Indian Pediatrics 2002; 39:1126-1130 

Anemia in Adolescent Girls: A Preliminary Report from Semi-urban Nepal

Binay Kumar Shah, *Piyush Gupta

From the Departments of Pediatrics, B.P. Koirala Institute of Health Sciences, Dharan, Nepal and *University College of Medical Sciences, Delhi 110 095, India.

Correspondence to: Dr. Piyush Gupta, Block R-6-A, Dilshad Garden, Near Telephone Exchange, Delhi 110 095, India. E-mail: [email protected]

Manuscript received: January 15, 2002, Initial review completed: May 7, 2002;

Revision accepted: May 31, 2002.

 

The present study was conducted to determine the prevalence of anemia in adolescent Nepalese girls in a semi urban setting. A total of 209 apparently healthy girls between the ages of 11-18 years were recruited and information collected on menarcheal status and socio-demographic profile. All girls were subjected to anthropometric examination and hematocrit estimation. Anemia was defined as hematocrit less than 36, as per WHO cut-off. The overall prevalence of anemia was found to be 68.8%. This prevalence was not related to girls’ age, body mass index, menarcheal status, and socio-demographic factors including parental education or occupation ( p = 0.05)

Key words: Adolescent, anemia, prevalence

Anemia is one of the most universally prevalent diseases in the world today. Iron deficiency anemia is the most common micronutrient deficiency. A WHO study shows that in developing countries 52% of pregnant women and about 35% to 40% of non-pregnant women suffer from iron deficiency anemia(1).

Compared to the vast amount of work done on pregnant women and young children, there are relatively few studies on the prevalence of anemia in adolescent girls. The exact figures for world-wide prevalence of anemia among adolescent girls are not known, but are estimated to be quite high. A recent study observed a high prevalence of anemia (62.2%) in pregnant Nepalese women(2) but no data is available for adolescent girls. A decrease in the prevalence of anemia during pregnancy could be achieved through improvement in the status of adolescent girls. The present study was undertaken to determine the prevalence of anemia in adolescent Nepalese girls in a semi-urban setting.

This cross sectional study was conducted in the Government Girls School of Dharan Municipality over a period of two months from April to May 1998. The school caters to the lower middle socio-economic group families. Dharan is a small semi-urban foothill town, more than 500 km east of Kathmandu (altitude 305 m). All the two hundred and twenty five girls from classes VIII to XII, between the age group of 11 and 18 years, were taken up for the study. Their ages were ascertained by questioning the girls about their date of birth and later confirmed from the school register. In case of any discrepancy between the two, the date in the school register was taken as accurate. All ages were expressed in years.

The girls were questioned and examined by BKS; a detailed socio-demographic profile was obtained including the parents’ education and occupation, type of housing, water supply, and toilet facilities. The type of diet consumed (vegetarian, non-vegetarian) and history of passage of worms was noted. The menarcheal status of each girl was recorded. Presence of pallor, icterus, edema, hyperpigmentation, lymphadenopathy, platy-nychia, bleeding spots, xerophthalmia, and goiter were recorded on a pre-designed proforma. Physical examination was con-ducted to rule out any systemic abnormality. Anthropometric measurements included weight and height taken by standard techniques. Girls suffering from any chronic illness e.g., asthma, rheumatic heart disease etc, or receiving any long term allopathic or indigenous drug treatment were excluded from the study. Similarly, girls with history of any severe illness within the past 2 weeks for which they required hospitalization were also excluded. Finally, 209 girls (median age 15 years) were included in the study.

The baseline hematocrit was estimated by the microhematocrit technique. Capillary blood was collected by finger prick into a heparinized microcapillary tube 7 cm long and 1 mm in diameter. Two-thirds of the tube was filled with blood. Their ends were sealed, and the tubes transported back to the laboratory, where they were centrifuged at 1500 rpm for 5 minutes. The packed cell volume (PCV) was read using a microhematocrit tube reader.

Prevalence of anemia was calculated as per WHO cut-off of hematocrit <36 in adolescent non-pregnant girls(3). Statistical analysis was carried out using SPSS software. Statistical tests used included chi-square test, student’s ‘t’ test, analysis of variance, and tukey tests to assess the relation of age, menarcheal status and various socio-demographic factors with prevalence of anemia; P <0.05 was considered significant. The study was approved and funded by the Research Committee of B.P. Koirala Institute of Health Sciences. Free and informed verbal consent of the subject and their parents was obtained.

The prevalence of anemia in adolescent girls was 68.8% (144/209). The hematocrit values ranged from 24 to 42 (median 34; mean 33.4; SE 0.23; 95% CI 32.9, 33.9). The prevalence of anemia was maximum (76.9%, 10/13), in the age category of 11-12 y, and least (63.6%, 42/66) at 14-16 yr (P > 0.05).

Prevalence of anemia was not found to be associated with parental education or occupation and type of dwelling unit (Table I). Relationship of prevlaence of anemia with personal characteristics such as type of diet consumed, passage of worms and menarcheal status is also depicted in Table I.

The mean weight and height of all girls was 42.8 ± 6.2 kg (median 44.0, range 27-59, 95% CI 42.0, 43.7) and 150.1 ± 6.7 cm (median 150.0, range 127-168.0, 95% CI 149.2, 151.0) respectively. Body mass index (BMI) ranged from 14.2-26.6 (median 19.0). Most of the girls (n = 121) had a normal BMI (between 18.5 to 25), while 87 (41.6%) had a BMI of less than or equal to 18.5. Only one girl had a BMI of more than 25. Prevalence of anemia in girls with BMI >18.5 (n = 122) was 65.5% as compared to 71.3% in those with a BMI £18.5 (P = 0.37). Hematocrit in the two categories was also comparable i.e., 33.3 ± 3.2 and 33.6 ± 3.7 respectively (P = 0.59).

Associated micronutrient deficiencies included xerophthalmia in 7 (3.3%) and goiter in 70 (33.5%) girls. All subjects with vitamin A deficiency and 72.5% with goiter were anemic. None of the girls had icterus, hyper-pigmentation, lymphadenopathy, edema, severe anemia or platynychia.

Table I- Prevalence of Anemia Related to Social and Personal Characteristics

Characteristics

Anemic
(hematocrit <36)
N = 144

Non-anemic
(hematocrit ³36)
N = 65

P value

Father’s education 

  Illiterate

9(81.8)

2(18.2)

0.37

  Up to high school

88(66.2)

45(33.8)

  Graduate

45(73.8)

16(26.2)

Father’s occupation

  unemployed

6(85.7)

1(14.3)

0.48

  unskilled worker

58(72.5)

22(27.5)

  skilled worker

78(66.7)

39(33.3)

Mother’ education

  illiterate

37(71.2)

15(28.2)

0.78

  up to high school

103(67.8)

49(32.2)

  graduate

4(80.0)

1(20.0)

Mother’ occupation

  housewife

128(71.1)

52(28.9)

0.17

  employed

15(53.6)

13(46.4)

Housing

  mud/thatch

49(64.5)

27(35.8)

0.30

  brick/concrete

95(71.4)

38(28.6)

Diet consumed

  vegetarian

25(71.4)

10(28.6)

0.72

  non-vegetarian

119(68.4)

55(31.6)

Passage of worms

  yes

27(65.9)

14(34.2)

0.64

  no

117(68.2)

51(30.4)

Menarcheal status

  premenarcheal

24(72.7)

9(27.3)

0.60

  postmenarcheal

120(68.2)

56(31.8)

Fathers of 5 girls and mother of one girl had died. Missing numbers are because of ignorance of the family 
regarding education status of the deceased father in 4 cases.
Figures in parentheses express percentages.

Nutritional anemia is prevalent all over the world, with an estimated one billion people being iron deficient(4). Studies on prevalence of anemia in adolescent girls are relatively few, especially in the developing world. However, this is the group that deserves particular attention. Adolescence is a period of rapid growth, weight gain and blood volume expansion. The overall iron requirement increases from a preadolescent level of approximately 0.7 - 0.9 mg iron per day to as much as 2.2 mg iron per day or perhaps more in heavily menstruating young women(5). A much larger amount of iron is actually needed to meet the growth requireements of adolescence and even a marginal iron deficiency during this period of growth can precipitate overt anemia. Malnutrition, chronic infections and worm infestations also contribute to a high prevalence of anemia.

In a few studies in developed nations, the prevalence of anemia in adolescent girls was 10.5%, 5.9%, and 4% in England, USA and Norway, respectively(6-8). In Kuwaiti, Peruvian, Indonesian, and Bangladeshi adolescent girls, the prevalence of anemia is noticed to be around 25-30%(9-12). This was in sharp contrst to our study where the prevalence of anemia was extraordinarily high. Though very different from data from the developed countries, our figures correspond to the few studies from the Indian subcontinent. Kapoor and Aneja(13), in a school based study in Delhi, found the prevalence of anemia among adolescent girls of lower socio-economic group to be 56%. Sharma and Sharma(14) from Rajasthan, found almost all adolescent pregnant women to be suffering from moderate to severe anemia. The high prevalence of anemia in the subcontinent can be related to a similar kind of diet consumed in these areas. The staple diet is a mixture of cereals, pulses, and vegetables. Bioavailability of iron from cereals and vegetables is low because of presence of phytates, oxalates and tannate that react with iron to form insoluble compounds. Most of the girls in our study were non-vegetarian, but their diet contained non-vegetarian food only once or twice a week, mainly because of economic and cultural constraints. Age and menarcheal status did not affect the prevalence of anemia in this study. However, Dallman, e t al.(7) found the prevalence to be highest in 15 to 17 year old girls, who were menstruating. Our findings suggest that dietary factors superimposed on physical growth spurt may be playing a larger role in causation of anemia than menstrual losses. However, a detailed dietary survey is required to address these issues.

In Nepal, a high prevalence of anemia has been observed among special ethnic groups such as Lama, Tamang and Sherpa(2). We however, did not classify our subjects because of a relatively small sample size. It is also known that higher education and high BMI are associated with a lower risk of anemia. In our study, very few mothers were educated. None of the children except one, had a high BMI. Prevalence of anemia and hematocrit value was not related to the socio-demographic factors probably due to the relative homogeneity of the study population.

The study highlights a high prevalence of anemia in adolescent Nepalese girls. Further studies with a larger sample size in diverse terrains of Nepal are needed.

Contributors: PG designed the study, performed statistical analysis and wrote the paper. He will act as guarantor for the paper. BKS collected and analyzed the data and helped in writing the paper.

Funding: The study was funded by the Research Committee of BP Koirala Institute of Health Sciences, Dharan, Nepal.

Competing interests: Another part of this study has been published in Arch Pediatr Adolesc Med 2002; 156: 131-135 entitled "Weekly vs. daily iron and folic acid supplementation in adolescent Nepalese girls" by the authors.

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