Ashley Francis

Medical Nutrition Therapy - Case Study 1

1. The patient has multiple signs and symptoms that would suggest anemia. The patient reports symptoms of fatigue and shortness of breath and the patient displays signs of pallor, all of which could be indications that the patient is anemic.1 2. The patient has the following abnormal values: ! Low RBC count ! Likely cause: Iron deficiency, and possible Copper, Vitamin B6, Folate, and Vitamin B12 deficiencies are likely causes as each of these nutrients is needed in the production on red blood cells.2 Pregnancy also results in a lower red blood cell count, due to the increase in plasma volume in pregnant women.3 The patients vaginal spotting, resulting in some blood loss, could have caused this test value.3 Anemia: Unhealthy and disfigured red blood cells result from anemia, which would cause low RBC levels.3 ! Low hemoglobin ! Likely cause: Iron deficiency, potential Vitamin B6, Vitamin B9, Vitamin B12 deficiencies could cause this lab value since each of these nutrients is involved in hemoglobin production.2 Pregnancy: The increased volume of blood plasma in pregnancy will decrease hemoglobin values.3 ! Low hematocrit ! Likely cause: Iron deficiency, possible B12 and B9 deficiencies.2 ! Low mean cell volume ! Likely cause: Iron deficiency, increased plasma volume consistent with healthy pregnancy.2 ! High total Fe binding capacity ! Likely cause: Iron deficiency, patients body is compensating for the low iron concentration of the blood by increasing the iron binding ability of their hemoglobin to increase the potential for binding of iron and meeting iron needs.2 ! Low Ferritin ! Likely cause: Iron deficiency, indicates low iron stores.2 ! Low Folate ! Likely cause: Folate deficiency, possibly B6 and B12 deficiencies.2 ! Low Retic. % ! Likely cause: Iron deficiency, increased plasma volume consistent with healthy pregnancy.2 ! Low mean cell hemoglobin ! Likely cause: Iron deficiency, possible B9, B12 deficiencies.2 ! Low mean cell hemoglobin content ! Likely cause: Iron deficiency, possible B9, B12 deficiencies.2

"!

Ashley Francis ! High RBC distribution ! Likely cause: Iron deficiency, possible Vitamin B6, Vitamin B9, Vitamin B12, and Vitamin A deficiencies. Increased plasma volume consistent with healthy pregnancy.2 High ZPP ! Likely cause: Iron deficiency, heme production is inhibited.2

3. An individual with low hemoglobin may be a concern for a physician because it could indicate irondeficiency anemia, among many other health complications that lead to decreased production or increased destruction of red blood cells. However, low hemoglobin is common in pregnancy, and is not necessarily an indication of poor maternal health. Low hemoglobin levels can be expected in late in pregnancy, to some degree, due to an increase in plasma volume, ultimately expanding the blood volume by 50%.4 It is also expected that with this increase in plasma volume, serum albumin, other serum proteins, and water-soluble vitamin levels will also decline.2 4. Megaloblastic anemia is caused by erythrocytes, leukocytes, platelets, and blood cell precursors that have been altered in shape and function due to improper DNA synthesis. Large red blood cell precursors result due to their inability to divide and differentiate. This form of anemia is usually a result of folic acid or vitamin B12 deficiency and has a slow onset.2 Pernicious anemia is a megaloblastic anemia that results in large red blood cells (macrocytosis). This anemia is usually caused by decreased levels of IF which results in B12 deficiency since IF is required for B12 absorption. Gastrointestinal diseases and cancers, strict vegetarian diets, as well as consumption of certain drugs and excessive alcohol may also be causes of this anemia.2 Normocytic anemia is the most common type of anemia. While this anemia does not affect MCV, it does decrease levels of hematocrit and hemoglobin. The prevalence of this anemia is greatest in individuals over the age of 85. Some potential causes of normocytic anemia include decreased production of fully functional red blood cells, increased destruction or loss of red blood cells, increased plasma volume, or a development of microcytic and macrocytic anemias. Deficiency in iron, Vitamin B12, or folate could all potentially play a role in this anemia.5,6 Microcytic anemia is characterized by small, hypochromic red blood cells, low MCV, and is commonly related to iron deficiency. The absence of iron stores in the bone marrow is the most accurate way for medical professionals to determine the presence of this anemia, although measurements of iron concentration, serum ferritin, transferritin saturation, iron-binding capacity, and serum transferrin receptors can be adequate indicators for diagnosing this anemia.2 Sickle cell anemia, the most common form of Sickle Cell Disease, is caused by abnormal hemoglobin that induces the formation of crescent-shaped cells. Sickle cells tend to stick together, which can lead to pain, weakness, organ damage, and poor immunity. A small percent of people with Sickle Cell Disease are cured through blood and bone marrow stem cell transplants.2 Hemolytic anemia is caused by the premature death or destruction of red blood cells in the body. In hemolytic anemia, bone marrow cannot replace red blood cells fast enough to meet the body's needs.2 5. Iron is involved in red blood cell health, the activity of heme and nonheme enzymes, transport of oxygen and carbon dioxide, hemoglobin and myoglobin activity, DNA synthesis, electron transport,

#!

Ashley Francis energy metabolism, synthesis of collagen, synthesis of certain neurotransmitters, and immune function. The need for iron increases with rapidly dividing and differentiating cells. This is a function of iron that is important to consider regarding fetal development. If a pregnant woman is deficient in iron during her fetus's development, the function of the growing fetus's organ systems could be impaired permanently. Low iron may lead to poor hemoglobin production in a pregnant woman; which would compromise the delivery of oxygen to her fetus. As a result, the mother's heart rate would increase, elevating her cardiac output and increasing the likelihood of preterm delivery, LBW of the infant, and poor neonatal health.2 6. Stages I and II of negative iron-balance are related to iron depletion. While 90% of the iron in our body is recycled, 10% must be replaced through dietary consumption. If this dietary requirement is not met, the depletion of iron stores in the body begins. These stages do not cause any bodily dysfunction. The only abnormal lab values in stage I of negative iron-balance are possible high serum transferrin receptors and possible low ferritin-iron. Lab values showing low RE marrow Fe (<2+), high transferrin IBC, low plasma ferritin (<25 mcg/L), high iron absorption (>10%), high serum transferrin receptors, and low ferritin-iron indicate stage II of negative iron-balance (iron depletion).2 Stages III and IV of negative iron-balance involve iron deficiency. These stages occur when the body stores have been depleted so much that the body no longer has an adequate source of iron to function properly. Signs and symptoms of iron deficiency may include the arise of brittle nails, soreness or swelling of the tongue, cracks in the sides of the mouth, enlargement of the spleen, frequent infections, pica, abnormal cognitive development in children, and restless leg syndrome. In addition to the lab value abnormalities of iron depletion, stage III of negative iron balance shows lab values of low plasma iron (<60 mcg/100ml), low transferrin saturation (<15%), low sideroblasts (<10%), and high RBC protoporphyrin (100).2 Anemia occurs with stage IV of negative iron-balance. This stage occurs after a long period of iron deficiency. Many signs and symptoms of iron-deficiency anemia are more severe variations of iron deficiency symptoms. Some other symptoms include impaired muscle function, fatigue, anorexia, growth abnormalities, pallor, epithelial disorders, reduction in gastric activity, glossitis, angular stomatitis, spoon-shaped nails (koilonychia), and eventual cardiac failure if treatment is not received in time. In the state of iron-deficiency anemia (stage IV of negative iron balance), will show microcytic/hypochromic erythrocytes, in addition to all other value abnormalities in iron deficiency.2 7. Mrs. Morris has a few possible risk factors for iron-deficiency anemia based on her history. Iron deficiency is prevalent in the U.S. among adolescent girls and women of childbearing age. If Mrs. Morris started her pregnancy with insufficient iron stores, her risk for iron-deficiency anemia was increased. She is also 23 weeks pregnant, which increases her dietary iron requirements even more. After the 20th week of pregnancy is when the combined mother and fetus iron needs are at their peak. Also, Mrs. Morris has not been taking prenatal vitamins regularly throughout her pregnancy, which may have caused inadequate iron intake and could lead to negative iron-balance. Additionally, Mrs. Morris experienced some vaginal bleeding prior to being admitted to the hospital. Blood loss is a potential risk factor for iron deficiency. It is also important to consider that since Mrs. Morris is a smoker, she has reduced uptake of vitamin C. Vitamin C helps with iron absorption, so decreased vitamin C uptake could also result in decreased iron uptake.2,7

$!

Ashley Francis 8. There is a strong relationship between the health of the fetus and the mothers iron status. Iron is required for rapid cell division in the fetus and oxygen delivery from the mother. Insufficient iron in the mother will increase the mothers cardiac output which could lead to a low birth weight baby, a preterm delivery, and/or incomplete development of the fetuss organ systems--all of which could result in permanent health problems for the baby.2,7 9. It is extremely important for pregnant women to note changes in macro- and micronutrient requirements. These nutrients are not only essential to the growth and health of the mother, but also the fetus.2 " Energy ! Additional calorie consumption is essential during pregnancy as both the mother and fetus have important metabolic demands. No additional energy requirements are needed in the first trimester. However, in the second trimester, it is recommended that pregnant women of a healthy pre-pregnancy weight increase their energy intake by 340-360 kcal/day. In the third trimester, the recommended energy intake is increased by 452-472 kcal/day (from baseline).2 " Protein ! Adequate protein stores are integral in the assurance of healthy development by the fetus. Protein intake is not altered until the second twenty weeks of pregnancy when recommended intake is increased from 0.8g/kg/day to 1.1g/kg/day.2 " Calcium ! Calcium requirements do not change from preconception to pregnancy. The DRI is 800 mg/day. If a woman chooses not to consume foods high in calcium such as milk and cheese, a vitamin D supplement may be taken.2 " Iron ! Iron is essential for the growth and development of the fetus. Before pregnancy, the DRI for iron in women is 8.1 mg/day, but because there is a higher demand for iron during pregnancy, the DRI increases to 22 mg/day. A study in 2008 showed that insufficient stores of iron during the prenatal phase (lasting up to the six-month mark) could be a risk for the fetus to develop neurological effects that are irreversible, even with iron supplementation as the child grows.2 " Vitamin B12 ! Vitamin B12, which is important for red blood cell production, proper functioning of the nervous system, and synthesis of DNA, has an increased RDA from 2.0 micrograms/day in non-pregnant women to 2.2 micrograms/day during pregnancy. Vitamin B12 deficiency is important to avoid during the early stages of pregnancy as it may contribute to neural tube defects and preterm labor.2 " Folate ! Folate plays an important role during the beginning phase of pregnancy as it functions to produce DNA in the cells. The RDA increases from 320 microgram/day in non-pregnant women to 520 microgram/day in pregnant women. A deficiency in folate can cause neural tube defects, which appear during the first 28 days of gestation. It is important for women to supplement folate during pregnancy.2 " Zinc ! It is important for pregnant women to increase zinc stores during their first trimester as zinc plays a major role in the formation of the fetuss organs and immune system. The RDA for pregnant women is 9.5 mg/day, as opposed to 6.8 mg/day for non-pregnant

%!

Ashley Francis women. Zinc deficiency can result in abnormal neurological development in the fetus, leading to abnormal behaviors in the child.2 Vitamin C ! Vitamin C is involved in collagen synthesis and should be taken in adequate amounts during pregnancy. If the mother is a smoker (like Mrs. Morris), Vitamin C is needed to improve pulmonary function of the fetus. Vitamin C intake should be increased to 85 mg/day for pregnant women, rather than the regular 75 mg/day for non-pregnant women.2

10. Iron is found in two forms: heme and nonheme. Heme iron is derived from hemoglobin and myoglobin in animal sources such as meat, poultry and fish. Heme iron is very well absorbed (up to 60%). Nonheme iron sources are plant-based products such as vegetables, nuts, dried beans, grains, tofu, fruit, and even some dairy. Nonheme iron is not as well absorbed as heme iron. The best dietary sources of iron are animal protein.2

!!!!!!!!!
11. Iron is stored in the intestinal cells in the form of ferritin in the Fe+3 form. Stored Fe can be reduced to Fe+2 and released as needed. Ferroportin transports Fe+2 across the basolateral membrane into the bloodstream. Fe+2 is converted back to Fe+3 by the action of either hephaestin or ceruloplasmin. Transferrin transports Fe3+ to the tissues. Most of the Fe is stored in the liver (60%), spleen, and bone marrow. Heme and Nonheme Fe are absorbed differently. Heme Fe binds to heme carrier protein 1 (hcp1), which is also a folate receptor, on the brush border membrane. Then, heme is hydrolyzed to Fe+2 by heme oxygenase. Nonheme Fe is first converted from Fe+3 to Fe+2 by duodenal cytochrome b (DcytB). Fe+2, or ferrous, is absorbed using DMT1.8 12. Using Mrs. Morriss current BMI would not be a true reflection of her overall health. During pregnancy, women of a healthy weight (18.5 < BMI < 24.9) are expected to gain 25-35 lbs.2 This weight increase would impact BMI significantly as BMI aims to measure adequate weight in regards to height. A pregnant woman who is gaining proper weight may have a BMI that classifies her as overweight (25 < BMI < 29) or obese (BMI > 30). Therefore, we can better assess Mrs. Morriss using her pregravid (pre-pregnancy) BMI.2 ! BMI = [Weight in pounds/{Height in inches x Height in inches}] x 703.2 ! Pregravid BMI = [135 lbs / (65 inches x 65 inches)] x 703 = 22.5 Mrs. Morriss pregravid BMI of 22.5 places her in the healthy weight range. Therefore, it is encouraged that she gains 25-35 lbs during this pregnancy.2 Mrs. Morris is currently at 105.19% of her usual body weight. ! Percent Usual Body Weight = (Actual body weight / Usual body weight) x 100.9 ! % Usual body weight = (142 lbs / 135 lbs) x 100 = 105.19% While Mrs. Morris is gaining weight, she is currently not gaining adequate weight. This is discussed in detail below. 13. Mrs. Morriss inadequate weight gain is illustrated on the attached maternal weight gain curve (see appendix A) and in the calculations below. Her current weight gain (represented by the red dot on the maternal weight gain curve) has been plotted and confirms she is below the normal range for a woman with healthy pregravid BMI.10 Additionally, it is worth noting that Mrs. Morris also did not gain adequate weight with her previous two pregnancies (see pink and green rectangles).

&!

Ashley Francis Current recommendations are that pregravid normal weight women gain between 1.1-4.4 lbs during their first trimester.2 They should subsequently gain 0.8-1 lbs per week during the second and third trimesters.2 Mrs. Morris has only gained 7 pounds during her pregnancy. At 23 weeks gestation, Mrs. Morris should have gained between 9.1lbs - 14.4lbs based on the calculations below. ! Minimum adequate weight gain (1.1 lbs during first trimester, followed by 0.8 lbs each week of 10 weeks in second trimester) = (1.1 lbs + (0.8 lbs X 10 weeks)) = 9.1 lbs ! Maximum adequate weight gain (4.4 lbs during first trimester, followed by 1 lbs each week of 10 weeks in second trimester) = (4.4 lbs + (1.1 lbs X 10 weeks) = 14.4 lbs 14. The Mifflin-St.Jeor (MSJ) equation tends to be the most accurate calculation of REE for normal weight and obese individuals.2 Utilizing the MSJ equation tailored for females, Mrs. Morriss daily energy requirement is 1,329.88 kcal/day. However, pregnant females require additional energy during their second and third trimesters in order to accommodate for fetal development.2 As previously noted, it is recommended that they increase their energy intake by 340-360 kcal/day during the second trimester, and add an additional 112 kcal/day in the third trimester.2 Therefore, since Mrs. Morris is currently in her second trimester; an additional 340-360 kcal/day should be added to the 1,329.88 kcal/day determined above. This means Mrs. Morris has a daily energy intake of 1,669.88-1,689.88 kcal/day. As Mrs. Morris has not gained adequate weight, perhaps it is best to err on the side of caution and recommend she consume 1,689.88 kcal/day. See calculations below: ! MSJ Female: Resting Energy Expenditure (REE) = 10W (kg) + 6.25H (cm) 5A (years) 161.2 o 142 lbs / 2.2 kg = 61.4 kg o 65 x 2.54 cm = 165.1 cm ! REE = 614 + 1,031.88 155 161 = 1,329.88 kcal/day ! 1,329.88 kcal/day + 360 kcal/day [2nd Trimester Requirements] = 1,689.88kcal/day Additionally, as noted before, increased protein intake is suggested to support fetal growth. During the first twenty weeks, pregnant womens protein recommendation remains 0.8g/kg/day. However, this recommendation is increased to 1.1g/kg/day (71 g/day) during the second twenty weeks of pregnancy.2 If we use Mrs. Morriss pregravid body weight to determine her 23rd week of gestation protein needs; her current protein recommendation is 67.54g/day based on the following equation: ! 1.1g/kg/day o 61.4 kg pregravid weight ! (1.1g/kg) X 61.4 kg = 67.54g/day* 15. When assessing Mrs. Morriss dietary intake using her completed 24-hour recall; we see that she is not meeting the recommended energy and protein requirements. Recommended Energy 1,689.88 kcal/day Actual 1,586.762 kcal Status Not meeting requirement. Inadequate energy intake. Needs more energy. Not meeting requirement. Inadequate protein intake. Needs more protein.

Protein

71 g (or 67.54 g* based on 1.1g/kg of Mrs. Morriss weight/day )

35.770 g

11, 2

'!

Ashley Francis 16. Again, using Mrs. Morriss 24-hour recall, we can see that in addition to not meeting her energy or protein needs she is also failing to consume enough iron. Recommended Iron 22 mg Actual 16.977 mg Status Not meeting requirement. Inadequate iron intake. Needs more iron.

11, 2

17. Pertinent nutrition problems and their corresponding diagnoses are written below. 1. Inadequate intake of fruits and vegetables. Nutrition diagnosis: Imbalance of nutrients. (NI - 5.5) 2. Diet low in good quality protein. Mrs. Morris states she is a picky eater and that there are a lot of foods she doesnt like. Nutrition diagnosis: Inadequate protein intake. (NI - 5.7.1) 3. Inadequate weight gain of only 7 lb. Nutrition diagnosis: inadequate energy intake. (NI - 1.2) 4. Insufficient intake of foods rich in iron and irregular intake of prenatal vitamins. Nutrition diagnosis: Inadequate iron intake. (NI -5.10.3) 5. Limited knowledge about diet adequate for pregnancy and the role of prenatal vitamins. Nutrition diagnosis: Food and nutrition related knowledge deficit. (NB - 1.1) 6. Inadequate consumption of increased energy and nutrients needed during pregnancy Nutrition diagnosis: Increased nutrient needs (NI 5.1) 18. PES statements for Mrs. Morris are provided below. 1. Imbalance of nutrients R/T inadequate intake of fruits and vegetables AEB 24 H recall and usual dietary intake. (NI - 5.5) 2. Inadequate protein intake R/T diet high in processed foods and low in meats and other protein sources AEB 24 H recall and usual dietary intake. (NI - 5.7.1) 3. A. Inadequate energy intake R/T diet low in calories that doesnt respond to high energy needs in pregnancy AEB inadequate increase in weight (7# at 23 weeks). (NI - 1.2) B. Inadequate energy intake R/T knowledge deficit regarding diet modification required in pregnancy AEB 24 H recall and usual dietary intake. (NI - 1.2) 4. Inadequate mineral intake - Iron R/T diet low in iron rich foods AEB the diagnosis of hypochromic microcytic anemia (ferritin level of 10 micrograms per deciliter). (NI - 5.10.3) 5. Food and nutrition related knowledge deficit R/T insufficient nutrition education AEB dietary history. (NB - 1.1) 6. Increased nutrient needs R/T pregnancy AEB inadequate weight gain. (NI - 5.1) 19. Ferrous sulfate side effects: " GI: ! constipation ! stomach upset ! nausea ! diarrhea ! heartburn ! vomiting

(!

Ashley Francis " " GI side effects are dose related and usually occur if the pt. is taking over 325 mg three times a day. Mrs. Morris is taking 120 mg/day total so these side effects are not likely. Other: ! stained teeth ! dark stool ! iron overload (usually due to genetic disorder, hemochromatosis, but can occur in people that take large doses of Fe over longer periods) Immunity: ! gastroenteritis IV Iron can cause: ! headache ! fever ! swollen lymph nodes ! painful joints ! hives ! worsening of rheumatoid arthritis.12

" "

Drug-nutrient interactions: " Vit C ! enhances Fe abs and maintains Fe ! releases Fe3+ from ferritin, and reduces to Fe2+ " Copper ! hephaestin and ceruloplasmin can act as ferroxidases ! oxidation of Fe2+ (ferrous iron) into Fe3+ (ferric iron), is necessary for transport in the plasma in association with transferrin, which can carry iron only in the ferric state. " Zinc ! Excess intake of nonheme from supplements, may inhibit Zn abs. " Calcium ! Calcium intake can decrease the nonheme absorption " Retinoic acid ! the combination of Vitamin A and Fe supplements ameliorate anemia more effectively " " Lead ! inhibits the activity of aminolevunic acid dehydratase, required in heme synthesis. Selenium ! Fe deficiency is associated with decreased [Se] and a Se-dependent enzymes.8

Fe supplements can interfere with a number of medications and need to be taken 2 hours prior or after the other medications. These are some of the medicines that can have adverse interactions: ! Allopurinol (Zyloprim) ! Penicillamine ! Nonsteroidal anti-inflammatory drugs (NSAIDs) The following medications may reduce the absorption of iron: ! Cholestyramine and Colestipol ! Medications used to treat ulcers, GERD, or other stomach problems ! Antacids

)!

Ashley Francis Iron decreases the absorption of the following medications: ! Tetracyclines ! Quinolones ! Bisphosphonates ! ACE inhibitors Iron may reduce the effectiveness of blood levels of the following medications: ! Carbidopa and Levodopa ! Levothyroxine Iron levels may be increased by: ! Birth control medications12 Nutrients that Enhance nonheme iron absorption: " Sugars (fructose, sorbitol) " Vit C (ascorbic acid reduces Fe3+ to Fe2+) " Lactic acid and citric acid " Meat, poultry, and fish factors " Mucin ! Endogenous chelator synthesized in the GI tract Nutrients that Inhibit of nonheme iron absorption: " Polyphenols reduce Fe abs (> 60%) ! Oxalic acid, Phytates " make insoluble complexes " Phosvitin, a phospholipid contained in egg yolks " Large quantity of Ca, calcium phosphates, Zn, Mn, or Ni (compete for DMT1 transporter) Foods that decrease Fe absorption: " tannins (teas, coffee) " calcium " polyphenols " phytates (legumes and whole grains) " some proteins in soybeans To maximize benefit of Fe supplementation, the following recommendations should be made to Mrs. Morris: " Eat healthy balanced diet: ! increase intake of foods that enhance Fe absorption: red meat, fortified cereal etc. ! avoid foods that inhibit Fe absorption: coffee, tea, legumes, soy, and whole grains " Take additional vitamin C and make sure to take prenatal vitamin8 20. Prenatal vitamin/mineral supplements usually provide: " Folate " vitamin B6 " Vitamin B12 " Choline

*!

Ashley Francis " " " " " " " " " " " " " " Vitamin C Vitamin A Vitamin E Vitamin D Vitamin K Calcium Cooper Fluoride Iodine Iron Magnesium Phosphorus Sodium Zinc

Most recommendation will increase approximately 15% when compared to pre-pregnancy values. Prenatal supplements will usually contain increased levels of: " Folate " Iron " Calcium " Plus DHA (200 mg)2 There are several recommendations that could increase the likelihood of Mrs. Morris taking her supplements more regularly: " Take supplement with food and never on an empty stomach to decrease the likelihood of nausea " If difficult to swallow, cut into smaller pieces. " Take with juice or smoothie 21. Factors to monitors to assess pregnancy, nutritional and Fe status: " Weight gain - assess pregnancy charts regularly to make sure the weight gain is increasing " Iron levels (monitor lab values: ferritin, TIBC, Hb, hematocrit) " Dietary intake (specifically caloric and protein intake) " Ferrous supplement intake and prenatal vitamin intake " Folate levels

"+!

Ashley Francis REFERENCES: 1. National Institutes of Health. Hematocrit. MedlinePlus. http://www.nlm.nih.gov/medlinrplus/ency/article/003646.htm. March 22, 2013. Accessed September 21, 2013. 2. Mahan LK, Escott-Stump S, Raymond JL. Krauses Food and the Nutrition Care Process. 13th ed. St. Louis, MO: Elsevier Saunders; 2012 3. National Institutes of Health. RBC Count. MedlinePlus. http://www.nlm.nih.gov/medlinrplus/ency/article/003646.htm. March 22, 2013. Accessed September 21, 2013. 4. Whittaker PG, Macphail S, Lind T. Serial hematologic changes and pregnancy outcome. Obstet Gynecol. 1996;88(1):33-9. 5. Brill JR, Baumgardner DJ. Normocytic anemia. Am Fam Physician. 2000;62(10):2255-64. 6. Tefferi A. Anemia in adults: a contemporary approach to diagnosis. Mayo Clin Proc. 2003;78(10):1274-80. 7. Scholl TO, Hediger ML, Fischer RL, Shearer JW. Anemia vs iron deficiency: increased risk of preterm delivery in a prospective study. Am J Clin Nutr. 1992;55(5):985-8. 8. Stipanuk MH, Caudill MA. Biochemical, Physiological, and Molecular Aspects of Human Nutrition. 3rd ed. St. Louis, MO: Elsevier Saunders; 2013 9. Rombeau JL, Barot LR, Williamson CE, Mullen JL. Preoperative total parenteral nutrition and surgical outcome in patients with inflammatory bowel disease. Am J Surg. 1982;143(1):139-143. 10. NC Department of Health and Human Services Womens and Childrens Health Section. Maternal Weight Gain Chart. USDA WicWorks web site. http://www.nal.usda.gov/wicworks/Sharing_Center/NY/prenatalwt_charts.pdf. Published June, 2010. Updated June, 2013. Accessed September 18, 2013. 11. Nutritionist Pro Analysis Software 12. Ehrlich SD. Iron. University of Maryland Medical Center web site. http://umm.edu/health/medical/altmed/supplement/iron. Published June 17th, 2011. Accessed September 15th, 2013.

""!

Ashley Francis Appendix A

10

"#!