Nutritional anemia is prevalent all over the
world, with an estimated one billion people being iron deficient (1).
Recent data from the District Nutrition Project (Indian Council of
Medical Research) in 16 districts of 11 states, on prevalence of anemia
in non pregnant adolescent girls (11-18 years) showed rates as high as
90.1% with severe anemia (Hb <7 g/dL) in 7.1%(2). In a study by Kapoor
and Aneja(3) from public and government schools in Delhi, anemia among
adolescent girls was as high as 50.8%. Compared to the vast amount of
work done in pregnant mothers and young children, there are relatively
few published studies on the prevalence of anemia in adolescents and
probably none in boys, and none from the city of Chandigarh.
The present study was designed to assess the
prevalence of anemia and determine serum ferritin status among
apparently healthy urban and rural school going children of Chandigarh
in the age group of 12 to 18 years.
Subjects and methods
This cross sectional study was conducted from August
2002 to November 2002 in the urban and rural areas of Chandigarh. A
total of 1180 students from thirteen schools between the age group of 12
to 18 years participated in the study. The selected urban schools were
within the 5 km radius of our hospital and only those schools who gave
us the permission to carry out this study were included. The two rural
schools selected were registered in the adolescent health project of our
department and come under rural health center of Department of Social
and Preventive Medicine of our Medical College.
The rural schools cater to low socioeconomic group of
population. The schools in urban areas included government and private
schools catering to middle and high socioeconomic group. Considering the
significance of variation in urban and rural samples, the samples size
was calculated taking the level of significance at 5% and the power to
80%, which was found to be 195 in each group. The age of children was
ascertained by questioning them and later confirmed from school
registers. In case of any discrepancy between the two, the date in the
school register was taken as accurate. Age in completed years was taken
for analysis.
A social demographic profile including parents’
education, family structure and diet consumed (vegetarian,
non-vegetarian) was noted. A detailed general physical examination was
done to look for pallor, icterus, edema, hyperpigmentation, lymph-adenopathy,
bleeding spots and signs of vitamin deficiency and was noted on a
pre-designed proforma. Physical examination was done to rule out any
systemic abnormality. The anthropometric measurements (weight and
height) were made by single observer eliminating inter observer
variability and errors. Nutritional status was evaluated using World
health organization (WHO)(4) recommended age specific cut-off points of
body mass index (BMI) based on the National Health and Nutrition
Examination Survey (NHANES) percentile values(5).The body mass index
(weight/height2) less than 5th percentile for that particular age was
the criteria used for classifying undernutrition. The study was carried
out after obtaining free and informed verbal consent of the students and
their parents. All the adolescents who were apparently healthy on
general physical examination were included in the study. Those
adolescents with chronic illness or receiving long-term drugs and
needing hospitalization in the last two weeks before the study were
excluded. Finally, 1120 students were included in the study and sixty
students were excluded based on above exclusion criteria and those who
did not volunteer to give blood for examination.
Samples were collected for estimation of hemoglobin
by cyanmethemoglobin method and serum ferritin by ELISA (UB 1 Magiwel
enzyme immunoassay) method. For hemo-globin estimation, 20 µL capillary
blood was collected by finger prick into 5 mL Drabkins solution from all
the participating students and measured on the same day. Samples for
serum ferritin was collected from 183 students, for which 3 ml of venous
blood was collected in test tubes, left to stand at room temperature for
half an hour, centrifuged at 3500 r.p.m. for 10 minutes, and the
separated serum was transfused to fresh vials and stored at –30şC,and
the kit was calibrated against the WHO standards. Amongst girls, every
fourth girl’s sample was taken. In boys, since they were reluctant to
give samples for serum ferritin, samples were collected from those
whosoever volunteered. The hemoglobin and ferritin were estimated under
strict quality control in the hematology laboratory of our medical
college which is enrolled with External Quality Assurance program
con-ducted by All India Institute of Medical Sciences, New Delhi
(supported by National Accreditation Board for Testing and Caliberation
Laboratories).
The criteria for detecting anemia was diagnosed as
per WHO guidelines, (values less than 12 g/dL for girls from 12 to 18yrs
and boys less than 14 years and less than 13 g/dL for boys from 15 to 18
yrs of age)(6). Iron deficiency was determined by taking the value of
serum ferritin less than 15 ng/mL(7) .
Statistical analysis was done by SPSS software and
Chi square test was used to calculate statistical significance.
Results
The study population comprised of 911 students from
urban and 209 from rural area respectively. There were 590 girls and 530
boys. The overall prevalence of anemia among adolescents was 16.25%
(182/1120). The hemoglobin values ranged from 6.5 to 18.2 (median 13.5;
mean 13.35 + 1.54; SE 0.05; 95% C). Prevalence of anemia was
significantly higher (P <0.01)amongst girls (23.9%,141/590) as compared
to the boys (7.7%, 41/530).
Anemia was significantly less among the urban school
going children as compared to rural school going ones (14.16% vs
25.4%; P <0.01). Both girls 34.23% (38/111) and boys 15.3% (15/98) of
the rural group were significantly more anemic than girls 21.5%
(103/479) and boys 6% (26/482) of the urban group (P < 0.05 and < 0.01,
respectively).
Serum ferritin level was estimated in 183 adolescents
of which 86.8% (159/183) were girls and 13.2% (24/183) were boys. The
serum ferritin level in girls below 15 ngm/mL was seen in 81.8%
(130/159) as compared to boys (41.7%; P <0.01).
Iron deficiency anemia i.e., hemoglobin level
below the cut off for the age and serum ferritin level less than 15 ng/mL
was noted in 11.4% of the girls and none of the boys, but the total
number of boys tested for serum ferritin was small. It was also noted
that in 73.2% (134/183) students despite being non anemic (normal
hemoglobin), the serum ferritin was reduced (<15 ng/mL) and on the other
hand there were six cases who were anemic but with serum ferritin level
more than 15 ng/mL.
14.3% (84/590) girls and 14.2%(76/530) boys were
undernourished (BMI <5th centile). Prevalence of anemia in girls whose
weight was more than 5th centile was 21.9% as compared to 35.7% in those
whose BMI was less than 5th centile (P <0.001). Similarly, in boys 6.7%
were anemic in well-nourished group as compared to 14.4% in
under-nourished group (P <0.05). Associated micro-nutrient deficiencies
included xeropthalmia in 18 and knuckle hyperpigmentation in two adoles-cents
and all of them were anemic. None of adolescents had icterus, lymph-adenopathy,
edema or bleeding spots.
Discussion
Nutritional anemia though global in occurrence, is
more of a concern in the developing countries because of the high
prevalence in these regions. In spite of its high prevalence in
children, studies on prevalence in adolescents specially boys are
relatively few from developing countries. Adolescence is a period of
rapid growth and with in-adequate and improper dietary habits, one is
vulnerable to all kind of nutritional morbidities. Malnutrition, and
worm infestation further aggravate the problem.
In a recent study conducted in semi urban Nepal, the
prevalence of anemia in adolescent girls aged 11-18 years was found to
be about 68.8%(8). In some of the less developed countries like Peru,
Indonesia and Bangladesh, the prevalence of anemia in girls has been
found to be around 25-30%(9).
Aggarwal, et al.(10) in a government school
based study from middle socio-economic group of North East Delhi
reported a prevalence of anemia as 45%. Similarly, studies on prevalence
of anemia from different states of rural India, reported a prevalence of
anemia from 46% to 98% (11-13).
In our study, prevalence of anemia in rural area,
where majority were from lower or middle income group, was 34.2%.
Whereas, in urban girls, who were from middle and high income group the
prevalence was 23.9%. These findings are similar to those described by
Vasanthi, et al. (14) where anemia and iron deficiency was of
higher order in the rural girls as compared to the urban slum adolescent
girls (28% to 24%). Similarly, Jondhale, et al. reported a
prevalence of anemia as 14% in adolescent girls where the household
income was more than Rs. 5000 per month and 26% where the household
income was less than Rs. 5000 per month(15).
There are hardly any studies on the prevalence of
anemia in boys. In our study, the overall prevalence of anemia in boys
was 8% similar to one from a developed county like Norway(7). In rural
area, the prevalence of anemia in the boys was 15.3%. Since the overall
prevalence of anemia in the girls from rural population in our study is
relatively low as compared to national standards, we speculate that if
more studies are conducted in boys from low socio-economic group or
rural or slum area, the prevalence of anemia in boys will be much higher
nation wide.
Various studies confirm that serum ferritin is one of
the most sensitive method for assessment of iron stores and for the
detection of mild iron depletion(16). Its levels are directly related to
bone marrow iron in all disease groups except those involving chronic
inflammatory stage, malignancy and increased red cell turnover(17).
However, the students enrolled for this study were healthy students and
did not have any apparent clinical disorder. Overall majority of
adolescent girls in our study were in pre-latent phase of iron
deficiency anemia ie 81.8% of them showing depleted iron stores and
11.4% showed iron deficiency anemia (Serum ferritin <15 ng/mL and
Hemoglobin <12 g/dL). Agarwal, et al.(10) in their study on
adolescents girls of northeast Delhi noted 85% girls to be iron
deficient and out of which 49.3% were anemic.
The present study reveals that most of the adolescent
girls are in the pre-latent phase of iron deficiency anemia(depleted
iron stores but normal hemoglobin levels), hence the diagnosis of anemia
is of particular importance in the adolescent girls because they enter
the reproductive cycle soon after menarche. Further studies on the
prevalence of anemia in the adolescent boys from low socioeconomic
status, specially rural and urban slum areas are needed to find out the
magnitude of the problem so that timely community based intervention can
be instituted.
Contributors: SB was involved in critical
revision of the manuscript for important intellectual content. SrB
helped in acquisition of data, interpretation of data and final approval
of the version and will act as the guarantor of the paper. RH was
involved in acquisition of data, analysis and interpretation of data,
drafting of manuscript. VP supervised conception and design, acquisition
of data.
Funding: None.
Competing interests: None stated.
Key Messages |
• The prevalence of anemia in Chandigarh was 23.9% and 7.7% in
adolescent girls and boys respectively and was related to
nutritional status.
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