NUTRITIONAL DEFICIENCIES AND ANEMIA HEMATOLOGY Noah Carpenter, MD Dr. Noah Carpenter is a Thoracic and Peripheral Vascular Surgeon practicing in Brandon, Manitoba. He is known for the development of surgical techniques. He attended the University of Manitoba where he graduated with the B.Sc. in chemistry, completed medical school and did his surgical residency and fellowship at the University and Affiliated Hospitals in Edmonton, Alberta. Dr. Carpenter did an additional fellowship at the University of Edinburgh, Scotland in Adult Cardiovascular and Thoracic Surgery, and has specialized in microsurgical techniques, vascular endoscopy, laser and laparoscopic surgery in Vancouver, British Columbia, Canada and Colorado, Texas, Vancouver, and Los Angeles. He has an Honorary Doctorate of Law from the University of Calgary, and was appointed a Citizen Ambassador to China, and has served as a member of the Native Physicians Association of Canada, the Canadian College of Health Service Executives, the Science Institute of the Northwest Territories, the Canada Science Council, and the International Society of Endovascular Surgeons, among others. He has been an inspiration to youth, motivating them to understand the importance of achieving higher education. ABSTRACT Anemia can occur for many different reasons. These include chronic disease, nutritional deficiencies, malignancy, medications, blood loss, and bone marrow disorders. An understanding of the different causes of nutritional anemia will help clinicians to better decide upon proper treatment and to avoid complications caused by anemia. Grading of the severity of anemia is also a critical aspect of diagnosis and treatment. The effect of nutritional deficiencies and related anemia as well as how anemia and nutritional deficiencies are treated is discussed. nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 1 Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 2 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Pharmacology content 0.5 hours (30 minutes). Statement of Learning Need Although it is easily identified and treated, anemia can be missed or the cause confused with another condition. Anemia is a health problem that affects vulnerable individuals such as children, pregnant women, and elderly, as well as economically disadvantaged regions of the world. Any prevention and treatment of anemia depends on proper diagnosis and surveillance of affected people. This includes appropriate utilization of diagnostic testing that focuses on factors affecting clinical outcomes. Course Purpose To provide health clinicians with an understanding of the diagnosis and treatment of anemia related to nutritional deficiencies. nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 2 Target Audience Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion) Course Author & Planning Team Conflict of Interest Disclosures Noah Carpenter, MD, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures. Acknowledgement of Commercial Support There is no commercial support for this course. Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 3 1. ____________ will raise a patient’s concentration of hemoglobin. a. Smoking and living at higher altitudes b. Pregnancy c. Iron deficiency d. Blood donations 2. In men and postmenopausal women, ______________ is the most common source of iron deficiency a. a vegetarian diet b. menorrhagia c. gastrointestinal bleeding d. low socioeconomic status 3. Elevated ______________ is a good sign of B12 deficiency. a. homocysteine levels b. methylmalonic acid c. mean corpuscular volume d. iron levels 4. Cobalamin, a water-soluble vitamin, that is important in the production of red blood cells, is also known as _________________. a. Iron b. Vitamin E c. Vitamin C d. Vitamin B12 5. True or False: Folic acid deficiency causes neurological symptoms, even in the absence of a vitamin B12 deficiency. a. True. b. False. Introduction nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 4 Anemia is often indicative of an underlying disease condition and can be multifactorial. There are three different etiologies of anemia with iron deficiency being the leading cause. The pathology underlying anemia involves a reduction in the concentration of hemoglobin or red blood cells in the blood and may require treatment depending on severity. The level of anemia often depends upon an individual’s age and gender, lifestyle patterns, and the altitude of a person’s residence. Anemia: An Overview Red blood cells (erythrocytes) are a type of blood cell produced in the bone marrow. They start off as immature cells and are released into the bloodstream after approximately seven days. The red blood cell (RBC) is shaped like a biconcave disk and the average RBC lifespan is about 120 days. Production of RBCs is controlled by erythropoietin, a hormone created mostly in the kidneys. RBCs do not have a nucleus. This is important because it helps the RBCs to vary their shape easily in order to travel through different blood vessels.1 Hemoglobin is a protein carried by red blood cells. Hemoglobin transports oxygen from the lungs to other parts of the body. It also brings back carbon dioxide to the lungs so that it can be released through exhalation.1 The complete blood cell count (CBC) laboratory test ranges for what is considered normal can vary depending on the source. Anemia is typically based on the hemoglobin value in the CBC. In addition to RBC count and hemoglobin, there are a number of other CBC laboratory values that are important in helping to diagnose anemia. The mean cell volume (MCV) is the average size of the RBCs. If a patient with anemia has a normal MCV, it is nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 5 called normocytic anemia. If the MCV is less than normal, it is considered microcytic, and an MCV greater than normal is considered macrocytic. The mean cell hemoglobin (MCH) is the average amount of hemoglobin in an average RBC. If the MCH is normal, it is considered normochromic. Likewise, a decreased value is considered hypochromic while an elevated value is considered hyperchromic. The red cell distribution width reveals the variability of RBC size.2 Below is a table displaying the normal ranges for blood cell values.1,2 NORMAL BLOOD CELL VALUES WOMEN MEN BOTH GENDERS Red Blood Cell 4.1 - 5.1 4.5 - 5.9 Hemoglobin (g/dL) 12.3 - 15.3 14 - 17.5 Mean cell volume (MCV) 80- 96.1 Mean cell hemoglobin (MCH) 27.5 - 33.2 Mean cell hemoglobin 33.4 - 35.5 concentration (MCHC) Red cell distribution width 11.5 - 14.5 (RDW) (%) Definition of Anemia Anemia is defined as a condition occurring when the number of red blood cells is inadequate to meet the physiologic needs of the body. A patient’s age, gender, smoking status, pregnancy state, and place of residence (altitude above sea level) can all affect the patient’s physiologic needs. For example, living and smoking at higher altitudes raises the concentration of hemoglobin.4-7,11 On the other hand, pregnant women usually experience a nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com 6 drop in hemoglobin, which starts in the first trimester and worsens in the second trimester.4 National Cancer Institute Terminology Criteria for Adverse Events: Anemia4,11 Grade 1 2 3 4 5 Hemoglobin Hgb <10 - 8 Hgb <8 g/dL Life- Death (Hgb) g/dL threatening <LLN - 10 outcomes; g/dL* Urgent treatment required. *LLN (lower limit of normal). Etiology The cause of anemia can be multifactorial. There are three main causes of anemia: 1) Decreased production of red blood cells, 2) Increased destruction of red blood cells, and 3) Blood loss.5-7 When considering the three major causes of anemia, it is important to note that blood loss leads to iron deficiency (discussed in a later section). The main focus here however is on acquired causes of decreased RBC production. The bone marrow needs certain ingredients to make RBCs, which include iron, vitamin B12, and folate. Iron Deficiency Anemia The most common nutritional deficiency in the world is iron deficiency. Greater than one-fourth of the global population is anemic with iron deficiency being approximately one-half of the total burden.10 In the United States, iron deficiency is noted in approximately 2% of adult men and 9%- 12% of Caucasian women. The incidence is even higher in minority women, estimated at close to 20%. Risk factors for iron deficiency include vegetarian nurseCe4Less.com nurseCe4Less.com nurseCe4Less.com