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Anemia Associated

With

Nutritional Deficiencies

Elisabeth Sosa, MSN, ARNP, AOCNP

Elisabeth Sosa, MSN, ARNP, AOCNP is a certified

adult oncology nurse practitioner. She practices within a large private practice

hematology/medical oncology group in Central Florida. She has previously been published in

the Clinical Journal of Oncology Nursing (CJON).

ABSTRACT

Anemia can occur for many different reasons. These include chronic disease,

nutritional deficiencies, malignancy, medications, blood loss, and bone

marrow disorders. It is important that nurses understand how anemia is

caused by nutritional deficiencies, as well as how anemia and nutritional

deficiencies are treated. Health care personnel with an understanding of

anemia are better prepared to ensure that affected individuals obtain

appropriate treatment and avoid complications. This course will discuss the

definition of anemia, as well as grading the severity and complications of

anemia.

Keywords: Anemia, Hematology, Red blood cells, Iron deficiency, Pernicious

Anemia, Vitamin B12, Folic acid.


Continuing Nursing Education Course Planners

William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,

Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner

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 1.5 hours. Nurses may only claim

credit commensurate with the credit awarded for completion of this course

activity.

Statement of Learning Need

An understanding of anemia due to nutritional deficiencies, as well as how

anemia and nutritional deficiencies are treated, is essential for health

professionals to support patients diagnosed with anemia.

Course Purpose

To help nurses develop an understanding of the treatment of anemia related

to nutritional deficiencies, and to learn about treatment options for types of

anemia as well as reasons why patients would require blood transfusions.


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

Elisabeth Sosa, MSN, ARNP, AOCNP, 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.

Activity Review Information

Reviewed by Susan DePasquale, MSN, FPMHNP-BC

Release Date: 1/1/2016 Termination Date: 7/1/2018

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.


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

The presence of anemia in an indivdiual often is indicative of an underlying

diseas-state. It is important for health professionals to understand the

pathology underlying anemia for both men and women. Anemia involves a

reduction in the concentration of hemoglobin or red blood cells in the blood

and, depending on the severity, may require treatment. The level of anemia

often depends upon the age and gender of individuals, including lifestyle

patterns and altitude of the person’s residence. This course introduces a

case study at the start and end of the study relative to nursing care.

Case Study: Vanessa

The following case study may be seen in the outpatient primary care setting.

The objective of this case study is to illustrate how patients with anemia may

present. Suggestions will be made later in this course on how the patient

should be treated, including appropriate diagnostic testing, pharmacological

treatment, and supportive care.

Vanessa is a 25-year-old female with no significant past medical history.

She is premenopausal and has heavy menstrual cycles lasting seven days

on average. She is not taking any kind of hormonal contraceptives. She

develops symptoms including excessive fatigue, headaches, muscle

cramps in her legs, and cravings for ice. She presents to her primary care

physician for further evaluation. The PCP sends Vanessa for blood work

and schedules a return appointment in one week to discuss results. Upon

Vanessa’s return visit, her physician reviews her lab studies. Vanessa’s

complete blood count (CBC) notes a normal white blood cell count (WBC)

of 6.7.


The platelet count is on the higher end of normal at 448,000. The

hemoglobin is decreased at 9.9. The MCV (mean corpuscular volume) is

also decreased at 77. The CMP is within normal limits. Thyroid studies are

also normal. However, the iron studies note significant deficiency with a

ferritin level of 5 and iron saturation of 4 percent. Her PCP starts her on

an iron supplement for the time being but refers Vanessa to a

hematologist for further evaluation.

Definition Of Anemia

Red blood cells (RBCs), which are also called 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

average lifespan of these cells, which are shaped like a biconcave disk, 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 cells to vary their shape easily so that they

can 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 ranges for what is considered normal can vary depending on the source.

Anemia is typically based on the hemoglobin value. In addition to red blood

cell count and hemoglobin, there are a number of other laboratory values

that are important in helping to diagnose anemia. The mean cell volume is


the average size of the RBCs. If a patient with anemia has a normal MCV, it

is called normocytic anemia. If the MCV is less than normal, it is considered

microcytic. If the MCV is greater than normal, it is considered macrocytic.

The mean cell hemoglobin 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.3

Table 1. 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

concentration (MCHC)

33.4- 35.5

Red cell distribution width

(RDW) (%)

11.5- 14.5


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, smoking and living at higher altitudes raise the concentration of

hemoglobin. On the other hand, pregnant women usually experience a drop

in hemoglobin, which starts in the first trimester and worsens in the second

trimester.4

Table 2. National Cancer Institute Common Terminology Criteria for Adverse Events:

Anemia5

Grade 1 2 3 4 5

Hemoglobin

(Hgb) <LLN-

10 g/dL*

Hgb <10 - 8

g/dL

Hgb <8 g/dL Life-

threatening

consequences.

Urgent

treatment

required.

Death

*LLN- lower limit of normal.

Causes Of Anemia

In some cases, anemia is multifactorial. There are three main causes of

anemia:

Decreased production of red blood cells

Increased destruction of red blood cells

Blood loss


When thinking about the three major causes of anemia, it is important to

note that blood loss leads to iron deficiency, which will be discussed shortly.

However, this course will mainly focus on acquired causes of decreased RBC

production. The bone marrow needs certain ingredients to make red blood

cells, which include iron, vitamin B12, and folate.3

Iron Deficiency Anemia

The most common nutritional deficiency in the world is iron deficiency. In

the United States, iron deficiency is noted in approximately two percent of

adult men and nine to twelve percent of Caucasian women. The incidence is

even higher in minority women, estimated at close to 20%. Risk factors for

iron deficiency include vegetarian diet, blood donation, and low

socioeconomic status in conjunction with being postpartum.6

Causes

The major causes of iron deficiency are listed below:

Insufficient dietary intake of iron (occurs mainly in infants and children)

Averting iron to fetus/infant during pregnancy and/or lactation

Chronic blood loss (respiratory, gastrointestinal, genitourinary tracts,

phlebotomy)

Iron malabsorption (patients who have had subtotal gastrectomy, gastric

bypass)

Intravascular hemolysis

Mixture of the above


In women, the most common cause of iron deficiency is chronic blood loss in

the form of menorrhagia. In men and postmenopausal women,

gastrointestinal bleeding is the most common source of iron deficiency.3, 6

Symptoms and Diagnosis

Symptoms of iron deficiency anemia include fatigue, shortness of breath on

exertion, and palpitations. Headaches and irritability can also occur. Cold

hands and feet, as well as tingling sensations in the legs may also happen.

Strange cravings to eat ice or clay, known as pica, may occur. Children can

have low attention spans, developmental delays, and behavioral problems. It

is important to note that the severity of symptoms does not always match

up with the severity of iron deficiency. Physical examination of patients with

anemia may be positive for pallor and smooth red tongue. Koilonychia, or

spoon-shaped nails, is usually only seen in very severe, chronic cases of

deficiency.3, 7

The CBC is a very important part of the puzzle in diagnosing iron deficiency.

Microcytic (decreased MCV), hypochromic (decreased MCHC) anemia is

usually seen. The RDW (red cell distribution width) is often elevated. WBC is

usually normal. Most of the time, the platelet count will be normal. However,

it is not uncommon to see elevated platelet count, which is usually related to

chronic blood loss.3

Iron studies include serum iron concentration, total iron binding capacity

(TIBC), and serum ferritin. The serum iron level is usually low. TIBC is

usually elevated. However, in mild cases the TIBC is in the higher range of

normal. Iron saturation, which is a calculation based on iron and TIBC, is


decreased. In patients with iron deficiency, the iron saturation is usually less

than fifteen percent. It is important to note that patients with chronic

inflammation can also have a low iron saturation value even though they are

not iron deficient.

The serum ferritin is a measurement of iron stores. Low ferritin levels are

seen in iron deficiency. However, patients with iron deficiency can have

elevated ferritin levels. This is because serum ferritin is an acute phase

reactant and is often increased during inflammatory states, such as chronic

kidney disease, malignancy, and hepatitis.3

Once a patient is diagnosed with iron deficiency, the work does not stop

there. The reason for iron deficiency must be discovered. Since

gastrointestinal loss is the most common cause of iron deficiency, stools

should be checked for occult blood. Further workup, including

esophagogastroduodenoscopy (EGD) and colonoscopy, may be required.

Women with menorrhagia will need to follow with a gynecologist. They may

require further testing, such as pelvic ultrasound.3, 7

Complications

Iron deficiency can become quite severe and lead to very serious problems if

it goes untreated. In pregnant females, the incidence of premature births

and low birth weight babies is higher with iron deficiency. Infants and

children with iron deficiency may experience growth and developmental

delays. Cardiac problems, including tachycardia and arrhythmias can also

occur. The heart is under more stress and works harder to pump blood

throughout the body. This increased work can lead to cardiomegaly.7


Treatment

Usually oral iron replacement is the first step in treating iron deficiency.

Increasing iron in the diet is not adequate. There are a plethora of oral iron

supplements. Ferrous sulfate is the least costly option. The daily dose of

elemental iron should be 150 mg to 200 mg, divided into three or four

doses.3

Educating Patients About Oral Iron Supplementation

Below are some important items to discuss with patients who are taking

iron.

Do not take iron with meals

Do not take iron with antacids or anything that reduces acid

Iron can often cause constipation. Laxatives or stool softeners may be

taken as needed.

Iron is best absorbed with vitamin C.

Iron supplementation can cause dark-colored stools.

Store iron supplements in a safe place, away from children.

The average time to normalization of hemoglobin levels is two to four

months. Patients should continue oral iron for approximately one year after

hemoglobin normalizes. In patients who continue to have blood loss, they

may need to be on iron replacement for as long as the bleeding continues.

The expected response may not occur if bleeding persists. If bleeding has

been controlled but response is poor, other things to consider include

malabsorption or other causes of anemia.3


Parenteral iron is also available for the treatment of iron deficiency. The

reasons for using parenteral iron include very severe deficiency,

malabsorption, and inability to tolerate oral iron (usually gastrointestinal

symptoms, such as colitis or severe constipation). There are a number of

different preparations. Dosing and frequency of treatment differ based on

the specific iron product. Some products can be given intravenously or

intramuscularly. Allergic reactions, including anaphylaxis, can occur.3

In extremely severe cases of iron deficiency anemia associated with blood

loss, patients may require transfusion of PRBCs (packed red blood cells).

Transfusions should only be administered to patients with hemoglobin less

than 7 - 8 and who are symptomatic (i.e., weakness, shortness of breath,

palpitations). Patients should be properly counseled about the risks of

transfusion.3 For more detailed information about blood transfusions, please

see the course list.

Vitamin B12 Deficiency

Vitamin B12, also known as cobalamin, is a water-soluble vitamin that is

important in the production of red blood cells. Vitamin B12 also has a role in

the health of the central nervous system. Vitamin B12 can be stored in the

liver for months to years. The average American diet is plentiful in vitamin

B12. It is found in various foods, including meat, shellfish, eggs, milk, and

dairy products.

Many other foods, such as cereal, have added B12. However, B12 is

absorbed more efficiently from animal-based foods.8


Causes

Individuals following a vegan diet may be at risk for B12 deficiency.

However, the most common cause of B12 deficiency is malabsorption.

Intrinsic factor is required for the absorption of B12. Malabsorption can be

due to several different factors, including:

Pernicious anemia (most common reason for malabsorption)

Gastric Bypass

History of gastrectomy (total and subtotal)

Ileal resection

Diseases/trauma to ileum (sprue, Crohn’s disease, radiation)

Zollinger-Ellison Syndrome

Pancreatic Disease

Blind Loop Syndrome

Diphyllobothrium latum infestation (intestinal parasites)

As mentioned above, pernicious anemia is the most common cause of

malabsorption. Pernicious anemia is actually an autoimmune disease. The

immune system destroys cells in the stomach. Because of this damage, the

gastric mucosa does not produce intrinsic factor adequately and B12

deficiency occurs.3, 8


Patients who develop anemia secondary to B12 deficiency usually develop

anemia slowly. Patients may experience fatigue, weakness, palpitations, and

lightheadedness. Because pernicious anemia can cause damage to the

nervous system, these patients may present with neurological symptoms.

Sometimes neurological symptoms occur before symptoms of anemia.


Neurological symptoms include numbness and tingling in the hands and feet,

as well as changes in position and vibration sense. If the brain is affected,

patients may experience sleepiness as well as changes in taste, smell, and

vision. Physical examination may reveal pallor and smooth, beefy red

tongue.3, 8

The CBC again is very useful in diagnosing B12 deficiency. This type of

anemia is usually a macrocytic anemia, meaning that the red blood cells are

larger than normal. The size of red blood cells varies and they can be oddly

shaped. This type of anemia is known as megaloblastic, meaning that the

red blood cells are large and have immature nuclei. The MCV is increased,

usually 100 or more. However, if there is also an iron deficiency or

inflammation, the MCV may not be elevated. Oftentimes, patients will also

have low WBC and platelet count.3

In order to confirm B12 deficiency, further testing is imperative. Serum B12

level is low, but this alone is not sufficient to diagnose a deficiency.

Sometimes the B12 level will be normal despite the presence of a deficiency.

Elevated methylmalonic acid is a good sign of B12 deficiency. The

homocysteine level is also elevated. The homocysteine level is not as reliable

as the methylmalonic acid level because homocysteine may also be elevated

in folate deficiency and hypothyroidism.3

As mentioned previously, pernicious anemia is a common cause of B12

deficiency. In order to diagnose pernicious anemia, further testing is

required. Serum parietal cell antibodies are usually present in these patients,

though this test is not specific. Serum intrinsic factor antibodies is a specific

test that will be elevated in these patients.3


Complications

If B12 deficiency goes untreated, complications can ensue. Neurological

symptoms, such as numbness and tingling in the hands and feet, can

sometimes be irreversible. Lack of muscle control and muscle stiffness,

known as spastic ataxia, may ensue. Dementia and psychosis are other

serious complications.3

Treatment

Patients who have B12 deficiency due to poor dietary intake (such as

vegans) may benefit from oral or sublingual B12 supplementation.

Sublingual B12 is more readily absorbed. However, B12 deficiency is usually

due to malabsorption issues. In those cases, parenteral B12 is used to treat

deficiency. The injection is normally given intramuscularly. When initiating

B12 replacement, there is a series of loading doses (1,000 micrograms daily

or weekly for several doses). The maintenance dose is usually 1,000

micrograms monthly. In some cases, this dose may not be sufficient and

higher doses will be required. B12 is not toxic but excess B12 will be

excreted through the urine. Patients who have had total gastrectomy or

terminal ileum resection should be started on B12 treatment after surgery. It

is important to monitor potassium levels in patients receiving B12

replacement as hypokalemia can develop.3, 8

Once treatment is started, patients often note improvement quickly. The

marrow starts to produce normal red cells within a day of starting treatment.

It takes about one to two months for the hemoglobin to return to normal

range. Most of these patients will not require blood transfusion as they have


likely adjusted to anemia over time. If neutropenia and thrombocytopenia

were present, these values also return to normal rather quickly.3

Folate Deficiency

Folate, or folic acid, is a B vitamin that is important in the production of red

blood cells. Folic acid also creates and fixes DNA. Folic acid is found in many

different foods, including green leafy vegetables, liver, poultry, shellfish,

citrus, beans, legumes, and eggs. Folic acid is water-soluble. Excess folic

acid is eliminated and only a limited amount is stored in the body. Deficiency

can occur after just a few weeks of not eating enough folic acid.9

Causes

The major causes of folate deficiency can be separated into three main

categories, which include decreased intake, increased need, and problems

with absorption. A diet low in folic acid is the most common cause of

deficiency. The list below provides more detail.3, 9

Decreased Intake:

Poor Nutrition

Alcoholism

Elderly

Children on synthetic diets

Hemodialysis

Hyperalimentation

Spinal cord injury

Premature infants


Increased Need:

Chronic hemolytic anemia

Pregnancy

Exfoliative dermatitis

Problems with Absorption:

Sprue, celiac disease

Other diseases of the intestine, such as Crohn’s disease

There are also a number of medications that can cause folic acid deficiency.

Some of these medications include methotrexate, aminopterin, sulfasalazine,

trimethoprim, triamterene, pemetrexed, hydroxyurea, phenytoin, and some

oral contraceptives. In some cases, it may be necessary for patients on

these medications to take supplemental folic acid.3


Symptoms of folate deficiency may include fatigue and weakness. The

anemia usually progresses gradually. Folic acid deficiency does not cause

neurological symptoms unless a vitamin B12 deficiency is also present. On

physical exam, patients may have gray hair, red swollen tongue, and mouth

sores. Children with folic acid deficiency may have stunted growth.9

The CBC is an important element in diagnosing folate deficiency. Just like

with B12 deficiency, this type of anemia is usually a macrocytic anemia,

meaning that the red cells are larger than normal. This will result in an

elevated MCV. Patients who present with macrocytic anemia should be


tested for both folic acid and vitamin B12 deficiencies. The serum folic acid

level will be low. However, it is important to remember that folic acid has

limited stores in the body. A low folic acid level may just signify decreased

intake in the few days before testing.3

Complications

In severe cases of deficiency, patients may also experience leukopenia and

thrombocytopenia. Folic acid deficiency in pregnant women may lead to

neural tube defects in the baby.9

Treatment

Folic acid deficiency is treated with oral supplementation. The dose is usually

betweem1mg and 5mg daily. Pregnant women should take 1mg of folic acid

daily during the entire pregnancy.3

Summary

There are many different causes of anemia. Nutritional deficiencies can often

lead to anemia. Iron, folic acid, and vitamin B12 are all important in the

production of red blood cells. When patients present with anemia, it is

imperative that the cause of anemia is identified early on so that adequate

treatment can be provided.

Severe anemia can lead to serious complications, including heart problems

and irreversible neurological changes. Patients with severe anemia may even

require blood transfusion.


On Reflection: Vanessa (case study at the beginning of the course)

Vanessa’s hemoglobin is 9.9, which would be considered Grade II anemia.

However, the most important thing to note is that Vanessa is symptomatic, with

complaints of fatigue and muscle cramps. She also has cravings for ice, known

as pica. She presents to the hematologist for further evaluation. The

hematologist performs a thorough history and physical examination. She is

somewhat pale, but otherwise her exam is unremarkable.

Although Vanessa’s PCP evaluated the iron studies, the hematologist proceeds

with an extensive anemia work up to ensure there are no other causes of

anemia. The hematologist evaluates levels of B12 and folic acid and orders stool

testing for occult blood.

Because Vanessa’s iron deficiency is severe and her menorrhagia is ongoing, the

hematologist recommends intravenous iron. He discusses intravenous iron

therapy with Vanessa, including the risks and possible side effects. He schedules

a return visit in one week to discuss results and start treatment. In the

meantime, he advises Vanessa to continue the oral iron supplement.

At Vanessa’s next visit, her workup is overall negative except for severe iron

deficiency caused by menorrhagia. The hematologist refers her back to her

gynecologist for evaluation of menorrhagia. Vanessa starts her IV iron that day

and tolerates it very well. Vanessa completes her iron treatment and her

gynecologist starts her on oral contraceptives. After she completes IV iron, she

continues on daily, oral iron supplement. Vanessa’s menorrhagia improves after

several months. When the iron studies are repeated three months later, results

show resolution of the iron deficiency. Her hemoglobin is normal at 13.1. Her

platelet count has also normalized at 355. Vanessa has no fatigue or other

symptoms of anemia. She continues to follow up regularly and has her iron

studies evaluated every three months.


Nurses play a crucial role in caring for patients with anemia and to keep

them safe. Part of the nursing role is to administer the treatments for

anemia. They often assist in educating patients and their families about the

treatments and possible side effects. As part of the healthcare team, nurses

are in an excellent place to improve patient outcomes.

Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment

of Knowledge Questions after reading the article, and providing feedback in the online course evaluation.

Completing the study questions is optional and is NOT a course

requirement.


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.


Correct Answers:

1. a

2. c

3. b

4. d

5. b

References Section

The reference section of in-text citations include published works intended as

helpful material for further reading. Unpublished works and personal

communications are not included in this section, although may appear within

the study text.

1. American Society of Hematology. (2015). Blood basics. Retrieved from

http://www.hematology.org/Patients/Basics/

2. Gersten, T. (2014). RBC indices. In Medline Plus. Retrieved from

http://www.nlm.nih.gov/medlineplus/ency/article/003648.htm

3. Lichtman, M. A., Kaushansky, K., Kipps, T. J., Prchal, J. T., & Levi, M. M. (2011). Disorders of red cells. In J. Shanahan & H. Lebowitz (Eds),

Williams manual of hematology eighth edition (pp.9-58). New York: McGraw Hill Medical.

4. National Cancer Institute. (2009). Common terminology criteria for

adverse events v4.0 (NIH Publication No. 09-7473). Retrieved from http://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03_2010-06-

14_QuickReference_8.5x11.pdf

5. World Health Organization. (2011). Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral

Nutrition Information System. Retrieved from

http://www.who.int/vmnis/indicators/haemoglobin.pdf

http://www.hematology.org/Patients/Basics/



6. Killip, S., Bennett, J. M., & Chambers, M. D. (2007). Iron deficiency

anemia. American Family Physician, 75(5), 671-678.

7. Mayo Clinic. (2014). Diseases and conditions: Iron deficiency anemia. Retrieved from http://www.mayoclinic.org/diseases-conditions/iron-

deficiency-anemia/basics/definition/con-20019327

8. Evert, A. (2013). Vitamin B12. In Medline Plus. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/002403.htm

9. Gersten, T. (2013). Folate deficiency. In Medline Plus. Retrieved from


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