Key Factors Influencing Anaemia

CHAPTER II

LITERATURE REVIEW

The present study will reveal the effectiveness of ragi porridge in increasing haemoglobin level among adolescent girls with anemia. An extensive review was made to strengthen the present study in order to lay down foundation. This helps to reveal the prevailing situation of the similar studies in different areas. The related literatures for this study is discussed in the following subtitles.

Studies related to prevalence and factors associated with anemia.

Studies where haemoglobin estimation was done by cyanmethaemoglobin method.

Studies where dietary supplements were used to prevent and control anemia.

2.1 Prevalence and Factors Associated with Anemia: A cross-sectional study was conducted in the urban area of Nagpur to study the prevalence of anemia among adolescent females and the socio- demographic factors associated with anemia . A total of 296 adolescent females (10-19 years old) were included in this study. The prevalence of anemia was found to be 35.1%. A significant association of anemia was found with socio-economic status and literacy status of parents. Mean height and weight of subjects with anemia was significantly less than subjects without anemia. A high prevalence of anemia among adolescent females was found, which was higher in the lower socio-economic strata and among those whose parents were less educated (Sanjeev Chaudhary,M., 2003).

Assessment of prevalence and associated causes of anemia among school girls of age 11- 14years in Masindi District, Western Uganda was done by a cross –sectional survey and the overall prevalence of anemia was found to be (45.9%) among the 109 students. The prevalence was higher in urban schools (61 % )than rural schools (30.9%). There was more consumption of plant food of low iron bioavailability than animal food. This resulted in majority of pupils having less than recommend intake of iron (50.5%). Anemia was associated with nutrient content of food, worm infestation , location of school and bleeding (Barugahara Evelyn Isingoma, 2008).

The anemia status and awareness about anemia among the adolescent girls was analyzed in 16 high schools located in two randomly selected Hatnura and Kondapur mandals of Medak district. Among the 1811 adolescent girls between 10 and 15 years of age, iron deficiency anemia was detected in 85% of adolescent girls. Mild, moderate and severe grades of anemia were 63.25%, 12.5% and 5.3% respectively. Signs and symptoms of anemia like pale eyes, pale tongue, pale nails, fatigue, breathlessness, poor appetite and lack of concentration was 12.5%, 14%, 9.2%, 26.5% and 8.6% girls respectively (Indian Institute of Health and Family Welfare Annual Report,2003).

A study was conducted in rural areas of Meerut district to find out the prevalence of anemia among adolescent girls and to study their socio-demographic characteristics in relation to anemia. Among the 504 adolescent girls included in the study 174(34.5%) girls were anemic. The prevalence of mild, moderate and severe anemia among adolescent girls was 19%, 14.1% and 1.4% respectively. The prevalence of anemia was higher in socio economic class V (50%) and reduced with rise in socio economic status, being minimum 27.3% in class I. Adolescent girls whose fathers were labourers were more anemic (44%) than whose fathers in agriculture (27.1%). Prevalence was higher (42.2%) in adolescent girls having illiterate mother and just literate mothers (51.9%). High level of anemia was observed in adolescent girls belonging to family size > 3(38%) than those from families of size <3 (27.2%) (Rawat, C. M. S., 2001).

At slum, areas of Ahmedabad city a study was conducted to high light the problem of anemia in school going pre-adolescents and adolescents girls residing in the slums and to determine the relationship between the prevalence of anemia and various socio–demographic variables. Among 1295 school girls (6-18 years) residing in 15 randomly selected slum areas majority 81.8% of girls were anemic out of which 55.2% were mildly anemic 36% moderately anemic and 0.6% severely anemic. Anemia was found to be higher among girls with the attributes of those with habit of post meal consumption of tea/coffee (94.4%), whose father’s were working as semiskilled/skilled workers (77%), those with BMI of 18.5 or lower (82.4%). The prevalence of anemia was lower in girls consuming green leafy vegetables. No relationship of anemia was observed with socio-economic status, parents’ education, status of menstruation and daily consumption of lemon/ sour fruits in this study (Verma. A.,2004).

Indian Council of Medical Research conducted multicentre study in 18 districts from 13 states of the country to assess the iron deficiency disorders. A community based survey was conducted including rural and urban children (<12 years) adolescent girls (11-18years) and pregnant women.. The overall prevalence of anemia among 4,332 non-pregnant adolescent girls from 16 districts was 90.1%.The overall prevalence of severe anemia was 7.1%, moderate anemia was 50.9% and mild anemia was 32.1% (Tuteja .G.S., 2001).

While approximately 8% of women are estimated to be iron deficient in the west, 10 – 20 % of younger girls are affected. Although these girls often appear to be in good health, low iron levels profoundly affect many aspects of their day to day lives, including an ability to concentrate, and thus their learning at schools is also affected (Mike Nelson, 2001).

A cross–sectional study was conducted to find out the epidemiological correlates of nutritional anemia among adolescent girls with anemia at rural Wardha. The prevalence of anemia was 59.8%.The prevalence of severe, moderate, mild anemia was 0.6%, 20.8% and 38.4% respectively.The impotant corelates of anemia was found to be vegetarian diet, excessive menstural bleeding,iron intake and worm infestation (Karur.S.,2006).

Iron deficiency anemia is a major nutrtional disorder in India and other developing countries.Large population surveys in rural India indicate that the prvalence of anemia according to WHO criteria ranges from 42% to 77% among different age groups. The prevalence of anemia is higher among children than the adults have. The prevalence is higher among girls 68.8% and women 64% than boys 56.8% and men 48%, respectively (Narasinga Rao.B.S., 2003).

A study was conducted to assess the prevalence of anemia among the vulnerable groups in rural areas of Jarkand. Heamoglobin estimation was carried out by cyanamethheamoglobin method on 597 preschool children, 548 pregnant women and 587 lactating mothers. The overall prevalence of anemia was 84 % among preschool children, 91% among pregnant women and 98% among lactating mothers. 5.5% preschool children, 12.7% pregnant women and 8% lactating mothers had severe anemia (Brahmam, et al.,, 2002).

A study on prevalence of anemia was conducted in seven states in India.The prevalence of anemia was lowest in Kerala and highest in Madhya Pradesh. Women in Kerala had higher literacy, better housing, better access to mass media and health care. In Tamil Nadu 90% were anemic, in Kerala 58% and 68% were anemic in Himachal Pradesh (Nutrition foundation of India,2005).

A study was conducted at nursing school of Vadodara on prevalence of anemia among students and to compare the nutritional status with the prevalence of anemia. The overall prevalence of anemia was 86.8% among 167 students, the prevalence of severe anemia was 1.2%, moderate anemia 43.11% and 42.5% had mild anemia. Anemia was uniformly widespread among all levels of nutritional status of students. The prevalence of anemia remained high and did not differ between all three groups of BMI, that is between those who were normal, under weight and over weight (Karkar.P.D., 2004).

A community based cross- sectional study was carried out among 250 adolescent girls aged 13-19 years in an urban community of Gulbarga to assess the health problems and suggest measures for improvement of health status of adolescent girls. The overall prevalence of anemia was found to be 94%. The prevalence was higher in the age group of 17-19 years 96.7% as compared to other age groups 13-15 years of age 95.1% and in the age group of 15-17 years 88.2% (Indupalli.A.S.,2004).

Even today nearly 1.5 billion people all over the world are affected by iron deficiency anemia. In India alone, depending on age and sex, iron deficiency anemia has been reported to range from 38-72%, majority of them being women and children.The iron deficiency anemia prevalence rate beyond the age of 6 years increases in girls. This could be due to certain factors like menstruation, gender discrimination in intra household food allocation and early marriage leading to early pregnancy. Adolescent girls form 22% of the total population and estimates suggest that about 25-50% girls become anemic by the time they reach menarche (Sharma, 2000).

Iron deficiency is the most common cause of anemia in adolescents in the United States, and an adolescent girl is 10 times more likely to develop anemia than a boy. Teenagers are at the highest risk of anemia during their adolescent growth spurt. Among girls, however, menstruation increases the risk for iron deficiency anemia throughout their adolescent and childbearing years. An important risk factor for iron deficiency anemia is heavier than normal menstrual bleeding, which affects about 10% of women in the United States (Lloyd Van Winkle, 2009).

2.2 Haemoglobin Estimation by Cyanmethaemoglobin Method: To accurately measure the haemoglobin photoelectric devices are used to assess the amount of light absorbed by a blood sample. Cyanmethaemoglobin method is the international standard for haemoglobin determination as stable reference solutions are available for calibration. Sensitivity approach is100% and specificity is greater than 90%(Path ,1998).

A cross-sectional survey was conducted in an urban area under Urban Health Training Center, Department of Preventive and Social Medicine, Government Medical College and Hospital, Nagpur to estimate the prevalence of anemia among adolescent females and to study the socio-demographic factors associated with anemia. Hemoglobin estimation was done by the cyanmethaemoglobin method using a Klett-Summerson photoelectric colorimeter with green filter and the prevalence of anemia was found to be 35.1% (Sanjeev. M. Chaudhary, 2008).

A study was conducted to assess the prevalence of anemia among the prevalence of anemia amongst the primary school age children 6-11 years of age in National Capital Territory of Delhi. Haemoglobin estimation was carried on by indirect cyan-methaemoglobin method within a week of collection of blood sample The children having Haemoglobin levels < 7,7-< 10.5 and 10.5-< 11.5, 11.5 and more gm/dl were classified as having severe, moderate, mild and no anemic respectively. The prevalence of mild moderate and severe anemia in this age group was reported as 22%, 43% and 4% respectively (Sethi.V.,2002).

A study was conducted to assess the nutritional status of adolescent girls at the Government Senior Secondary School in village Chandawli of District Faridabad in Haryana among students of Classes six to twelve. Haemoglobin was estimated by cyan-methaemoglobin method using a calorimeter. Known standards were run along with the test samples for maintaining quality control. The prevalence of anemia was noted to be 39.6% (Anand.K., 2001).

A study was conducted on identification of an appropriate strategy to control anemia in adolescent girls of poor communities.. Haemoglobin status was estimated by cynamethaemoglobin method using the filter paper technique. Since a major part of the study was carried out in distant village. This technique was found feasible (Sharma Anshua et al., 2000).

An epidemiological survey was conducted to find out the prevalence of anemia among adult males and non-pregnant females in rural North India.The haemoglobin status was estimated by direct cynamethaemoglobin method. The prevalence of anemia among females was 50% while among males it was 44.3% (Malhotra.P.,2003).

A study was carried out by the Indian council of medical research to assess the status of anemia among pregnant women and adolescent girls from 16 districts of 11 states of India. Anemia was diagnosed by estimating the hemoglobin concentration in the blood with the use of the indirect cyanmethaemoglobin method method.The survey showed that 84.9% were anemic (Tuteja.G.S., 2006).

A hospital based study was conducted at a rural area in Haryana To compare the hemoglobin estimates obtained from filter paper cyanmethemoglobin and hemocue method. It was revealed that the hemocue method overestimated the hemoglobin values when compared to the filter paper cyanmethemoglobin method by 1.8 g/dl (Pathak, Kapoor et al.,2009).

2.3 Dietary Supplements to Prevent and Control Anemia: A randomized, controlled double-blind trial conducted in 2007 at a. state-run school in Sobral, Brazil, among children aged 2-3 years. The study objective was to evaluate whether regular consumption of rapadura (jaggery) as a natural sweetener in fruit juices (mixed with ascorbic acid) is capable of preventing or treating anemia in preschool children. The study was carried out over 12 weeks among two groups of children aged 2–3 years. One group was given cashew fruit juice sweetened with 25 g of jaggery mixed with 40 mg of ascorbic acid, while the other group received the same quantity of cashew juice and ascorbic acid sweetened with refined sugar. The study took place over 56 school days .The jaggery -fortified beverage and the beverage sweetened with refined sugar were offered to the intervention group and the control group, respectively, in individual (200-ml) portions. For the group consuming the jaggery –fortified beverage mixture, mean Haemoglobin level was 11.1 ± 1.09g/dl at baseline and it was 11.6 ± 2.10 g/dl after intervention. For the control group, mean Haemoglobin level was 10.2 ± 1.20 g/dl 3.11% at baseline and 10.3 ± 1.26 after the intervention (Gopi.Ghosh.N ., .2006).

A longitudinal human feeding trial was conducted to evaluate the use local foods for increasing heamoglobin level. One ragi based diet and one rice based diet was evaluated, 25 pregnant women received ragi based diet and 25 received rice based diet and 25 served as non supplement control group. These women were followed through pregnancy, delivery and 18 months of lactation their infants were also monitored from growth to school age. An improving trend in health status of women and growth pattern of their children was noticed compared to the control counterparts. For the multi generational study 35 young women who were in the earlier study were followed up during their first pregnancy and data was compared with those from their own mothers. Remarkable improvement in birth weight and other measures were evident. Heamoglobin level of the intervention group in second generation was 13.8 gm/dl and first generation intervention group was 8.5gm/dl. Heamoglobin level of the control group in second generation was 10.0gm/dl and first generation control group was 8.3gm/dl (Devadas. R.P., 2001)

A quasi experimental study was conducted to develop an iron rich supplement with locally available foods and to test its feasibility in school going children (7-9 years) belonging to low income families. Children from the upper primary school in Rajendra Nagar were screened for haemoglobin levels and 36 children having haemoglobin levels below 11 g/dl were selected. A supplement food was developed using locally available foods like jaggery, processed rice flakes, cress seeds, and amaranth seeds (45 : 40 : 10 : 5). The, children were given one ladoo per day for a period of 60 days. Effect of supplement on haemoglobin levels, height and weight were assessed. Significant increase in hemoglobin levels was observed in both the boys and girls after 30 days of supplementation only. The increase was comparatively more in the first 30 days than the second 30 days. In majority of the subjects progression from one Haemoglobin levels to the next higher level was observed (Sood, 2002).

An experimental study was conducted at three primary schools in Salem district to assess the effect of weaning biscuits supplementation of the nutritional parameters and cognitive performance of the selected children. Eighty Grade II malnourished primary school children were divided into four groups with twenty subjects in each group and given the weaning biscuits. 20 children kept as control group who were on home diet only. 20 children supplemented with Potato flour biscuits. 20 children supplemented with Wheat biscuits. 20 children supplemented with Ragi biscuits. Each supplemented groups received six biscuits comprising the weight of 60 grams daily for three months. Anthropometric measurements like height and weight, clinical picture for signs of anemia were studied before and after supplementation Supplementation with potato biscuits, wheat and ragi biscuits had wiped out the symptoms of pot belly and oedema (symptoms related to PEM) where as in control group these symptoms still existed. Reduction in anaemia related symptoms of brittle and spoon shaped nails were notable in supplementation group, as a reflection of the increased hemoglobin level. In general, reduction in all the clinical symptoms of nutritional disorders was observed in supplemented groups than in the control group (Peerkhan Nazni, 2010).

A study was conducted on children in the age group of 7 – 9 years from primary corporation school located in the urban areas of Chennai district to reduce the prevalence of iron deficiency anemia and also to improve the immune status, school performance through dietary supplementation with micronutrient rich foods. The children with moderate anemia were divided into three groups of 50 children each to receive the food based supplement micronutrient rich balls prepared from wheat germ (60 g), gingelly seeds (5 g) and rice flakes (15 g) mixed with jaggery syrup (11gm). Second group synthetic supplement Riconia tablet (a micronutrient fortified tablet) and the third group constituted the control group with no intervention. The supplementation was for a period of six months children received 50gm of two balls daily. At the end of the supplementation, all the children who received iron supplements in the form of food recorded the highest increments (5.5 g/dl) in blood haemoglobin level. All the children except those in the control group had more than 12 g/dl of haemoglobin indicating normal iron nutritional status (Narayanasamy Sangeetha , 2009)

The best sources of iron among the cereals are ragi and bajra. At least twice a week, one can take it in the form of porridge, preferably every day. Jaggery can be used instead of sugar to sweeten milk, desserts, etc as jaggery has a high iron content. (Lily Madlok, The Hindu, May 26, 2003).