In the study period the FFQ was proposed to 72 patients attending the HHT Crema Center, of these 66 accepted to fill the questionnaire; 85 more questionnaires were filled by accessing the website of HHT Italian Foundations (which has 897 members). In total, 151 questionnaires were completed, two surveys were incomplete and were excluded from the final analysis. Thus, 149 questionnaires were evaluated. Among these, 72 participants were female and 77 were male, with a mean age of 53 ± 14 years.
Overall, 26 (18%) patients observed that some dietary items seemed to improve epistaxis. The most commonly reported protective aliments were blueberries and red fruits in 8 cases (31%), green vegetables in 5 (19%) and legumes in 4 (15%). Accordingly, 46% of these patients reported higher consumption of dietary items perceived to be protective. On the other hand, 38 patients (26%) reported that some dietary items could exacerbate/worsen nose bleeds. Among these, the most common were spices (especially chili pepper) in 13 (36%) cases, chocolate in 12 (36%), alcohol consumption in 10 (28%), strawberries in 3 (8%) and ginger in 3 (8%). A reduced intake of dietary items perceived to worsen nose bleeds was reported in 22 of 38 patients (58%). The data on dietary items affecting epistaxis are detailed in Table 1.
In our population, 58 patients (32 females; mean age: 57 years) were prescribed an oral iron medication represented by ferrous sulfate (Fe++ 80-105 mg per tablet) and ferrous (II) glycine sulfate complex (Fe++ 100 mg per tablet). Thirty-two (16 females; mean age: 55 years) were on parenteral iron supplementation, mostly ferric carboxymaltose (Fe++ 2 ml/100 mg). Additionally, 19 patients were taking iron-based nutritional supplements such as liposomal iron or sucrosomial iron. Among patients taking iron supplements/medication, 29 (26.6%) reported a reduction in epistaxis during the assumption, while 7 (6.4%) reported iron therapy worsened epistaxis. Of the latter, seven patients, two received both parenteral and oral iron therapy, one parenteral iron therapy and four oral iron.
In the HHT patients, the mean daily intake of iron was 8.46 ± 2.78 mg; the mean intake was 8.94 ± 2.85 mg/day in men and 8.66 ± mg/day and 7.98 ± mg/day in women aged < 50 years and > 50 years, respectively. Among the three groups, the main contributor to dietary iron was vegetables (32.1%), followed by cereals (31.3%) and meat, fish, meat and eggs (17.1%). The iron supply from different dietary items is reported in Table 2.
Comparison of the iron daily intake in HHT patients with the AR for the Italian population showed that the mean iron daily intake in male patients was significantly higher than the AR reported in the LARN (8.9 ± 2.9 mg/day vs 7 mg/day, p <0.0005), the mean iron daily intake in female patients aged < 50 years was lower than the AR (8.7 ± 2.6 vs 10 mg/day, p 0.017) and the mean iron daily intake in female patients aged > 50 years was significantly higher than the AR (8.0 ± 2.7 mg/day vs 6.0 mg/day, p <0.0005). An inadequate intake of iron was observed in 20.8% (16/77) of male patients, up to 70% (14/20) in female patients aged < 50 years and 18.7% (9/49) in female patients aged > 50 years.
We found no significant differences in dietary iron intake between HHT patients who reported modified diets and those who did not (8.2 ± 2.8 mg/day vs 8.4 ± 2.9 mg/day, p= 0.6739).
No differences were observed in the dietary iron intake of male patients and female patients aged > 50 years taking iron medication. However, female patients aged < 50 years not taking iron medication had a significantly higher dietary iron intake than those taking it (Table 3). Overall, in patients taking iron medication, iron intake (resulting from both diet and prescription) was significantly higher than the AR (p< 0.01).
Data on the hemoglobin levels were available for 104 cases (51 male patients, 15 female patients < 50 years and 38 females > 50 years). In men, the mean hemoglobin value was 12.6 ± 2.5 g/dl; in this group, a diagnosis of anemia, defined as a hemoglobin value < 13 g/dl, was established in 31 patients (60.8%). For women aged < 50 years, the mean hemoglobin value was 13.3 ± 2.4 g/dl; a diagnosis of anemia, defined as hemoglobin values < 12 g/dl, was established in 5 patients (33.3%). In women aged > 50 years, the mean hemoglobin value was 12.1 ± 2.4 g/dl; 15 patients (39.5%) were anemic (hemoglobin values < 12 g/dl).
Data on blood iron and ferritin were available for 69 and 80 cases, respectively: the mean iron value was 44.2 ± 30 mcg/dl, while the mean ferritin was 27 ± 26 mcg/l.