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Indian Pediatr 2015;52:
867-869 |
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Determinants of Nutritional Anemia in
Adolescents
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Deena Thomas, Jagdish Chandra, *Sunita Sharma,
#Anju Jain and Harish K
Pemde
From Departments of Pediatrics, *Pathology and
#Biochemistry, Lady Hardinge Medical College, New Delhi,
India.
Correspondence to: Dr Deena Thomas, 52-C, Pocket-6,
MIG Flats, Mayur Vihar, Phase-III, Delhi-110096, India.
Received: October 29, 2014;
Initial review: December 05, 2014;
Accepted: July 15, 2015.
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Objectives: To associate the severity of nutritional anaemia
with serum levels of ferritin, vitamin B12 and folate; and to determine
demographic, socio-economic and nutritional correlates for nutritional
anemia in adolescents.
Methods: Cross-sectional hospital-based study
among 200 adolescents (10-18 y) with anemia. Dietary intake (24-h
recall), and serum levels of folate, vitamin B12 and ferritin were
estimated.
Results: Iron, folate and vitamin B12 deficiency
was present in 30.5% 79.5% and 50% of adolescents, respectively.
Statistically significant association was observed between severity of
anemia and serum vitamin B12 levels, iron intake, folate intake, Vitamin
B12 intake, vegetarian diet, attainment of menarche and history of worm
infestation.
Conclusions: Folate and vitamin B12 deficiencies
are more common than iron deficiency in anemic adolescents. Low dietary
intake of these nutrients seems to be a significant determinant of their
deficiencies.
Keywords: Ferritin, Folic acid, Iron-deficiency, Vitamin B12
deficiency
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Adolescence is a vulnerable period in the
human life cycle for the development of nutritional anemia. Anemia has a
negative effect on cognitive performance in adolescents [1]. Choudhary,
et al. [2] reported two-thirds of the anemic adolescents in
community were suffering from iron deficiency anemia (IDA). In a study
by Patra, et al. [3] on severely anemic adolescents admitted in a
tertiary care hospital, megaloblastic anemia was most common type of
anemia (42.5%) and iron-deficiency accounted for 15% cases [3]. Compared
to the vast amount of work done in pregnant mothers and young children,
there are relatively few published studies in India evaluating
deficiencies of Iron, Vitamin B12 and Folate in adolescents having
nutritional anemia and its association with severity of anemia. This
study was planned with an objective of finding association of the levels
of micronutrients with the severity of nutritional anemia in
adolescents.
Methods
The present study was a hospital-based
cross-sectional observational study conducted in the Department of
Pediatrics, Lady Hardinge Medical College, New Delhi, India, during
November 2011 to April 2013. Adolescents (age 10-18 years) attending the
outpatient department or admitted in the hospital, and having hemoglobin
values below the cut-offs (Hb <12g/dL in 10-18 y girls and 10-14 y boys
and Hb<13g/dL in 15-18 y boys) were included in the study after written
informed consent from parent/guardian. Those who had received blood
transfusion or hematinics in past 4 weeks or having apparent infection
(fever, diarrhea, cough or burning micturition) or any chronic disease
were excluded from the study. A detailed history and physical
examination of the study population was carried out. The premorbid
dietary intake of the child was assessed by 24-hour recall method. This
data was entered in ‘Diet soft’ software from which the daily intake of
iron, folate and vitamin B12 was calculated.
Complete blood count with peripheral smear
examination was done. Serum ferritin was estimated by a
Microplate Immunoenzymometric assay using Calbiotech Ferritin ELISA Kit,
California, US (FR06F) while serum Folate and Vitamin B12 were estimated
through automated immunoassay system using Beckman Coulter Access-2
(Beckman Coulter, Inc. Access Folate Reagent- A14208 and Access Vitamin
B12 Reagent-33000), California, US.
The severity of anemia was graded as mild (>10 g/dL
but below age related cut-off for defining anemia), moderate (7-9.9 g/dL)
and severe (<7g/dL). Serum vitamin B12 level of <200 pg/mL, folate level
<5 ng/mL and ferritin level < 30ng/mL were considered as deficient.
Normocytic anemia was defined as MCV 78-98 fL in males and 78-102 fL in
females; microcytic as MCV <78 fL; and macrocytic as MCV >98 fl in males
and >102 fL in females. The SPSS 21.0 software was used for data
analysis. Fischer’s exact test and analysis of variance were performed;
P<0.05 was considered as significant.
Results
A total of 350 adolescents (155 inpatients) with
pallor were screened of which 200 (99 males) satisfied the inclusion
criteria. Two-thirds (69.5%) of participants belonged to early
adolescence age (10-13.9 y). Almost half (54%) of the adolescents
had normal BMI (+1 to -2 SD), 27.5% were very underweight (<-3 SD),
17.5% were underweight (-2 to -3 SD), and only 1 % were overweight (+1
to +2 SD). Dietary evaluation revealed that energy intake was
deficient in 94.5% of adolescents, iron intake was deficient in 99.5%,
vitamin B12 intake was deficient in 14.5% and folate intake was
deficient in 62.5% of anemic adolescents.
Mean (SD) hemoglobin was 9.4 (2.5) g/dL with 50.5%
having mild anemia, 29% having moderate anemia while 20.5% having severe
anemia; 55% had normocytic anemia, 27.5% had microcytic, 8.5% had
macrocytic, and 9% had dimorphic anemia. Median levels of micronutrients
across different groups of anemia severity are presented in Table
I. Iron deficiency was present in 30.5% subjects, vitamin B12
deficiency in 50% of subjects and folate
deficiency was present in 79.5% of subjects. Isolated iron, vitamin B12
and folate deficiency was seen in 5%, 4% and 25%, respectively while
combined folate and vitamin B12 deficiency was seen in 32%. Deficiency
of all the three micronutrients was documented in 12% while 9% had no
deficiency.
TABLE I MicroNutrient Intake and Levels Across Different Groups of Anemia Severity
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Mild Anemia |
Moderate Anemia |
Severe Anemia |
Total |
Iron (mg/d), intake, mean (SD) |
11.4 (3.4) |
9.9 (3.2) |
9.4 (3.0) |
10.5 (3.4) |
Vit.B12 (mg/d) intake, mean (SD) |
1.0 (0.8) |
0.8 (0.7) |
0.5 (0.7) |
0.9 (0.8) |
Folate (mg/d) intake, mean (SD) |
144.0 (59.4) |
135.3 (50.4) |
110.2 (47.435) |
135.1 (55.9) |
Serum ferritin (ng/mL), median (IQR) |
45.3 (12.3-150.8) |
45.1(5.8-163.8) |
35.4 (2.2-132.7) |
43.6 (6.3-144.0) |
Serum vitamin B12 (pg/mL), median (IQR) |
206.0 (160.0-302.5) |
241.0 (166.5-313.0) |
119.0 (160.0-241.0) |
198.5 (145.3-305.5) |
Serum folate (ng/mL), median (IQR) |
4.0 (2.9-4.6) |
3.7 (3.1-4.9) |
3.27 (2.30-4.94) |
3.7 (2.9-4.7) |
Severe anemia was significantly associated with
history of worm infestation, attainment of menarche, vegetarian diet and
low serum B12 levels (Table II). Low intake of iron,
vitamin B12 and folate were also significantly associated with severe
anemia.
TABLE II Association of Sociodemographic Parameters with Severity of Anemia
Variables |
Severe anaemia |
Mild- moderate anemia |
OR (95% CI) |
P value |
|
(n=41) n (%) |
(n=159) n (%) |
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Female gender |
25 (60.9) |
76 (47.7) |
1.70 (0.84-3.43) |
0.16 |
Vegetarian diet |
17 (41.4) |
22 (13.8) |
4.41 (2.04-9.51) |
<0.001 |
Upper lower socioeconomic status |
32 (78.0) |
105 (66.0) |
1.82 (0.81-4.10) |
0.18 |
History of worm infestation |
13 (31.7) |
29 (18.2) |
2.08 (0.96-4.50) |
0.04 |
Post menarchal |
15 (36.5) |
46 (28.9) |
1.02 (0.40-2.57) |
0.02 |
BMI < –3SD |
12 (29.2) |
43 (27.0) |
1.11 (0.52-2.83) |
0.84 |
Serum ferritin <30 ng/mL |
18 (43.9) |
43 (27.0) |
2.11 (1.03-4.29) |
0.055 |
Serum vitamin B12 <200 pg/mL |
28 (68.2) |
72 (45.2) |
2.60 (1.25-5.39) |
0.01 |
Serum folate <5 ng/mL |
31 (75.6) |
128 (80.5) |
0.75 (0.33-1.69) |
0.51 |
Discussion
Our study showed that deficiency of folate, vitamin
B12 and iron are common in anemic adolescents. Higher proportion of
severely anemic individuals (20.5%) in our study can be attributed to
hospital-based nature of the study. Prevalence of iron deficiency,
vitamin-B12 deficiency and folate deficiency in our
study is comparable to earlier reports from India [3-6]. Under the
National programs (Iron plus initiative and weekly iron folate
supplementation), the beneficiary receives supplemental iron and folic
acid. Deficiency of B12 is currently not being addressed through these
programs [7,8].
Vegetarianism was significantly associated with
severe anemia which was similar to the findings by Verma, et al.
[9]. Attainment of menarche was also significantly associated with of
anemia which was in agreement with the findings of Heath, et al.
[10] who reported that high menstrual blood loss was associated with
increased risk of anemia. A significant association between history of
worm infestation and severity of anemia in the present study was in
agreement to findings of Shield, et al. [11] who demonstrated a
statistically significant inverse correlation between hookworm egg count
and hemoglobin level.
Our study findings are limited by the hospital-based
design of the study. Another limitation is that presence of infections
which were not picked up on detailed history and examination could have
erroneously elevated the serum ferritin above the cut-off used for
defining iron deficiency anemia.
We conclude that low intake of iron folate and
vitamin B12 is a significant determinant towards causing nutritional
anemia in adolescents. Supplementation with not only iron and folic acid
but also vitamin B12, besides deworming, is required through national
programs.
Acknowledgement: Department of Nutrition and
Dietetics, All India Institute of Medical Sciences, New Delhi for
providing ‘Diet Soft’ software.
Contributors: DT: Data collection, statistical
analysis and preparing the manuscript; JC: study concept and critical
revision of manuscript; HKP: statistical analysis and manuscript
revision; SS and AJ: laboratory investigations and manuscript revision.
Funding: None; Competing interests: None
stated.
What This Study Adds?
• Deficiency of folic acid, vitamin B12 and
iron are common among adolescents with anemia.
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