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Indian Journal of Community Medicine

Epidemiological Correlates of Nutritional Anemia in Adolescent Girls of Rural Wardha

Author(s): S. Kaur, P.R. Deshmukh, B.S. Garg

Vol. 31, No. 4 (2006-10 - 2006-12)

S. Kaur, P.R. Deshmukh, B.S. Garg

Abstract

Objectives: To study the epidemiological correlates of nutritional anemia among adolescent girls in rural Wardha. Methods: A cross-sectional study was carried out in adolescent girls of four villages of Kasturba Rural Health Training Centre, Anji. The relevant information was collected with anthropometric measurements and hemoglobin estimation. Univariate and Multivariate Logistic Regression analysis was done using SPSS 10. Results: The prevalence of anemia was found to be 59.8%. In univariate analysis, low socioeconomic status, low iron intake, vegetarian diet, history of worm infestation and history of excessive menstrual bleeding showed significant association with anemia. While Multivariate logistic regression analysis suggested that strongest predictor of anemia was vegetarian diet (OR=5.83, CI=3.73-9.13) followed by history of excessive menstrual bleeding (OR=5.65, CI=1.26-25.38), iron intake <14mg (OR=4.16, CI=2.08-8.31) followed by 14-20mg (OR=2.07, CI=1.06-4.05) and history of worm infestation (OR=4.11, CI=1.70-9.93). However age, education, socioeconomic status, BMI and status of menarche did not contribute significantly.

Key words: Vegetarian Diet, Iron deficiency, BMI, Menstrual Bleeding, Hemoglobin

Introduction

World interest in adolescent health issues has grown dramatically in the past decade beginning with the International Year of Youth in 1985 and the World Health Assembly in 1989, when discussions were focused on the health of youth.1

Among adolescents, girls constitute a vulnerable group, particularly in developing countries where they are traditionally married at an early age and exposed to a greater risk of reproductive morbidity and mortality. Adolescence represents a real opportunity to make a difference in lifelong patterns.2

The prevalence of anemia is disproportionately high in developing countries, due to poverty, inadequate diet, certain diseases, pregnancy/lactation and poor access to health services.

The nutritional anemia in this group attributes to high MMR, high incidence of low-birth weight babies, high perinatal mortality and fetal wastage and consequent high fertility rates. This phase of life is also important due to the ever-increasing evidence that control of anemia in pregnant women may be more easily achieved if satisfactory iron status can be ensured during adolescence.2 To plan effective interventions, it is important to understand the epidemiology. Hence, the present study was carried out to study the epidemiological correlates of nutritional anemia among adolescent girls in rural Wardha.

Material and Methods

It was a cross-sectional study carried out in four villages; namely, Anji (6000 population), Borgaon (1150 population), Pawnoor (1350 population) and Chaka-majra, (1500 population) of Kasturba Rural Health Training Centre, Anji which is field practice area of Department of Community Medicine, Mahatma Gandhi Institute of Medical Sciences, Sewagram from October 2000 to May 2002. All unmarried, non-pregnant and non-lactating adolescent girls in the age group 13-19 years in the study area were covered. Considering the prevalence of anemia in adolescent girls as 40%, with 10% error, the estimated sample size was 600. In 10,000 proposed population for the study, the census was carried out and all 630 eligible adolescent girls were included in the study.

A pre-tested and pre-designed proforma was used to collect the information on socio-demographic characteristics like age, educational status, family size, monthly family income; medical history like age at menarche, history of worm infestation, excessive menstrual bleeding in the past 3 months and dietary history. Height, weight and hemoglobin were recorded. Hemoglobin estimation was done using cyanmethaemoglobin method3. For interpretation of anemia, cut-off point for hemoglobin level taken was < 12g/dl4. The severity of anemia was graded as Mild (10-12gm/ dl), Moderate (7-10gm/dl) and Severe (<7gm/dl)4. Data was entered and analyzed in SPSS 10.0. Univariate and multivariate analysis was carried out.

Results

There were 630 subjects in the study population of whom majority (68.7%) were early adolescents (13-16 years). Only 0.9% girls were illiterate while more than 50% girls had completed secondary level education. Majority girls belonged to families with income group in Grade III (Rs. 300-499) followed by Grade IV (Rs.150-300). 85.9% girls had attained menarche and only 6.6% girls had history of excessive menstrual bleeding. With regards to daily iron intake, 90% girls had daily iron intake <20mg; 58.6% girls were non-vegetarian. Worm infestation was present in 10.3% girls (Table 1).

Table I. Epidemiological Determinants of anemia: Univariate logistic regression analysis.

Variables Total (%)
(N=630)
No.
Anemic
girls (%)
OR C.I.
for OR
(Lower-Upper)
p- value
Age
Early
adolescence
433(68.7) 251(58.0) 1 - -
Late
adolescence
197(31.3) 126(64.0) 1.29 0.91-1.82 0.16
Education
Graduate &
above
35(5.6) 21(60.0) 1 - -
Higher
Secondary
187(29.7) 122(65.2) 1.25 0.60-2.63 0.55
Secondary 360(57.1) 203(56.4) 0.86 0.42-1.75 0.68
Primary &
middle
42(6.7) 27(64.3) 1.11 0.44-2.82 0.82
Illiterate 6(0.9) 4(66.7) 1.33 0.21-8.29 0.76
Socio-Economic status
Grade I 12(1.9) 5(41.7) 1 - -
Grade II 116(18.4) 63(54.3) 1.66 0.50-5.55 0.41
Grade III 229(36.3) 126(55.0) 1.71 0.53-5.56 0.37
Grade IV 209(33.2) 136(65.1) 2.61 0.80-8.51 0.11
Grade V 64(10.2) 47(73.4) 3.87 1.08-13.85 0.04
Body Mass Index
>85th
percentile
95(15.1) 59(62.1) 1 - -
5-85th
percentile
502(79.7) 296(59.0) 0.88 0.56-1.38 0.57
<5th
percentile
33(5.2) 22(66.7) 1.22 0.53-2.81 0.64
Status of Menarche
Attained 541(85.9) 327(60.4) 1 - -
Not-attained 89(14.1) 50(56.2) 1.19 0.76-1.87 0.45
Dietary habits
Non-
vegetarian
369(58.6) 153(41.5) 1 - -
Vegetarian 261(41.4) 224(85.8) 8.54 5.70-12.80 0.00
Iron intake/day
20-27 mg 63(10.0) 22(34.9) 1 - -
14-20 mg 291(46.2) 153(52.6) 2.07 1.17-3.64 0.01
<14 mg 276(43.8) 202(73.2) 5.09 2.84-9.11 0.00
History of worm infestation
Absent 565(89.7) 320(56.6) 1 - -
Present 65(10.3) 57(87.7) 5.45 2.55-11.62 0.00
History of excessive menstrual bleeding (89 girls had not attained menarche)
Absent 505(93.4) 293(58.0) 1 – - -
Present 36(6.6) 34(94.4) 12.29 2.92-51.69 0.00
Overall 630(100) 377(59.8) - -

In the present study, the prevalence of anemia was found to be 59.8% (Table 1). The prevalence of severe, moderate and mild anemia was 0.6%, 20.8% and 38.4% respectively (Table 2). Overall mean hemoglobin levels was 11.35±1.67.

Table II. Anemia in Adolescents.

Hemoglobin (gm/dl) No. of
girls (%)
<7 4 (0.6)
7-10 131(20.8)
10-12 242(38.4)
>12 253(40.2)
Total 630(100)

In univariate analysis, girls with socioeconomic status Grade V (OR=3.87, CI=1.08-13.85) were associated with increased likelihood of anemia compared to girls with Grade I. Those with iron intake 14-20mg were 2 times more likely to have anemia (OR=2.07, CI=1.17-3.64) than girls with >20mg iron intake, while those with <14mg were 5 times more likely to have anemia (OR=5.09, CI=2.84-9.11). Strongest predictor to anemia was history of excessive menstrual bleeding (OR=12.29, CI=2.92-51.69) and vegetarian diet (OR=8.54, CI=5.7-12.8) followed by history of worm infestation (OR=5.45, CI=2.55-11.62). Age, education, BMI and status of menarche did not show any significant association with anemia (Table 1).

Multivariate logistic regression model suggested that vegetarian diet (OR=5.83, CI=3.73-9.13), history of excessive menstrual bleeding (OR=5.65, CI=1.26-25.38), iron intake <14mg (OR=4.16, CI=2.08-8.31) followed by 14-20mg (OR=2.07, CI=1.06-4.05) and history of worm infestation (OR=4.11, CI=1.70-9.93) were important determinants of anemia. Age, education, socioeconomic status, BMI and status of menarche did not contribute significantly (Table 3).

Table III. Multivariate logistic regression analysis by Backward Conditional Method: Final model.

Variables OR C.I. for OR
(Lower – Upper)
p-value
Dietary habits
Vegetarian 5.83 3.73 – 9.13 0.00
Iron intake/day
<14 mg 4.16 2.08 – 8.31 0.00
14-20 mg 2.07 1.06 – 4.05 0.03
History of worm infestation
Present 4.11 1.70 – 9.93 0.00
History of excessive menstrual bleeding
Present 5.65 1.26 – 25.38 0.02

Discussion

The Government of India has made the adolescent health as a part of RCH package since 1997. The anemia in this age group has been identified as an important health problem by DeMaeyer and Adiels-Tegman6 followed by further reinforcement at the 1994 International Conference on Population and Development held at Cairo.

In the present study, the prevalence of anemia was found to be 59.8%. Rana et al7 and Seshadri et al8 reported a similar prevalence of 60% and 63% respectively. Chaturvedi et al9, Kotecha et al10 and Agarwal11 reported a prevalence of 73.7%, 74.7% and 47.6% respectively. These differences in the prevalence of anemia may be due to difference in the study area. WHO / UNICEF12 has suggested that the problem of anemia is of very high magnitude in a community when prevalence rate exceeds 40%. Considering that anemia development is a consequence occurred at a later stage of iron deficiency, the problem of iron deficiency in these adolescent girls with a prevalence of 59.8% should be considered serious and calls for an action. The mean hemoglobin in the present study was 11.3 ±1.7gm/dl which was higher than that reported by Mehta et al (10.6±1.2gm/dl) and lower than Kotecha et al10 reported as 11.8 ±1.4g/dl. The prevalence of severe, moderate and mild anemia was 0.6%, 20.8% and 38.4% respectively. High prevalence of mild and moderate anemia demands due emphasis so as to bring down total prevalence of anemia in adolescent girls.

Epidemiological correlates

In the present study, the important correlates of anemia were found to be vegetarian diet, excessive menstrual bleeding, iron intake and worm infestation. However age, status of menarche, BMI, education and socio-economic status did not contribute significantly.

Verma et al14 also quoted that compared to non-vegetarians (38%), more vegetarians (65.9%) were anemic. Hashizume et al15 too found that high iron intake was significantly associated with decrease prevalence of anemia (OR=0.39, CI=0.16-0.93). In developing countries like India, poor bioavailability of dietary iron coupled with low intake of haem iron derived from animal foods is a major etiological factor for anemia. A number of strategies are available for dietary modifi cation based either on promoting the intake of iron absorption enhances, including haem iron, or on reducing the ingestion of absorption inhibitors (such as phytates and tannins) to double the bioavailability of iron.

Worm infestation may also influence anemia to a large extent and calls for a dowering campaign along with IFA distribution in control programme for Anemia in Adolescents. It was found to be a strong predictor of anemia in the present study too (OR=4.11, CI=1.70-9.93). Stoltzfus et al16 found that 25% of all anemia, 35% of iron deficiency anemia and 73% of severe anemia was attributable to hookworm infection.

Rajaratnam et al17 documented a higher prevalence of anemia in girls who had attained menarche. Poor hemoglobin levels too can be a major cause of delayed menarche.18 Heath et al19 in also found that high menstrual blood loss was associated with increase risk of anemia. This further reiterates and emphasizes the need for corrective measures for anemia and iron deficiency in girls before they enter adolescence so as to compensate the additional requirements for growth and development during puberty and combat the extra losses during menstruation.

In the present study, age, education status, socio-economic status and BMI was not significantly related with anemia. Mehta et al13 and Kotecha et al10 also reported that age is not a significant correlate of anemia. Educational and socioeconomic status alone may not have any significant effect on anemia.10,20

The study provides an indication to initiate the anemia prophylaxis measures for adolescent girls in India including nutrition education in schools.

Reference

  1. Kurz KM, Johnson-Welch C. The nutrition and lives of adolescents in developing countries: Findings From the nutrition of adolescent Girls research program. Washington DC, International Center for Research on Women, 1994.
  2. World Health Organization. Programming for adolescent health and development. Technical Report Series No.886; 1999.
  3. Bruce LE and Mc Arthur JR. Fundamental Diagnostic Hematology. Anemia. Second edition. Published jointly by; US Department of Health Services and World Health Organization; 1992.
  4. World Health Organization. Nutritional anemia, Report of a WHO Scientifi c Group. Technical Report Series No. 405; 1968: 5-15.
  5. World Health Organization. Control of nutritional anemia with special reference to iron deficiency. Technical Report Series No.580; 1975.
  6. Demaeyer E and Adiels-Tegman. The prevalence of anemia in the world. World Health Statistics Quarterly 1985; 38: 302- 316.
  7. Rana T. Age at menarche – Nutritional status and other associated factors in urban Hyderabad girls. Ph.D. Thesis. Submitted to National Institute of Nutrition, Hyderabad 1983.
  8. Seshadri S. A data base for iron deficiency anemia in India; Prevalence, etiology, consequences and strategies for control, Task force for micronutrients malnutrition control, Department of Women and Child Development, Ministry of Human Resource Development, New Delhi, 1996.
  9. Chaturvedi S, Kapil U, Gnanasekaran N, Sachdev H.P.S, Pandey R.M and Bhanti T. Nutrient intake amongst girls belonging to poor socio-economic group of rural area of Rajasthan. Indian Pediatrics 1996; 33: 197-202.
  10. Kotecha P.V, Patel R.Z and Nirupam S. Prevalence of anemia among adolescent school girls, Vadodara district. Vadodara, Government Medical College, Vadodara, August 2000.
  11. Agarwal K.N. Assessment of prevalence of anemia and iron stores in response to daily/weekly iron-folate supplementation in adolescent girls from urban slums of North East Delhi. UNICEF Contract no. 95/0075; 1998.
  12. WHO/UNICEF. Indicators for assessing iron deficiency and strategies for its prevention. Draft based on a WHO/UNICEF Consultation, World Health Organization, Geneva; 1996.
  13. Mehta M. Effectiveness of daily and weekly iron and folic acid supplementation in anaemic adolescent girls. UNICEF funded final report of the research project, Bombay urban ICDS Project 1998: 21-25.
  14. Verma M, Chhatwal J, Kaur G. Prevalence of anemia among urban school children of Punjab. Indian Pediatrics 1998 Dec; 35 (12): 1181-6.
  15. Hashizume M, Shimoda T, Sasaki S, Kunii O, Caypil W, Dauletbaev D, Chiba M. Anemia in relation to low bioavailability of dietary iron among school-aged children in the Aral Sea region, Kazakhstan. Int J Food Sci Nutr 2004 Feb; 55(1): 37- 43.
  16. Stolzfus RJ, Chwaya HM, Tielsch JM, Schulze KJ, Albonico M, Savioli L. Epidemiology of iron deficiency anemia in Zanzibari schoolchildren: the importance of hookworms. Am J Clin Nutr 1997 Jan; 65(1): 153-9.
  17. Rajaratnam J. and Asokan, J.S. Prevalence of anemia among adolescent girls of rural Tamil Nadu. Indian Paediatrics 2000; 37: 532-535.
  18. Chakraborty N. Health and Nutritional Status of Adolescent girls in a selected slum of Bombay. Ph.D. Thesis submitted to S.N.D.T. University, Mumbai, 1995.
  19. Heath AL, Skeaff CM, Williams S, Gibson RS. The role of blood loss and diet in the etiology of mild iron deficiency in premenopausal adult in New Zealand women. Public Health Nutr 2001 April; 4(2): 197-206.
  20. Kapoor G, Aneja S. Nutritional disorders in adolescent girls. Indian Pediatrics 1992; 29: 969-973.

Department of Community Medicine, Mahatma Gandhi Institute of Medical Sciences, Sevagram – 442 102, Distt. Wardha (MS)
E-mail: [email protected]
Received: 8-2-05

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