Katherine Silva

NFS 443
Anemia Lab
September 2014
1.

Using the BMI calculator from the Nutrition Care Manual, KMs

BMI is 24.2.
Her BMI indicates she is within the recommended healthy range.
According to the Nutrition Care Manual, the normal weight range for
someone of her height (52), is between 101 pounds and 136 pounds.
Her IBW according to the Hamwi formula is 110 pounds. (100 pounds
for the first 5 feet, and 5 pounds for each additional inch).
2.

Using the REE calculator provided by the Nutrition Care Manual,

KMs REE is estimated at 1,280. The formula used for this calculator is
the Mifflin-St Jeor.
KM normally does cardio exercises on a daily basis for an hour. This
would give her an activity factor of 1.75 for the high end of very active
people, but currently, she has changed her workout routine to 3 days
per week. This recent change gives her an activity factor of about 1.6
for very active people, and is what I will base her calorie needs by.
1,280 x 1.6 = 2,048 kcals/day

To get the most well-rounded results, I will also use the Harris Benedict
equation to compare with the Mifflin-St. Jeor.

655 + (9.6 x 60) + (1.8 x 157.5) (4.7 x 29)

655 + 576 + 283.5 136.3 = 1,378
1,378 x 1.6 = 2,205 kcals/day
With only a difference of 157 calories, the two estimates energy
calculations were very close. Either result would be fine to use for
dietary recommendations, or perhaps as a range so an extra snack
would be able to fit in on some days if needed.
3.

KMs lab values all came back abnormal. Her hemoglobin level at

9 g/dL is very low compared to the normal 12-16 g/dL range.

Hemoglobin is the iron-containing transport protein in the red blood
cells that drops fairly late in iron deficiency development. This low
level, along with the several months of fatigue, indicates KM has been
iron deficient for quite some time and is in the late stages of iron
deficiency anemia development.
Her hematocrit level was also low at 34%, below the normal
range of 37-47%. These low levels indicate a decrease in number or
size of her red blood cells. With both hemoglobin and hematocrit levels
low, it is a strong indicator of iron deficiency.
The MCV level of 72 fL. is low compared to the normal range of
80-95 fL. A lower than normal level shows that her red blood cells are
smaller than average, or microcytic, which is a symptom of iron
deficiency.

Her low level of ferritin at 8 ng/dL compared to the normal range

of 10-150 ng/dL, indicates low iron stores. The ferritin level in the blood
is a direct reflection of the amount stored in the tissues.
Serum iron levels are at 50 ug/dL, which is low compared to the
normal range of 60-160 ug/dL. This test of iron levels will appear low
during the initial stages of iron deficiency. It is no surprise that her iron
levels are low, especially with her low level of hemoglobin, with iron
being a requirement for hemoglobin production.
The last determining factor for her nutritional diagnosis is the
total iron binding capacity (TIBC). When iron stores are low, the liver
tries to compensate by producing more transferrin in an attempt to
maximize the use of what little iron is left in the blood.
It is clear that KM is suffering from iron deficiency anemia and
needs prompt treatment because she is in the late, severe stages. It is
also appropriate to note her prior medical history. Her heavy menses
will make her at higher risk for becoming iron deficient again after
being treated for this occurrence because this will tap in to her iron
stores on a monthly basis.
4.

Since KM is a vegetarian, she has to rely on non-heme food

sources of iron. Vegetarians need more iron than other individuals

because of the low bioavailability of their food choices. The
recommended daily amount for pre-menopausal women is 18 mg. This
value is multiplied by 1.8 for vegetarian women, giving them a

recommended total of 32 mg per day. Vegetables like dark leafy

greens, soy products, legumes and beans are all high in iron.
Unfortunately , these foods are less bioavailable than animal sources.
To increase bioavailability of these foods, vitamin C and other acidic
fruits and vegetables will help absorb these non-heme sources in the
body. Vitamin C helps with the conversion of iron to the more
absorbable ferrous iron in the GI tract. It will also counter the action of
iron inhibiting foods.
Most breads are fortified with iron and other minerals. Whole
wheat bread and enriched breads can be used for toast at breakfast or
sandwiches at lunch. Flour tortilla wraps will be a great source
especially if used to wrap foods like iron-rich hummus, and acidic fruits
and vegetables such as tomatoes to increase absorption. Cereals are
also a good source including oatmeal, cream of wheat, and of course,
the name brand Total cereal.
Soy and fermented soy products can be easily incorporated into
lunch and dinner. Miso soup as a side dish, tofu in a vegetable stir fry,
or soybeans for a salad topping are some examples of how to use them
in meals.
Beans, nuts, seeds, and lentils are all great sources of iron for a
vegetarian. As stated previously, eating them with vitamin C rich foods
will provide the best absorption. I would suggest using them as side
dishes at meals or even as an entre. A good combination would be

stuffed bell peppers filled with garbanzo beans and lentils. The vitamin
C from the bell peppers will optimize absorption of the beans and
lentils. Sunflower and pumpkin seeds are a good source of iron. A
handful would work well on top of salads or a snack throughout the
day.
Some vegetables high in iron include spinach, broccoli,
mushrooms and potatoes. Spinach can be used as the primary base in
a salad or sauted with other foods. It is relatively high in oxalates,
which prevent absorption, so it should be consumed with acidic fruits
and vegetables. Spinach and mushrooms would make a great pizza
topping and would benefit from the acidic tomato sauce.
Snacks throughout the day, as stated before, could be nuts and
seeds. Additionally, dried apricots and raisins which are both rich in
iron and vitamin C, would work well with nuts and seeds. A trail mix
including all these things plus some iron enriched pretzels is a way to
use them as a snack.
There are also certain foods that should be limited or avoided
completely, at least until iron stores are back to normal. KM does enjoy
her tea in the morning, but tea contains iron inhibiting polyphenols, or
tannins. The same principle applies to coffee. Milk does not have much
iron and can also lower absorption because of the mineral interaction
that occurs between the calcium and iron. These foods should be
limited, or at least, not eaten when taking iron supplements.

It might be beneficial to invest in a good iron skillet or other iron

cookware if this is something the client is interested in and is able fit
into her lifestyle. Iron cookware is a good method to increase iron
content in cooked foods. Acidic foods such as tomato sauce will
especially help transfer iron from the cookware to the food and in turn,
increases total iron content.
Lastly, an iron supplement is definitely needed. A ferrous sulfate
iron supplement is usually one of best choices among other
supplements. Everyone has a different reaction to iron supplements.
They tend to cause constipation in some individuals, so it may be more
comfortable to take them at bedtime with plenty of water to reduce
this symptom. To maximize iron absorption of the supplements, they
should be taken between meals on an empty stomach. Tea, coffee, and
milk should be eaten far apart from consuming the supplement.
KM is very physically active on her normal schedule. She has
decreased her workouts recently and they should stay decreased even
further to just light workouts such as brisk walks a few times per week
until she is seen for her follow up and iron stores a back to normal. This
could possibly take months since the stores are severely depleted.
Concerning her family history of CVD and her current diet, I
would recommend some dietary changes. Instead of using butter, I
would recommend margarine to reduce the saturated fats and her risk
for CVD. Benecol brand spread is known to help control cholesterol

levels so this might be a good choice for prevention of high cholesterol.

Instead of cream, whole, or 2% milk, a better choice in preventing CVD
would be skim or 1% milk. An even better choice would be soy milk
which contains some iron. Her evening snack on her 24 hour recall is
very high in fat and sugar. Foods like ice cream and pie shouldnt be
used so much for snacking, but rather for special occasions to keep her
saturated fat and refined sugar low.
5.

Using the calorie intake diabetic exchange tool on the Nutrition

Care Manual website, her exchanges were estimated and printed out.
For her vegetarian protein sources, I used the meat(very lean)
category.
6.
Breakfast
2 Starch
1.5 Fat
2 Fruit
2 Dairy (FF)
1 Nonstarchy
vegetable
1 Lean meat

1
1
1
1

Snack
Starch
Fat
Fruit
Dairy (FF)

2
1
2
1

Lunch
Starch
Fat
Fruit
Dairy (FF)

2 Nonstarchy
vegetable
1.5 Lean

Snack
1 Starch
1 Fat
1 Fruit

Dinner
2 Starch
2 Fat
1 Dairy (FF)
3 Nonstarchy
vegetable
2 Lean meat

meat

7. SOAP note
S: Pt C/O extreme fatigue increasing over past several mos, especially

during PA. Reports no recent weight change. No recent change in

appetite. Decreased cognitive ability at work. PMH of regular but heavy
menses. Vegetarian diet for several years which includes dairy, but no
eggs or meat. FH of CVD (father s/p CSBG 1 yr ago).
O: 29 yo female, Ht 62 inches, Wt 132 pounds, BMI 24.2. BP and HR
WNL.
Pt is afebrile. Lab values: Hgb 9 g/dL, Hct 34%, MCV 72 fL, ferritin 8
ng/mL, serum iron 50 ug/dL, TIBC 475 ug/dL.
A: Diet lacking in iron-rich foods due to a strict vegetarian regimen.
Iron deficiency anemia R/T inadequate iron consumption AEB extreme
fatigue, lowered cognitive ability, low levels of Hgb, Hct, MCV, ferritin,
serum iron, and an increase in TIBC.
P: Ensure adequate kcals of 2,048/d and adequate protein of 107.5 g/d.
Addition of a daily iron supplement to ensure needs are met. Education
on the vegetarian diet concerning good iron sources, and the
absorption inhibiting/increasing food components. Instructions and
cautions for pt to keep in mind while introducing a new iron
supplement. Follow up appointment to check iron levels and tolerance
to new diet plan.