Original Articles

Indian Pediatrics 1999; 36: 991-998

Micronutrient deficiency disorders amongst pregnant women in three urban slum communities of Delhi 

Umesh Kapil, P. Pathak, M. Tandon, C. Singh*, R. Pradhan and S.N. Dwivedi**

From the Departments of Human Nutrition; Biostatistics** All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India and Rural Health and Training Center Najafgarh* New Delhi, India.
Reprint requests: Dr. Umesh Kapil, Additional Professor, Department of Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India.
Manuscript received: November 19, 1998; Initial review completed: January 28, 1999; Revision accepted: May 4, 1999.

Objective: To assess the prevalence of three micronutrient deficiency disorders (MDDs), i.e., iron deficiency, iodine deficiency and vitamin-A deficiency individually and in combination amongst pregnant women. Methods: A hospital based study was conducted amongst 829 pregnant women of II and III trimester attending antenatal clinic, Rural Health Training Center (RHTC), Najafgarh, New Delhi. Anemia was assessed by the presence of clinical signs and by hemoglobin levels. Iodine deficiency disorders (IDD) were assessed by clinical examination of thyroid gland and by urinary iodine excretion levels. Iodine content of the salt consumed by the pregnant women was also assessed by iodometric titration method. Vitamin A deficiency (VAD) was assessed by the presence of clinical symptoms of nightblindness. Current dietary intake, morbidity conditions on the day of survey and anthropometric measurements of pregnant women were also documented. Results: Prevalence of anemia, IDD and VAD amongst pregnant women was 78.8%, 22.9% and 4.8%, respectively. One per cent of the pregnant women had concomitant presence of all the three MDDs. Pregnant women having combined prevalence of IDD and anemia, IDD and VAD, and VAD and anemia was 15.1%, 0.18% and 2.69%, respecively. Eighty nine per cent of the pregnant women were consuming salt with iodine content of more than 15 ppm which was recommended at household level. Results on dietary intake showed that 18%, 34%, 85% and 57% of the pregnant women were consuming less than 50% of calories, proteins, iron and b-carotene, respectively as compared to their RDA. Forty per cent of the pregnant women were suffering from various morbidity conditions on the day of survey. Conclusions: The prevalence of micronutrient deficiencies amongst pregnant women of urban slum communities is high.

Key words: Iodine deficiency disorders, Iron deficiency, Micronutrient deficiency, Pregnancy, Vitamin A deficiency.

The problem of micronutrient malnutrition in developing countries encompasses a spectrum of deficiencies, of which those of major public health significance are deficiency of one or more of the three micronutrients iron, iodine and vitamin A.

Iron Deficiency Anemia (IDA) is also an important public health problem, which contributes to morbidity and mortality in women and young children(1). The prevalence of anemia amongst pregnant women in India is 87.6%(2). Severe anemia in pregnant women increases the risk of maternal and fetal morbidity and mortality. Milder degrees of anemia have been documented to be associated with low birth weight. Infants born to anemic women have less than half of the iron reserve than those born to non-iron deficient women.

Iodine Deficiency Disorders (IDDs) are another major public health problem in India. It significantly raises the risk of still births and abortions amongst pregnant women. Iodine deficiency during pregnancy also leads to decreased availability of iodine to the fetus. This causes decreased synthesis of thyroxin which prevents normal development of fetal brain and body. A high prevalence (4.2%) of neonatal hypothyroidism has been reported in India(3). Children born to iodine deficient women also have lower IQ scores.

Vitamin A Deficiency (VAD) is the most common global cause of preventable blindness in children and leads to increased morbidity and risk of mortality amongst them. Night blindness is one of the primary indicators of VAD. Studies suggest that night blindness is widespread in South East Asia and affects 10-50% of women during pregnancy(4,5).

The published data on concomitant presence of one or more micronutrient deficiency disorders (MDDs) like anemia, iodine deficiency and vitamin A deficiency amongst pregnant women is limited. Hence the present study was undertaken to assess the prevalence of micronutrient deficiency disor-ders, i.e., anemia, IDD and VAD, individually and in combination amongst pregnant women and to assess the possible underlying causes of MDDs in pregnant women.

Subjects and Methods

Sample Size

For the calculation of sample size, the prevalence of IDD, VAD and anemia amongst the pregnant women was considered as 12%, 10% and 70%, respectively. The sample size was calculated considering the prevalence of VAD in pregnant women, i.e., the MDD of least prevalence. Thus, sample size was worked out considering prevalence of 10% (p = 0.01); level of significance as 5% (a = 0.05) and with an anticipated deviation of 20% in the prevalence (i.e., 20% of 10%) in either of the direction. Accordingly, a sample size of 768 pregnant women was obtained.

Setting

The study was carried out amongst pregnant women belonging to three urban slum communities of Delhi. A total of 829 pregnant women in II and III trimester attending the Antenatal Clinic, Rural Health Training Center, Najafgarh, New Delhi were studied. All consecutive pregnant women attending the clinic for the first time were enrolled for the study.Verbal consent of the pregnant women was taken to participate in the study. The study was conducted during the months of February and May 1998. All the clinical examination and biochemical estimations to be undertaken were explained to them.

The pregnant women were inquired about their age, gestational age, socio-economic status and other socio-demographic parameters.

Assessment of Anemia

Anemia was assessed by assessing the clinical signs _ pallor of tongue and pallor of conjunctiva. Hemoglobin levels were estimated using the Sahli's method(6). Anemia was classified according to the WHO classification. Hemoglobin levels more than 11g/dl were classified as non-anemic(7).

Assessment of IDD

IDD was assessed by clinical examination of thyroid gland using the standard method, as recommended by the joint WHO/UNICEF/ICCIDD consultation(8).

A casual urine sample was collected from 82% of the subjects (n=680) for the estimation of urinary iodine excretion (UIE) levels to assess the iodine nutriture status. Iodine was determined by wet digestion method using standard laboratory techniques(9). UIE level less than 10 mcg/dl was considered as indicator of iodine deficient nutriture.

More than 20% of pregnant women were selected randomly and requested to bring a sample of 20 g salt consumed in their families in autoseal LDPE pouches. Iodine content of the salt samples was estimated using the standard iodometric titration method. Salt samples having iodine content less than 15 ppm were classified as with inadequate iodine(8).

Assessment of VAD

VAD was assessed by administering a pretested semistructured questionnaire on the presence of symptoms of nightblindness. The women were asked specific questions-(i) if they could clearly see at the time of sunset and later in dim light; (ii) if they had any problems in cooking food during dusk period due to lack of proper vision; and (iii) if there was a change in their activity pattern because of problems in vision in the dusk. The subjects with positive response to the questions, were classified as suffering from VAD.

Assessment of Anthropometric Measurements

Anthropometric measurements were taken using standard equipments. SECA electronic weighing scale was used for weight measure-ment to the nearest 100 g. Anthropo-metric rod was used for height measurement to the nearest 0.1 cm.

Assessment of Dietary Intake

Ten per cent of pregnant women included in the study were selected randomly. The dietary intake of individual subjects was assessed using the 24 hour dietary recall method(10). The intake of energy, protein, iron and b-carotene of the subjects were calculated by using computer software programme based on the Nutritive Value of Indian Foods(11) developed at All India Institute of Medical Sciences, New Delhi. Recommended Dietary Allowances suggested by the Indian Council of Medical Research for pregnant women (sedentary worker) were utilized to assess the adequacy of nutrient intake by the subjects(12).

Assessment of Morbidity Status

The morbidity conditions on the day of survey was assessed by inquiring about the presence of signs and symptoms of various morbidity conditions. Systemic clinical exami-nation was done for the morbidity conditions of urinary tract infection (UTI), lower respi-ratory tract infection (LRTI), upper respiratory tract infection (URTI), reproductive tract infection (RTI), pre-eclampsia (PET), diarrhea (DIA) and fever (FEV).

Results

Socio-Demographic Profile

A total of 829 pregnant women attending the Antenatal Clinic constituted the study population. All the pregnant women in the age of group of 17-40 years were included in the study. Fifty four per cent (n = 448) of the women were in II trimester (12 to <28 weeks gestational age) and 46% (n=381) in III trimester (gestational age 28 weeks and more). All the pregnant women were residing in three urban slum communities.

Prevalence of Anemia

It was found that 78.8% pregnant women were suffering from anemia as defined by their hemoglobin levels. The prevalence of mild, moderate and severe anemia in pregnant women was 29%, 48%, and 2%, respectively (Table I).

Table I^__ Distribution of Pregnant Women According to Their Hemoglobin Level (n=694).
                    

The clinical signs of anemia, i.e., conjunctival pallor was observed in 55.2% and tongue pallor in 27.5% of the pregnant women. Twenty three per cent of the pregnant women had both, i.e., presence of tongue as well as conjunctival pallor.

Prevalence of IDD

Presence of goiter was found in 16 (1.9%) pregnant women. Only one pregnant woman had grade II goiter. One hundred and fifty six subjects (22.9%) had UIE levels less than 10 mcg/dl indicating deficient iodine nutriture (Table II).

Table II^__ Distribution of Pregnant Women According to Their Urinary Iodine Excretion                     (UIE) Levels (n=680).

One hundred and seventy four (20%) pregnant women were selected randomly and were requested to bring salt samples. The salt samples were tested for the iodine content. It was found that 89% of the salt samples had adequate iodine content, i.e., 15 ppm and more. Only 3.4% salt samples had nil iodine content.

Prevalence of VAD

The prevalence of VAD was 4.8%. Out of the 40 cases who had VAD in current pregnancy, 10 subjects also had nightblindness during their previous pregnancy (Table III).

Table III^__ Distribution of Pregnant Women According to the Presence of Nightblindness                       (NB) (n=829).

Concomitant Prevalence

Data on 557 pregnant women was collected for their concomitant prevalence of the three MDDs. One per cent of the pregnant women were suffering from all the three micronutrient deficiency disorders, i.e., IDD, VAD and anemia. Similarly, 15.1% of the pregnant women were suffering from IDD and anemia and 0.10% from IDD and VAD.

Table IV^__ Distribution of Pregnant Women According to the Prevalence of the Three MDDs                      (n=557).

Pregnant less than 140 cm Seven pregnant women were "at risk" with age less than 18 years. These anthropometric measurements indicated poor nutritional status of the pregnant women.

Dietary Intake

Dietary intake data was collected from more than 10% of the subjects (109 pregnant women). The mean daily intake of calories, protein, iron and b-carotene was 1500 Kcal, 46.4 g, 14.6 mg and 2064 mcg, respectively. Nutrient intake in the pregnant women was significantly less than their recommended dietary allowance. Results showed that 18%, 21%, 85% and 57% of the pregnant women were consuming less than half of RDA of calories, protein, iron and b-carotene, respectively (Table V). Dietary intake data indicated poor nutritional intake by the pregnant women possibly due to poor purchasing power of the family.

Morbidity Status of Pregnant Women

The assessment of presence of morbidity on the day of survey revealed that 39.6% of the  subjects had one or more of the morbidity conditions inquired. The most common morbidity was of reproductive tract followed by upper respiratory tract and urinary tract infections (Table VI).

The prevalence of anemia amongst pregnant women was found to be 78.8%. An earlier study conducted in 1988 also revealed that 62.3% of pregnant women had hemoglobin levels below 11 g/dl(13). The prevalence of anemia in pregnancy has been documented between 34.6% to 98.3% by different research surveys(14,15). Findings of our study are comparable to the earlier published data.

The prevalence of IDD amongst pregnant women was found to be 22.9% with the criteria of UIE levels of less than 10 mcg/dl. The high percentage of pregnant women with inadequate iodine nutriture may be due to low intake of food and iodized salt with adequate iodine. An earlier study conducted reported a prevalence of IDD as 9.5% amongst pregnant women in an endemic district of Himachal Pradesh(16).

The prevalence of VAD in the present study was 4.8%. Studies from Bangladesh and Nepal have reported the prevalence of nightblindness to be 15-20% in pregnant women (4,17). The lower prevalence of VAD amongst Indian pregnant women may be due to comparatively better dietary intake amongst them. Diets of pregnant women in poor communities are deficient in many nutrients including vitamin A.

In the present study, the dietary intake of pregnant women was poor in all the nutrients including vitamin A. Fifty seven per cent of the pregnant women were consuming less than 50% of vitamin A as per the RDA. Supple-mentation of vitamin A (9000 mcg/day) to women of poor economic group during the last trimester of pregnancy has been documented to result in significant decrease in nightblindness and increase in vitamin A levels of cord blood(18).

In the present study, the high prevalence of anemia could be accounted for by the low intake of dietary iron by the pregnant women. Only 2% of the pregnant women consumed iron as per their RDA. Eighty five per cent of the pregnant women were consuming iron less than 50% their RDA. The majority of subjects in the present study were vegetarians with nil intake of animal foods. This may also be a contributory factor to the high prevalence of anemia.

Infections also cause anemia. In the present study, 39.6% of the pregnant women were suffering from one or more of the evaluated morbidity conditions at the time of survey. This  could be an associated etiological factor of anemia amongst them. An earlier study conducted in urban Baroda also reported similar results(19).

The present study highlighted that the pregnant women belonging to underprivileged communities suffer from multiple micronutrient deficiency disorders. One per cant of all pregnant women had all the three MDDs, i.e., anemia, IDD and VAD. There was also a generalized inadequate intake of food which is the source of these micronutrients. There is thus a need of developing strategies for improving the overall diet of the pregnant women for preventing MDDs rather than propagating supplementation of individual micronutrients.

Acknowledgements

The authors would like to thank Dr. M.D. Nayak, Officer Incharge, Rural Health Training Center, New Delhi for the help extended in conducting the study. The authors would also like to thank Ms. Sudesh, Laboratory Technician, for her help. The infrastructure facilities provided by the Director, All India Institute of Medical Sciences are duly acknowledged.

References

1. Singla PN, Marwah P, Aggarwal KN. Deficiency anemias in pregnant women in Northern India. Estimation of prevalence based on response to hematinic supplementation. Indian J Prev Soc Med 1983; 14: 64-65.

2. Evaluation of the National Nutritional Anemia Prophylaxis Programme. Indian Council of Medical Research, New Delhi, 1989.

3. Kochupillai N, Godbole MM, Pandav CS, Ahuja MMS. Neonatal thyroid status in iodine deficient environments of the sub-Himalayan region. Indian J Med Res 1984; 80: 293-299.

4. Katz J, Khatry SK, West KP Jr, Humphrey J, LeClerq SC, Kimbrough_Pradhan E, et al. Night blindness is prevalent during pregnancy and lactation in rural Nepal. J Nutr 1995; 125: 2122-2127.

5. Malyavin A, Beauphanny V, Arouny A, Cohen A. National Vitamin A survey in Lao, PDR. Report of the XVII International Vitamin A Consultative Group meeting. Guatemala City, Guatemala, 18-22 March 1996. International Life Science Institute, Washington DC, 1996.

6. Programme for Appropriate Technology in Health (PATH). Anemia Detection in Health Services: Guidelines for Programme Managers. Washington, US Agency for International Development, 1996; p 37.

7. Gammon A, Baker SJ. Studies in methods of hemoglobin estimation suitable for use in public health programmes. Indian J Med Res 1977; 65: 150-156.

8. Report of Joint WHO/UNICEF/ICCIDD Consultation on Indicators for Assessing Iodine Deficiency Disorders and their Control Programmes. Geneva, World Health Organization, 1992; pp 22-29.

9. Dunn JT, Crutchfield HE, Gulekunstr, Dunn D. Methods for Measuring Iodine in Urine. A Joint Publication of WHO/UNICEF/ICCIDD, 1993; pp 18-23.

10. Thimmayamma BVS. A Handbook of Schedules and Guidelines in Socio-economic and Diet Surveys, Hyderabad, National Institute of Nutrition 1987.

11. Gopalan C, Ramashastri BV. Nutritive Value of Indian Foods, NIN, ICMR, Hyderabad 1993; p 156.

12. Nutrient Requirement and Recommended Dietary Allowances. National Institute of Nutrition, Hyderabad, 1990.

13. Field Supplementation Trial in Pregnant Women with 60, 120 and 180 mg of Iron with 500 mg of Folic Acid. Indian Council of Medical Research, New Delhi, 1992.

14. Collaborative Study on High Risk Pregnancies and Maternal Mortality. An ICMR Task Force Study. Indian Council of Medical Research, New Delhi, 1990.

15. Changes in Hemoglobin Levels During Pregnancy in Rural Women. Annual Report, National Institute of Nutrition, Hyderabad, 1982, p 69.

16. Kapil U, Saxena N, Ramachandran S, Nayar D. Iodine status of pregnant women residing in a district of endemic iodine deficiency in the state of Himachal Pradesh, India. Asia Pacific J Clin Nutr 1997; 6: 224-225.

17. Bolem MW, Matzger H, Huq N. Vitamin A deficiency among women in the reproductive years: An ignored problem. In: Report of the XVI International Vitamin A Consultative Group Meeting, 24-28 October 1994, Chiang Rai, Thailand. Washington DC: IVAC G Secretariat, ILSI Research Foundation, 1985, p 78.

18. Venkatachalam PS, Belvady B, Gopalan C. Studies on vitamin A nutritional status of mothers and infants in poor communities in India. J Pediatr 1962; 61: 262-268.

19. Sharma K. Studies on Nutritional Anemia and Nutritional Anemia Control Programme in an Urban Slum Setting in India, with Special Reference to Pregnant Women, Lactating Women and Preschool Children. Doctoral Dissertation. M.S. University of Baroda, India.