it is recommended that you take calcium supplements. For those people who are lactose intolerant, make sure to buy the lactose free options that are fortified with 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- please note that although spinach is a good source of calcium, it is also high in iron and therefore patients following a low iron diet should have less spinach in their diet. Other foods such as fortified soya products and fish eaten with the bones such as sardines, salmon and whitebait all contain food sources of calcium. 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 (balance) which is useful for those people who also have diabetes. Research has shown, 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 taking it as the intake of 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
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

We all need oxygen to survive! However sometimes, within our body’s, oxygen can be converted into chemical substances known as ‘free radicals’. Under controlled conditions, free radicals can have important uses in the body. Uncontrolled free radical reactions, however, can result in great damage and lead to disease.

Antioxidants are important in any diet, because as their name suggests, they have a role to play in keeping the amount of free radicals in check, in so doing antioxidants prevent oxidative damage in the body. Antioxidants therefore plays 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. It is best to add the olive oil towards the end of cooking, after the food is cooked or on raw vegetables because heat can destroy the vitamin E content of food.

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

 

  1. Nutrients you should be eating less of

Types of food 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
  1. What supplements should I take?

It is important that you aim to get your vitamins and minerals from the foods that you eat. The EAT WELL GUIDE can help you to make healthier food choices. Always follow the recommendations from your consultant with regards to the use of supplements, when your food intake is less than optimal.

*Ensure to check with your GP before intake*

    • Folic acid: is recommended for thalassaemia intermediate patients 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 (without iron) is suggested
  1. Healthy food swaps

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 eaten in moderation 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 INTO YOUR DAILY ROUTINE

    • Drink tea between meals rather than with your meals especially after foods that are high in iron and vitamin C (coffee should be limited to one a day as the caffeine can thin bones as it may interfere with calcium absorption)
    • Add milk or dairy products into your meals e.g. lasagne, moussaka
    • Aim to sit in the sun for around 20 minutes at a time, as the sun is the main source of Vitamin D and will help to boost Vitamin D intake.

Turmeric is an antioxidant that has anti-inflammatory properties and is a great addition to meals. You can season your food with turmeric and add great flavour to your meals. Curcumin, which is the active polyphenol (substance) in turmeric, has been found to significantly reduce serum levels of non-transferrin bound iron, therefore curcumin has a beneficial effect on reducing excess iron. Much research has been done showing a positive benefit to using curcumin however, it is important to note that curcumin supplements are not a treatment for iron overload, and it is vital to continue to use your iron chelation medicine. Curcumin supplements should be discussed with your haematology team before consumption.

This article is intended to provide generic nutritional advice for patients living with thalassaemia, and it is important to note that everyone has their own nutritional needs that is specific to them. For nutritional advice that is tailored to you, it is recommended that you be referred to a registered dietician.

References:

  1. Mohammadi, E., Tamaddoni, A., Qujeq, D., Nasseri, E., Zayeri, F., Zand, H., Gholami, M. and Mir, S.M., 2018. An investigation of the effects of curcumin on iron overload, hepcidin level, and liver function in β‐thalassemia major patients: A double‐blind randomized controlled clinical trial. Phytotherapy Research32(9), pp.1828-1835.
  2. Srichairatanakool, S., Thephinlap, C., Phisalaphong, C., Porter, J.B. and Fucharoen, S., 2007. Curcumin contributes to in vitro removal of non-transferrin bound iron by deferiprone and desferrioxamine in thalassemic plasma. Medicinal chemistry3(5), pp.469-474.
  3. Zijp, I.M., Korver, O. and Tijburg, L.B., 2000. Effect of tea and other dietary factors on iron absorption. Critical reviews in food science and nutrition40(5), pp.371-398.
  4. Swe, K.M.M., Abas, A.B., Bhardwaj, A., Barua, A. and Nair, N.S., 2013. Zinc supplements for treating thalassaemia and sickle cell disease. Cochrane Database of Systematic Reviews, (6).
  5. Thalassemia Standard of Care Guidelines: Nutrition – Thalassemia.com
  6. Living with Thalassemia: Nutrition and Diet – Thalassemia.com
  7. Goldberg, E.K., Neogi, S., Lal, A., Higa, A. and Fung, E., 2018. Nutritional deficiencies are common in patients with transfusion-dependent thalassemia and associated with iron overload. Journal of food and nutrition research (Newark, Del.)6(10), p.674.
  8. Fuchs, G.J., Tienboon, P., Linpisarn, S., Nimsakul, S., Leelapat, P., Tovanabutra, S., Tubtong, V., DeWier, M. and Suskind, R.M., 1996. Nutritional factors and thalassaemia major. Archives of disease in childhood74(3), pp.224-227.