1. Diet and Haemochromatosis On behalf of The Haemochromatosis Society
Presentation by Cristina Testa BSc Hons RD
Specialist Oncology/Stroke Dietitian at Northampton General Hospital
As part of Northamptonshire Healthcare NHS Foundation Trust

2. Introduction Learning about you: – Haemochromatosis
Inherited genetic disorder, 3 different HEF types- Homozygosity (a genetic defect on both chromosomes (C282Y/C282Y), Hetrozygosity (a genetic defect on any chromosomes (H63D/wt)
Background to iron absorption in the body
Hepcidin – Hormone key role in iron absorption – controls Ferroportin regulates iron into blood stream
Normal iron absorption – when serum ferritin value is high – Ferritin is good reflection of body iron stores in the blood- higher hepcidin value and the lower the absorption of iron
Haemochromatosis- When defect in HFE protein gene lower production of Hepcidin feedback system less effective and more iron is transported from blood cells into blood stream.
Standard treatment – Venesection or phlebotomy – removal of blood from body to lower iron levels.

3. Outline and Aim Can diet improve management of haemochromatosis?
How can dietary manipulation help?
Iron in food – types
Foods that can affect iron absorption
Take home messages for diet at home
AIM:
To give a rounded balanced view on current dietary advice based on current knowledge and resources for haemochromatosis.
Image made by Cristina Testa

4. Iron in food 2 different types of iron: Haem iron –
found in meat- beef, poultry, fish – 30-70% iron content, and 15-35% is absorbed
Non Haem iron –
found in plant e.g. green leafy vegetables –spinach, and non cellular animal sources e.g. milk and milk products, 100% of iron content in plant foods , 2-20% often <10% absorbed.

5. Iron in food – Meat
Haem iron found in animal sources most commonly meat- increases overall iron status by increasing serum ferritin (iron in blood)
All meat contains iron some higher than other haem content – rule of thumb redder meat more haem containing
Still need meat and fish as provide B12 vitamin
Have 3-4 days meat free- meat substitutes such as eggs tofu quinoa
Fish have 2 x a week
Avoid organ meat –this is non haem iron however very rich and well absorbed 100g would give entire daily intake iron for men and women >50
Avoid raw seafood- particularly shellfish and any cooked fish that has been sprinkled or had fresh seawater added after cooking – bacteria Vibrio Vulnificus as this can cause rapid and life threatening infection

6. Iron in food – Vegetables
Non haem iron present in foods such as green leafy vegetables eg spinach, beans.
Vegetables contribute 7% of iron intake
Important to have vegetables of different colours due to antioxidants.
Also spinach contains oxlate is an inhibitor of absorption

7. Iron in food – Fortified, Supplemental and other
Fortified foods
Iron is added to some foods e..g white flour and breakfast cereals
A Study in Sweden showed stopping of fortification was associated with less iron absorption, resulting in fewer phlebotomies per year.
A study in the United Kingdom suggested that little or nothing of the added iron would be absorbed.
To avoid these foods if able, not much is known regarding absorption of the iron in these foods.
Dark chocolate contains iron, therefore choose milk chocolate but again keep in moderation alongside healthy eating advice.

8. Iron in Supplements
Iron supplements e.g. ferrous sulphate, ferroglobin (vitabiotics).
Iron in multivitamin and mineral supplements – often with Vitamin C.
Study found 20% of supplemented iron absorbed and stored.
Advice: to avoid unless other wise advised by Haematologist or GP.

9. Foods that affect iron absorption
Enhancers
Meat enhances iron absorption due to a ‘meat factor’ which can help absorption of both haem and non haem iron
Organic acids e.g. ascorbic – found in orange juice (vitamin C)
Alcohol –enhances absorption of iron and may also cause liver damage if too much taken (Red wine in moderation can be of benefit as contains tannins which can inhibit absorption)

10. Foods that affect iron absorption
Inhibitors
Tea – black and herbal tea eg green tea bind non haem iron
Coffee – contain poly phenols
Shell of nuts, seeds, legumes and grain- due to phyates – inhibit non haem iron absorption – full extent not known
Calcium- inhibits haem and non haem absorption – found in milk and dairy sources. However weak effect if taken between meals and no studies or effects shown on haemochromatosis patients

11. A healthy balanced diet and lifestyle
Eat well guide formally plate published FSA 2016 – for everyone
Base meal on starchy carbohydrate e.g. potatoes, rice, pasta – choose wholegrain due to fibre content
Try to eat plenty fruit veg - a day
Eat more fish, alternative sources of protein;
Beans, pulses
Cut down in saturated fat and sugar, salt
Eat less chocolate, crisps sweets
Get active and be healthy weight – BMI 20-25kg/m2
As shown those with BMI > 30 obese
have higher blood iron levels

12. Take home messages
Consider changes in diet:
2-3 free meat days/ week and have meat substitute and fish x 2 week if possible.
Avoid iron supplements or if taking multivitamin ensure iron is not contained within and if contains vitamin C avoid taking with meals.
Avoid/ limit keep alcohol intake within moderation
Avoid organ meat eg liver
Enjoy balanced diet of all other food groups on eat well guide.
Keep healthy weight
Do not restrict diet to unrealistic expectations – it is still likely that venesection/phlebotomy will be needed
NB: Manipulating diet - iron absorbed 2-3mg from meat VS venesection can remove 250mg iron.
Post venesection however best to drink plenty of fluids eg water, milk, tea and be aware of high iron foods and limit intake as iron absorption may be higher post venesection due to less iron in blood.

13. References
Dietary advice in HFE-hemochromatosis, by GM van Doorn - ‎2012
BDA (British Dietetic Association) Eating Guidelines for Hemochromatosis, =
The Haemochromatosis Society
Iron disorders Institute, 2006
Hemochromatosis Australia

14. Thank you for listening...Any questions?
Image made by Cristina Testa