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Indian Journal of Community Medicine

Impact of Iron, Folate and Vitamin C Supplementation on The Prevalence of Iron Deficiency Anemia In Non-pregnant Females of Peri Urban Areas of Aligarh

Author(s): S Mehnaz, S. Afzal, S. Khalil, Z. Khan

Vol. 31, No. 3 (2006-07 - 2006-09)

S Mehnaz, S. Afzal, S. Khalil, Z. Khan

Introduction

Nearly 1.5 billion people all over the world are affected by iron deficiency anaemia (IDA). In India also, depending on age and sex, prevalence of IDA has been reported to range from 38-72 per cent, majority of them being women and children. The IDA prevalence rate beyond the age of six years is higher in girls. This could be due to certain factors such as menstruation, gender discrimination in intra-household food allocation and early marriage leading to early pregnancy. Estimates suggest that about 25-50 per cent girls become anaemic by the time they reach menarche. Thus, in these adolescent girls, pregnancy only serves to aggravate their pre-existing anemia.

Though supplementation with iron and folic acid remains the cornerstone in treatment and prevention of anemia, addition of vitamin C has its other added advantages. Iron deficiency anemia is prevalent throughout the world because of the inefficient absorption of nonheme iron, which forms the bulk of the iron in the diet. Absorption of this type of iron is impaired by substances in food, which reduce its availability. Ascorbic acid reverses the effect of dietary inhibitors and is one of the most powerful known promoters of nonheme iron absorption2.

In view of the above facts, the present study was carried out to ascertain the impact of iron supplementation alone and with vitamin C on the prevalence of iron deficiency anemia among the non-pregnant females of the age group 15-55 yrs.

Material and Methods

The study was conducted in ‘Qila ka nagla’ a periurban field study area registered under ‘Urban Health Training Center’ (UHTC), Department of Community Medicine. Jawaharlal Nehru Medical College. Aligarh Muslim University. Aligarh. All the 515 households in this area are registered under UHTC. From these households all the non-pregnant females of the age group of 15-55 yrs formed the reference population, of whom 177 females were randomly selected, (sample size calculated with 10% error, with 95% confidence limits) taking the prevalence rate of iron deficiency anemia among adolescent and non-pregnant females to be 70%1.

They were interviewed using a prestructured performa. Physical examination, haemoglobin estimation by Sahli’s haemoglobinometer and standard blood smear examination were also done.

Two non-anaemic (Hb%>12m%) were excluded Rest were divided into experimental (87) and control group (88) by randomization using random number table. The experimental group was further divided into two sub-groups 1 and 2. Subgroup 1(44) were supplemented with iron (200mg) and folic acid (0.5mg)/ day and sub-group 2 (43) were supplemented with iron (200mg), folic acid (0.5mg) and vitamin C (l00mg) /day for a period of 100 days. No supplements were given to the control group.

Both the control and experimental groups were followed for a period of 100 days and haemoglobin measurements done at the start of the study, at 30 days and at 100 days of supplementation. Drop out rate was 7.34%.

Exact description of the information was delivered to the subjects of the study e.g. the objective and purpose of the study, any long term or short-term risks or discomforts, duration of procedures, duration of the study etc, and then oral consent was taken from them.

Results

Sixty-eight subjects (38.85 %) were in the age group of 15-25 yrs, sixty six (37.7 %) in 26-35 yrs, 25 (14.28 %) in 36-45 yrs and 16 (9.14 ) in 45-55 yrs. Most (83) females of the study population belonged to social class III and IV.

A very high overall prevalence of iron deficiency anaemia (98.87 %) was found in the study population. The gradation in anemia was- mild in 14.8% (26) cases, moderate in 72% (126) cases and severe in 13% (23) cases. The general blood picture was predominated by microcytic hypochromic type while a few had normocytic hypochromic type of blood picture.

After interventions, at 100 days, the proportion of mild anemia (Hb% 10-11.9gm%)3 increased from 14.8 % (26) to 29.14 % (51), while that of moderate (Hb% 7-10gm%)3 and severe anemia (Hb%<7gm%)3 decreased from 72% (126) to 36% (63) and 13% (23) to 10.28% (18) respectively (Table I). Forty three (24.57%) cases attained normal range of haemoglobin after the interventions.

The iron /folate supplementation given daily in sub group 1 brought about significant change (p<0.0.5) in the mean haemoglobin level both at 30 days and 100 days, the improvement being 0.94g/dl and 2.72g/dl respectively. In sub group 2 vitamin C supplementation along with iron/folate supplementation also brought about significant improvement (p<0.0.5) at 30 days (1.6g/dl) and 100 days (4.36g/dl). In the control group where no supplementation was given the mean increase in haemoglobin was 0.23g/dl at 30 days and 0.10g%dl at 100 days, which was found to be insignificant (p>0.05). (Table II).

Table I: A Comparison of Prevalence of Anaemia Before and After Interventions

After Interventions (N=132)
  Normal Mild Moderate Severe Total
Mild 10 13 01 02 26 (14.8%)
Moderate 31 35 58 02 126 (72%)
Severe 02 03 04 14 23 (13%)
Total 43(24.57%) 51(29.14%) 63(36%) 18 (10.28%) 175
(N=175)
*Before interventions out of 175 study subjects nobody was normal, all were anaemic. The χ2 test was applied and the p value obtained was found to be significant,i.e. (p<0.05).

Table II: The Increase in Mean Haemoglobin of the Study Population at the Start of the Study and at 100 Days

  Mean 0th
day Hb
(initial)
Mean 30th
day Hb
(gm%)
Mean
increase
after 30
days (gm%)
Mean Hb
(gm%) after
100 days
Mean
increase
after 100 days
(gm%)
Controls 8.33 8.40 0.23 8.43 0.10
Cases 8.30 9.24 0.94 11.02 2.72
(sub-group 1)
Cases 8.70 10.30 1.6 13.06 4.36
(sub- group 2)

(ANOVA TABLE)

Source of
variation
Sum of
square (ss)
Degree of
freedom (df)
Mean sum of
square (M.S.S)
Variance
Ratio’F’
Treatments 573.35 2 286.67 F=286.67/0.02
Error 3.86 173 0.02 F=143.43
Total 577.21 175    
The value of F is significant. The value of p is <0.05 (significant)

Discussion

The highest prevalence of iron deficiency anemia in the study was found in the age group of 15-25 yrs i.e. adolescents and young females. There was considerable improvement in the haemoglobin status of the anaemic females on supplementation with iron/folate alone or with vitamin C. It was also observed that the rate of rise in Hb percentage was more in the females who had their Hb percentage at a lower range before supplementation. However, the mean increase in Hb percentage was equal in all age groups.

The dietary intake of Vitamin C along with iron rich sources enhances the absorption of iron significantly4,5. The difference in the response of the subjects getting Vitamin C supplementation with Fe/folate as compared to those receiving only Fe/folate in the present study seems to confirm this. Experimental studies on anaernic preschool children consuming a purely vegetarian diet have shown that 100g of crystalline ascorbic acid taken as a tablet along with lunch and dinner meals for two months brought about a significant improvement in the haemoglobin level that was higher than the rise obtained with iron supplements in the same study (1.9g/dl Vs l.lg/dl)6.

In another intervention study done on adolescent girls of poor community it was observed that even weekly supplementation of vitamin C along with iron/folate had a significant higher increase in haemoglobin concentration (0.76g/dl), as compared to weekly iron/folate supplementation alone (0.71 g/dl) after three months of supplementation. Also daily supplementation with iron /folate demonstrated an increase in haemoglobin by 0.99g/dl at the end of three months 1. In yet another study it was observed that supplementation of 50mg of vitamin C along with iron/folate increased the iron absorption to 7.7% as compared to iron/folate supplementation alone where the iron absorption was 1.6% only7.

On observing a high prevalence rate of iron deficiency anemia in this study, it may be concluded that adolescents and non-pregnant females of the reproductive age group should be included in the government’s R.C.H. programme of provision of free iron/folate tablets, and giving vitamin C along with it may be an added advantage. Emphasis should also be made on the need to improve the diet through increased intake of fruits and vegetables rich in vitamin C (e.g. guava, amla, oranges, tomatoes).

Our study also demonstrate that the hard core cases (14 of 23 severe anemia cases) remained in severe category even after intervention. Thus, factors other that nutritional deficiency might have been involved e.g. some underlying disease. Major shift (impact of intervention) was noted in moderate cases where 66 (52%) improved. However, two cases of mild and moderate anemia each lapsed into severe anemia after intervention. This need further in depth study of such cases.

References

  1. Sharma A. Identification of an appropriate strategy to control anemia in adolescent girls of poor communities. Indian Pediatrics 2000;37: 261-267.
  2. Lynch SR . Ascorbic acid and iron nutrition. ASDC J Dent Child 1981;48: 61-3.
  3. Anna V.Guidelines for the control of Iron Deficiency in countries of the Eastern Mediterranean Middle East and North Africa, WHO, Regional office of the Eastern Mediterranean 1996; 2:8.
  4. De Maeyer EM,Dallman P,Gurney J M, Hall berg L, Sood S K, Srikanta S G. Preventing and Controlling Iron Deficiency Anaemia Through Primary Health Care. Guide for health administrators and programme managers. World Health Organization, Geneva 1989; 24-25.
  5. Fishman. SM. The role of vitamins in prevention and control of anemia. Public Health Nutrition 2000 June; 3(2): 125-50.
  6. Gillespie S. Malnutrition in South East Asia, a regional profile, Rosa publications No.5, UNICEF, Regional Office for South Asia Nov. 1997 : 92-93.
  7. Davidsson L . Influence of ascorbic acid on iron absorption from an ironfortified, chocolateflavored milk drink in Jamaican children. Scientific Abstracts: Comprehensive Nutrient Review: Iron Research Abstracts, 113_1998;67:8737.

Deptt. of Community Medicine, Jawaharlal Nehru Medical
College, Aligarh.

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