Prevalence of Iron Deficiency Anaemia among Adolescent Girls

CONTENTS

ABSTRACT

1. INTRODUCTION
Risk Factor of Anaemia
Causes of Anaemia
Stages of Anaemia
Nutritional Requirement during Adolescents
Objectives of the Study

2. REVIEW OF LITERATURE

3. RESEARCH METHODOLOGY
Material Selection
Development of Questionnaire
Clinical and Bio Chemical Assessment
Nutrition Education
Procedure

4. RESULTS

6. DISCUSSION

7. CONCLUSION AND RECOMMENDATIONS

BIBLIOGRAPHY

APPENDIX

LIST OF TABLES

1.1 Periods of development in adolescence

1.2 Cut –off points for the diagnosis of anaemia

3.1 List of Sample Schools

3.2 BMI classification of Body Mass Index (BMI)

3.3 Classification of anaemia

3.4 Normal Values of Serum Iron

3.5 Normal values of serum ferritin

4.1 Age wise distribution of respondents

4.2 Distribution of respondents according to type of family

4.3 Distribution of respondents according to the number of family members

4.4 Distribution of respondents according to the number of children in their family

4.5 Distribution of respondents according to their ordinal position in the family

4.6 Respondents standard of enrollment in school

4.7 Distribution of respondents according to the educational qualification of their parents

4.8 Distribution of respondents according to the monthly income of their family

4.9 Descriptive statistics of Height (cm) of respondents

4.10 Descriptive statistics of Weight (Kg) of respondents

4.11 Body Mass Index of the respondents

4.12 Clinical Signs and Symptoms of the respondents

4.13 Clinical Signs and Symptoms of the respondents

4.14 Clinical Signs and Symptoms of the respondents

4.15 Health status of the respondents

4.16 Types of past illness of the respondents

4.17 Menarche status of the respondents

4.18 Source of drinking water consumed by the respondents

4.19 Hygiene of drinking water consumed by the respondents

4.20 Junk foods taken by the respondents

4.21 Frequency of junk foods taken by the respondents

4.22 Packed school lunch consumed by the respondents

4.23 Consumption of fruits and milk by the respondents

4.24 Consumption of green vegetables by the respondents

4.25 Staple Diet of the Respondents

4.26 Hemoglobin Status of the respondents

4.27 Frequency distribution of respondents according to serum Iron level

4.28 Frequency distribution of respondents according to serum Ferritin level

4.29 Nutritional Intake of Respondents as per 24 Hours Dietary Recall

LIST OF FIGURES

1.1 Flowchart showing causes of Iron Deficiency Anaemia (IDA)

4.1 Age wise distribution of respondents

4.2 Distribution of respondents according to type of family

4.3 Distribution of respondents according to the number of family members

4.4 Distribution of respondents according to the number of children in their family

4.5 Distribution of respondents according to their ordinal position in the family

4.6 Distribution of respondents according to the monthly income of their family

4.7 Body Mass Index of the respondents

4.8 Types of past illness of the respondents

4.9 Packed school lunch consumed by the respondents

4.10 Consumption of fruits and milk by the respondents

4.11 Consumption of green vegetables by the respondents

4.12 Hemoglobin Status of the respondents

ABBREVIATIONS

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CHAPTER – 1

INTRODUCTION

Health is a fundamental human right and health is central to the concept of quality of life (Sundar Lal, 2007). Adolescent is a period of second decade of life and constitute over one fifth of India’s population Adolescence begins when the secondary sex characteristics appear and ends when somatic growth is completed and the individual is psychologically mature, capable of becoming a contributing member of society. Adolescents are in the age group of 12 to 18 years. Girls begin to menstruate at this age. The girl should have weight approximately 42-64 kg and height approximately 155-169 cm. Total nutrient requirements are increased during adolescence age to support a period of dramatic growth and development. Eating right food at right time will prevent the nutritional deficiencies especially Iron deficiency disorders (Dorothy et al., 2007).

Adolescence is a critical stage in the life cycle, when the health of females is affected due to growth spurt, beginning of menstruation, poor intake of iron due to poor dietary habits and gender bias. Iron deficiency anaemia affects over 60% of the adolescent girls in India. Anaemia in adolescent girls has far-reaching implications. The anemic adolescent girls grow into adult women with compromised growth, both physical and mental. These women have low pre-pregnancy weight, and are more likely to die during childbirth and deliver low birth weight babies (UNICEF, 2012).

In adolescence, development occurs in three periods and these are shown in Table 1.1.

Table 1.1: Periods of development in adolescence

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Source: B. Srilakhsmi (2002) Dietetics (4th edition).

Iron is one of the micronutrient. It is used for formation of hemoglobin, oxygen transportation, brain development, regulation of body temperature and muscle activity. When the iron is decreased in human body, it is called as iron deficiency. Iron deficiency is the most common etiological factor in anaemia. The decreased hemoglobin level is called as iron deficiency anaemia (Park, 2007).

Anaemia is a serious public health problem, which affects the mental and physical development, as well as health maintenance and work performance. Iron deficiency is by far the most common cause of anaemia worldwide. About 2 billion people suffer from varying degrees of anaemia in developing countries. Iron deficiency occurs when insufficient iron is absorbed to meet the body’s needs. This may be due to inadequate iron intake, poor iron absorption, increased iron need or chronic blood loss. Prolonged iron deficiency leads to iron deficiency anaemia (IDA).

Table 1.2: Cut –off points for the diagnosis of anaemia

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Source: K. Park, (2000). Text book of Preventive and social medicine, 16th edition

RISK FACTORS FOR ANAEMIA

Anaemia is the most common cause of maternal deaths, accounting at number fifth of all maternal deaths (more than one lakh women in India die of pregnancy-related deaths, out of which 22,000 are related to nutritional anaemia). Severe anaemia accounts for 20.3% of maternal deaths.

The risk of dying from haemorrhage and infection is five to ten times greater among anemic women compared with non-anemic women.

Anaemia among women also contribute to infant health by intra-uterine growth retardation, low birth weight and ultimately perinal mortality, and a higher risk of irreversible brain damage in infants. Anaemia is more likely to occur during:

- Preschool age when growth is rapid
- Adolescence when there is rapid growth and menstrual loss of iron
- Pregnancy, when there is rapid growth of foetus and maternal tissues.

Nutritional anaemia is widely prevalent in many parts of the world, particularly in developing countries. Although many nutrients and co- factors are involved in the maintenance of a normal haemoglobin concentration, the most common nutrient deficiency in nutritional anaemia, from the public health point of view, is iron deficiency. Iron requirements of children are closely related to growth and the requirements of iron increase during the periods of rapid growth, both in pre-school and school age children. In girls, there is a further increase in iron requirements at the onset of menstruation (Goyle and Prakash, 2009).

CAUSES OF ANAEMIA

Iron-deficiency anaemia (IDA), often caused by insufficient iron intake, is the major cause of anaemia in childhood. It has become much less common in the United States over the past 30 years, primarily due to iron-fortified infant formulas and cereals. Iron-deficiency anaemia doesn't develop immediately. Instead, a person progresses through stages of iron deficiency, beginning with iron depletion, in which the amount of iron in the body is reduced while the iron in RBCs remains constant. If iron depletion isn't corrected, it progresses to iron deficiency, eventually leading to IDA. Not having enough iron in our body causes iron-deficiency anaemia. Lack of iron usually is due to blood loss, poor diet, or an inability to absorb enough iron from the foods that we eat.

Blood loss

When one loses blood, one loses iron. If enough iron is not stored in one’s body to make up for the iron loss, the person develops iron-deficiency anaemia. In women, low iron levels may be due to blood loss from long or heavy menstrual periods or bleeding fibroids in the uterus. Blood loss that occurs during childbirth is another cause for low iron levels in women. Internal bleeding (bleeding inside the body) also may lead to iron-deficiency anaemia. This type of blood loss isn’t always obvious, and it may occur slowly. Some causes of internal bleeding are:

- A bleeding ulcer, colon polyp, or colon cancer
- Regular use of aspirin or other pain medicines, such as no steroidal anti-inflammatory drugs (for example, ibuprofen and naproxen)
- Urinary tract bleeding

Poor diet

The best sources of iron are meat, poultry, fish, eggs, and iron-fortified foods (foods that have iron added). If a person doesn’t eat these foods regularly, or if he/she doesn’t take an iron supplement, he/she is more likely to get iron-deficiency anaemia. Vegetarian diets can provide enough iron if the right foods are eaten. For example, good non meat sources of iron include spinach and other dark green leafy vegetables, certain types of beans, dried fruits, and iron-fortified breads and cereals. During some stages of life, such as pregnancy and childhood, it may be hard to get enough iron in diet. This is because the need for iron increases during these times of growth and development.

Inability to absorb enough iron

Even if there's enough iron in our diet, our body may not be able to absorb it. This may be due to intestinal surgery or diseases of the intestine, such as Crohn’s disease or celiac disease. Prescribed medicines that reduce acid in the stomach also can interfere with iron absorption.

Women

Women of child bearing age are at increased risk for iron-deficiency anaemia because of blood loss during their monthly periods. About 1 in 5 women of child bearing age has iron-deficiency anaemia. Pregnant women also are at higher risk for the condition because they need twice as much iron as usual. The extra iron is needed for increased blood volume and for the foetus' growth. About half of all pregnant women develop iron-deficiency anaemia. The condition can increase a pregnant woman's risk for a premature or low-birth-weight baby.

Adults who have internal bleeding

Adults who have internal bleeding, such as intestinal bleeding, can develop iron deficiency anaemia due to the blood loss. Certain conditions, such as colon cancer and bleedings, ulcers can cause blood loss. Certain medicines such as aspirin also can cause internal bleeding.

Other risk groups

People who get kidney dialysis treatment may develop iron – deficiency anaemia. This is because blood is lost during dialysis. Also the kidneys are no longer able to make enough of a hormone needed to make red blood cells ( U.S. Department of Health & Human Services, 2011).

STAGES OF ANAEMIA

According to Herbert (1992) deviations from normal iron status have been summarized as follows:

- Stages I and II negative iron balance (i.e. iron depletion)-In these stages, iron stores are low and there is no dysfunction. In stage I negative iron balance, reduced iron absorption produces moderately depleted iron stores. Stage II negative iron balance is characterized by severely depleted iron stores. More than 50 % of all cases of negative iron balance fall into these stages. When persons in these two stages are treated with iron, they never develop dysfunction or disease.
- Stages III & IV negative iron balance (i.e. iron deficiency)-Iron deficiency is characterized by inadequate body iron, causing dysfunction and disease. In stage III negative iron balance, dysfunction is not accompanied by Anaemia; however, Anaemia does occur in stage IV negative iron balance.
- Stages I & II positive iron balance- Stage I positive iron balance usually lasts for several years with no accompanying dysfunction. Supplements of iron or vitamin C promote progression to dysfunction or disease, whereas iron removal prevents progression to disease. Iron overload disease develops in persons with stage II positive balance after years of iron overload have caused progressive damage to tissues and organs. Again iron removal stops disease progression. Iron status has a variety of indicators. Serum ferritin levels are in equilibrium with body iron stores. Very early (stage I) positive iron balance may be best recognized by measuring total iron binding capacity (TIBC) (transferrin IBC). Conversely, measurement of serum (plasma) ferritin levels may best reveal early (stages I &II) negative iron balance, although serum total iron- binding capacity may be as good as indicator.

Because anaemia is the last manifestation of chronic, long term iron deficiency, the symptoms reflect a mal-function of a variety of blood systems. Inadequate muscle function is reflected in decreased work performance and exercise tolerance. Neurologic involvement is manifested by behavioral changes, such as fatigue, anorexia and pica especially pagophagia (ice eating).

- and colleagues, in their report of International Nutritional Anaemia Consultative Group (1998) support earlier work by Pollitt and colleagues (1986) that abnormal cognitive development in children suggests the presence of iron deficiency before it has developed into overt anaemia. Growth abnormalities, epithelial disorders and a reduction in gastric acidity are common. A possible sign of early iron deficiency is reduced immune competence, particularly defects in cell mediated immunity and the phagocytic activity of neutrophils which may lead to an increased propensity for infection. As iron deficiency Anaemia becomes more severe, defects arise in the structure and function of the epithelial tissue, especially the tongue, nails, mouth, and stomach. The skin may appear pale and the inside of the lower eyelid may be light pink instead of red. Fingernails can become thin and flat and eventually koilonychias (spoon shaped nails) may be noted. Mouth changes include atrophy of the lingual papillae, burning, redness, and in severe cases a completely smooth, waxy, and glistening appearance to the tongue (glossitis). Angular stomatitis may also occur, as may a form of dysphagia (difficulty in swallowing). Gastritis occurs frequently and many results in cardiovascular and respiratory changes that can eventually lead to cardiac failure. Some behavioral symptoms of iron deficiency seem to respond to iron therapy before the Anaemia is cured, suggesting they may be the result of tissue depletion of iron containing enzymes rather than the result of a decreased level of hemoglobin (Krauses, 2000).

Iron absorption refers to the amount of dietary iron that the body obtains. Healthy adults absorb about 10% to 15% of dietary iron, but individual absorption is influenced by several factors.

Storage levels of iron have the greatest influence on iron absorption. Iron absorption increases when body stores are low. When iron stores are high, absorption decreases to help protect against toxic effects of iron overload. Iron absorption is also influenced by the type of dietary iron consumed. Absorption of heme iron from meat proteins is efficient. Absorption of heme iron ranges from 15% to 35%, and is not significantly affected by diet. In contrast, 2% to 20% of nonheme iron in plant foods, such as rice, maize, black beans, soybeans and wheat is absorbed. Nonheme iron absorption is significantly influenced by various food.

Meat proteins and vitamin C will improve the absorption of nonheme iron. Tannins (found in tea), calcium, polyphenols, and phytates (found in legumes and whole grains) can decrease absorption nonheme iron. Some proteins found in soybeans also inhibit nonheme iron absorption. It is most important to include foods that enhance nonheme iron absorption when daily iron intake is less than recommended, when iron losses are high (which may occur with heavy menstrual losses), when iron requirements are high (as in pregnancy), and when only vegetarian nonheme source of iron are consumed. (Rani, 2010).

Iron deficiency anaemia will be prevented by adequate dietary intake or iron such as green leafy vegetables such as amaranthus, spinach, coriander leaves, drumstick leaves, radish leaves, vegetables such as beet root, drumstick, cereals like ragi, barley, rice (raw milled), legumes like bengal gram dhal, black gram dhal, soyabean, nuts and oil seeds and fruits such as chickoo, pomegranate and jaggary (Swaminathan, 2008).

illustration not visible in this excerpt

Source: Krauses (2000) Food nutrition and diet therapy (11th edition).

Figure 1.1: Flowchart showing causes of Iron Deficiency Anaemia (IDA)

NUTRITIONAL REQUIREMENT DURING ADOLESCENCE

1. Energy

Caloric needs increase with the metabolic demands of growth and energy expenditure. Although individual needs vary, girls consume less kilocalories than boys. Boys need 2500-2600kcal a day. The calories for both boys and girls from age group of 1-3 years to 7-9 years remain the same. During the adolescent year from the age of 10 years there is a marked difference in the caloric needs of boys and girls.

2. Protein

The protein for the both boys and girls are the same up to the age of 10 years. But there is gradual difference in their requirement from the age of 10 years and the boys have a greater requirement as compared to girls. This pattern is similar in caloric requirement also.

3. Minerals

Calcium and iron are particularly needed during adolescence. Bone growth demands about 150 mg of calcium to be retained each day to allow the increase in bone mass. Iron is needed for haemoglobin synthesis which is required for expansion of blood volume and for myoglobin which is needed for muscle growth.

4. Vitamins

The need for thiamine riboflavin and niacin, increase directly with increased caloric intake .Folic acid and B12 are essential for DNA and RNA synthesis and needed in higher amounts when tissue synthesis is occurring rapidly. Tissue growth involves amino acid metabolism particularly transamination to synthesis of nonessential amino acids. So the requirement for B6 is increased. Skeletal growth requires vitamin D while the structural and functional integrity of newly formed cells depends on the availability of vitamin A, C and E ( Srilakhsmi , 2002).

Iron deficiency is the most common and widespread nutritional disorder in the world and effects a large number of children and women in developing countries, it is the only nutrient deficiency which is also significantly prevalent in industrialized countries. The numbers are staggering 2 billion people i.e. – over 30% of the world’s population are anemic, many due to iron deficiency, and in resource-poor areas, this is frequently exacerbated by infectious diseases. Iron deficiency affects more people than any other condition, constituting a public health condition of epidemic proportions. More subtle in its manifestations than, for example, protein-energy malnutrition, iron deficiency exacts its heaviest overall toll in terms of ill-health and premature death. Iron deficiency and anaemia reduce the work capacity of individuals and entire populations, bringing serious economic consequences and obstacles to national development. Overall, it is the most vulnerable, the poorest and the least educated that are affected by iron deficiency (WHO, 2012).

STATEMENT OF THE PROBLEM

Adolescent is one of the most challenging period in human development. The relatively uniform growth of childhood is suddenly altered by a raped increase in the growth rate. The sudden changes create nutritional needs. Adolescent is considered as especially nutritionally vulnerable period for several reasons. First they have an increased demand for nutrients because of the dramatic increase in physical growth and development. Second the change in the life style and food habits of adolescent effect nutrients intake and needs. Third adolescence nutrient needs are effected by participation in sports, pregnancy, development of an eating disorder, excess diet, use of alcohol and drugs or some other situations.

In world health report of World Health Organization (WHO) states that the world wide mortality rate of iron deficiency anaemia is 60,404,000 in 2005 (WHO, 2005).

High prevalence of iron deficiency anaemia reflects their poor status of nutrition because of their rapid growth combined with poor eating habits and menstruation (Wongs, 2009).

Estimates suggest that over one third of the world’s population suffers from anaemia, mostly iron deficiency anaemia. India continues to be one of the countries with very high prevalence. National Family Health Survey (NFHS) reveals the prevalence of anaemia to be 70-80% in children, 70% in pregnant women and 24% in adult men. Prevalence of anaemia in India is high because of low dietary intake, poor availability of iron and chronic blood loss due to hook worm infestation and malaria. Anaemia has also well known adverse effects on physical and cognitive performance of individuals, the true toll of iron deficiency anaemia lies in the ill-effects on maternal and fetal health. Poor nutritional status and anaemia in pregnancy have consequences that extend over generations (WHO, 2009).

Against this backdrop the present study has been undertaken as a study of “Prevalence of Iron Deficiency Anaemia among adolescent Girls and impact of Health and Nutrition Education programme in changing their Dietary Behaviour”

OBJECTIVES OF THE STUDY

1. To assess the prevalence of iron deficiency anaemia among the subject group by bio-chemical tests
2. To assess the nutritional status of the subjects by anthropometric measurements
3. To examine the clinical signs and symptoms of the subject group there by assessing the presence of various nutritional deficiencies
4. To assess the 24 hour dietary recall of the subjects
5. Implement Health and Nutrition Education Programme on the subjects already selected
6. To assess the change in hemoglobin levels of anemic subjects after imparting Health and Nutrition Education.

In the present chapter besides introduction the problem taken for present research, objectives of study were also laid down. Since secondary data forms an important data of any research work, accordingly the next chapter has been devoted to the review of literature.

CHAPTER – 2

REVIEW OF LITERATURE

he survey of the related literature is an important step in conducting educational research. It enables the investigator to locate the gaps and find the trends in research in a particular filed. The information about the designs, samples and research tools employed by other investigators help the future investigators to formulate their design with more accuracy. Investigators must be aware of the new researches conducted in the past and only then he/she will be in a position to contribute something in original. Good (1972) has rightly remarked, “without a critical study of the related literature, the investigator will be groping in the dark and perhaps uselessly, repeat the work already done. Therefore to save time, energy and resources it is necessary to undertake a detailed and penetrating study of all available literature.

Review of literature is a broad, comprehensive, systematic identification and summary of written materials that contains information on related problem. Review of literature is an integral component of any study or research project. It inspires insight and enhances the depth of knowledge into the problem. The review of literature throws light on the study and their findings related to the study (Basavanthappa, 1998).

Hall G.S. (1844-1924) was first psychologist who systematically conducted research on adolescents in the beginning of the present century and collected enormous data on adolescents. According to his study, adolescent in terms of psychological changes occurring in adolescents. He begins this period from 10-13 years of age and ends when full adult status is attained by 22-25 years of age. It is found that adolescence is a period of storm and stress.

Erikson (1964) a famous psychoanalyst, who developed very comprehensive theory of human development, stated that adolescence as a period of rapid changes physical, physiological, psychological and social According to Adams (1973)"Adolescence can be defined as a holding period in which education maturating and waiting are the major tasks to be faced." For this reason it seems scarcely profitable to define adolescence as being tied with age. It is the time when child begins to feel a lesser need for the security of familial supervision and protection at the time when physiological and hormonal development begins to approximate adult maturity and lastly when psychological maturing moves in the child in the direction of becoming responsible in society adolescence has begun.

Pastides (1981) initiated a study in order to estimate and compare the occurrence of nutritional anemia in three groups of adolescents and young adults. The first group comprised 159 individuals aged 14-21 years, who had been previously screened for thalassemia in three cities of England. The second group was comprised of 163 Derby High School students, aged 14-18 years, who had also been previously screened for thalassemia. The third group consisted of 118 Yale undergraduate students, aged 16-21 years, who were monitored for nutritional anemia while undergoing routine physical examinations at the Yale University Health Service. The prevalence of nutritional anemia varied from 0.0% to 5.5% among the three female groups, and from 4.4% to 17.9% among the three male groups. Only the Yale undergraduate male group was found to be anemic and the Yale undergraduate females were discovered to have the highest prevalence.

Chauhan (1983) stated that the adolescence is the most important period in human development about which poets, writers and historians have made occasional references and have held esteem the sacrifices made by the adolescences. It is the transaction period and turning point in the life of the individual.

Switoniak et al. (1992) in their study found the prevalence of iron deficiency anemia in 224 women aged 31-47 years, working in textile industry. Anemia was found in 11.2% participating women, evident iron deficiency was found in 13.4% of population.

Hallalberg et al. (1993) stated that the prevalence of iron deficiency was determined in Göteborg, Sweden, in a sample of 15-16 year old girls (n = 220) and boys (n = 207) using serum ferritin (SF). In a this study of women regarding the relationship between SF and stainable bone marrow iron, it was established that at a cut off value for SF of< 16 micrograms/l in 75% of women with no iron stores sf concentration was below this value (sensitivity 75%), whereas in 98% of iron-replete women it was above this cut off value (specificity 98%). thus the study showed that in 40% of the girls and 15% of the boys sf was below the cut off value, indicating iron>

Ayoub (1995) Conducted study on girl students of first and second academic years of Dubai Medical College it was found that the mean Hb was 12.83±1.49 and that for serum iron was 13.73 micromol/l. Anemia was detected 24.62% of the group among which Arab Gulf Nationalities constituted 31.25%. Egyptians showed the highest prevalence of anemia (50%). The study showed a significant effect of chronic blood loss whether menstrual or from any other cause which effected the Hb level. Also living in the hostel away from parents and families was reflected upon their dietary habits and had a significant reflection upon the prevalence of anemia among the studied group.

Alaofe (1996) found that 43% of subjects were anaemic (haemoglobin<120 g/l). iron deficiency defined by a four-model index based on two or more abnormal values in the four independent indicators of iron status used (serum iron, total iron-binding capacity, mean corpuscular volume, mean corpuscular haemoglobin concentration) was present in 14% of the subjects, while 13% had iron deficiency anemia (haemoglobin</120g/l+)

A study conducted by Adgeppa et al. (1997) in Indonesia including 805 adolescent girls showed that 21.1% of the girls (170) were anaemic having haemoglobin level less than 12 g/dl and according to Kanani et al. (1997) stated in their review on anemia among adolescent girls revealed that 70% of adolescent girls in low income communities had Hb levels, 110 g/L. When the WHO cut off of 120 g/L was applied, the prevalence was even higher (80–90%).

Singh (1998) concluded that there was a significant difference in prevalence of anemia in adolescent girls in relation to caste, socio-economic status, father's occupation and mother's education. Reverse association was seen between socio-economic status and the prevalence of anemia in adolescent girls. Lower the socio-economic status, higher the prevalence of anemia i.e. maximum (47.6%) in class V and minimum (29.1%) in class I and II. Fathers who were professionals had least prevalence of anemia in their adolescent girls. Akkamahadevi et al. (1998) studied the prevalence of anemia in adolescent girls (12-18 years) of rural and urban areas of Dharwad Taluka. Among 172 adolescents, 23.84% of the girls were severely anaemic, 22.67% moderately anaemic and 24.42% were having mild anemia. The prevalence was higher in rural girls (57.8%) compared to urban counterparts (31.32%).

Meier et al. (1999) found that 47% of all placebo-supplemented and 16% of all iron-supplemented patients exhibited IDA (p<0.001); 59% of adolescent placebo-supplemented and 20% of adolescent iron-supplemented patients exhibited ida (p=0.021).also Maeda et al. (1999) in their study conducted screening for anemia among adolescents in Tokyo enrolment started from 1966 and included 793 junior and senior high school students in the screening program. It increased to more than 70,000 by 1989. A normal haemoglobin (Hb) level was present in 90% of students before 1981, and in 98% of boys and 95% of girls in 1990 and found that the %age of girls with a normal Hb level decreased gradually after 1991. The high incidence of anemia suggested an increase in the prevalence of iron deficiency. Kapoor et al. (1999) in his study conducted on the prevalence of anemia found that anemia was prevalent 27.8% in young boys 12-14 years as compared to 41.3% in older boys 15-18 years. Anemia was present in 51% of young girls compared to 38.5% in older girls. The mean haemoglobin was higher in boys as compared to girls in both the age groups. In Sri Lanka, a study was conducted on 690 adolescent girls to estimate the prevalence of anemia (Jayatissa and Piyasena, 1999). Results indicated that 21.1% (146) of girls were having haemoglobin less than 11.5 g/dl and thus were anaemic.

Terhune et al. (2000) conducted a study and found that the prevalence of iron deficiency anemia was 6.2±0.8% in Mexican American females and 2.3±0.4% in non-Hispanic white females. The prevalence of iron deficiency anemia was 2.3 times higher in Mexican American than in non- Hispanic white females. According to Jackson et al. (2000) in a study of prevalence anemia in adolescent Kuwaiti schoolgirls, and its association with hemoglobinopathies as well as the most common environmental cause, Fe deficiency. A cross-sectional sample of 1051 healthy adolescent schoolgirls was studied. Sample size was based on WHO criteria. Anemia, Fe deficiency and hemoglobin (Hb) variations were studied by Hb concentration, and erythrocyte protoporphyrin (EP). Out of the subjects sampled, 30% were anemic. Mildly elevated EP values were found in 68%. Girls with high erythrocyte protoporphyrin (EP) levels. Up to 25% of the girls may have had Fe deficiency anemia. Hemoglobinopathies were neither prevalent nor significantly associated with anemia. These data indicate that environmental factors play a significant role in anemia among healthy, well-to-do Kuwaiti adolescent girls. Ahmad et al. (2000) found that the prevalence of anemia (Hb<120 g/l) among the studies sample was 27%, 17% had depleted iron stores (SF<12 μg/l). of all anaemic girls, 32% had iron deficiency anemia Creed et al. (2000) in his study found that the prevalence of anemia is 35% in non pregnant women of fertile age and 24.7% in adolescent girls in slums of Spain. The major cause of anemia is low intake of dietary iron and results showed that there was a change in knowledge about anemia and improved dietary iron intake in 71 girls who completed the study as compared with the 66 girls in the control group. Similarly Rajaratnam Jolly et al. (2000) in his study concluded that the prevalence of anemia was 44.8% with severe anemia being 2.1%, moderate 6.3% and mild anemia 36.5%. There was a decrease in the prevalence as the age increased, however the difference was not statistically significant. The prevalence of anemia was 40.7% in premenarcheal girls as compared to 45.2% in postmenarcheal girls. Shahabuddin et al. (2000) conducted a study on nutritional status of adolescents in a rural community of Bangladesh. It was reported that 98% (1453 out of 1483) of adolescent girls suffered from anemia. Kanani et al. (2000) revealed that the prevalence of anemia is high in adolescent girls in India, with over 70% anaemic. Iron-folic acid (IFA) supplements have been shown to enhance adolescent growth elsewhere in the world. To confirm these results in India, a study was conducted in urban areas of Vadodora, India to investigate the effect of IFA supplements on haemoglobin, hunger and growth in adolescent girls 10–18 years of age. Results show that there was a high demand for IFA supplements and >90% of the girls consumed 85 out of 90 tablets provided. There was an increase of 17.3 g/L haemoglobin in the group of girls receiving IFA supplements, whereas haemoglobin decreased slightly in girls in the control group. Girls and parents reported that girls increased their food intake. A significant weight gain of 0.83 kg was seen in the intervention group, whereas girls in the control group showed little weight gain. The growth increment was greater in the 10-14 year old age group than in the 15-18 year old group, as expected, due to rapid growth during the adolescent spurt. IFA supplementation is recommended for growth promotion among adolescents who are underweight. According to Lynch (2000) iron deficiency anemia (IDA) during pregnancy is associated with significant morbidity of mothers and infants. Over 50% of pregnant women in developing countries suffer from IDA. It is also prevalent among adolescent girls because the growth spurt and onset of menstruation increase iron requirements. Women who conceive during or shortly after adolescence are likely to enter pregnancy with low or absent iron stores or IDA. Iron supplementation during adolescence is one of the new strategies advocated to improve iron balance in pregnancy. However, iron requirements are highest in the second and third trimesters. Furthermore, although supplementation will correct anemia and increase iron stores in girls, the positive effect on iron status will be temporary if their diets do not contain adequate bio-available iron. Although iron status in early pregnancy may be improved if the period of supplementation continues up to the time of conception, supplementation before pregnancy should be viewed as an additional strategy to supplementation during the second and third trimesters.

Saluja N., et al. (2001) found that the prevalence of anemia was significantly higher among adolescent girls belonging to joint family (45.2%) than those belonging to nuclear family (28.3%). Prevalence of anemia was also found to be significantly associated with socio-economic status as anemia was higher in socio-economic class V (50%) and significantly reduced with rise in socio-economic status being minimum (27.3%) in class I. Prevalence of anemia was found to be significantly higher (44%) in those adolescent girls whose fathers were working as labourers than those of agriculturists (27.1%). Prevalence of anemia was also found to be significantly higher in those adolescent girls having illiterate (42.2%) and just literate mother (51.9%) as compared to better literate mothers. A significantly high prevalence of anemia was found in adolescent girls belonging to families having family size >3(38%) than 27.2% in those girls from families of family size Brabin et al. (2001) revealed that the relationship of anemia as a risk factor for maternal mortality was analyzed by using cross-sectional, longitudinal and case-control studies because randomized trials were not available for analysis. The following six methods of estimation of mortality risk were adopted: 1) the correlation of maternal mortality rates with maternal anemia prevalence derived from national statistics; 2) the proportion of maternal deaths attributable to anemia; 3) the proportion of anemic women who die; 4) population-attributable risk of maternal mortality due to anemia; 5) adolescence as a risk factor for anemia-related mortality; and 6) causes of anemia associated with maternal mortality. The average estimates for all-causes of anemia and attributable mortality (both direct and indirect) were 6.37, 7.26 and 3.0% for Africa, Asia and Latin America, respectively. Case fatality rates, mainly for hospital studies, varied from<1% to="">50%. The relative risk of mortality associated with moderate anemia (hemoglobin 40-80 g/L) was 1.35. Population-attributable risk estimates can be defended on the basis of the strong association between severe anemia and maternal mortality but not for mild or moderate anemia. According to Al-Buhairan A.M., et al. (2001) reported that anemia varied from a low of 17% in Saudi Arabia to a high of over 70% in Yemen among preschool children; from 14% in the United Arab Emirates to 42% in Pakistan among adolescents; and from a low of 11% in Egypt to over 40% in the Syrian Arab Republic and Oman among women of childbearing age. The comparatively low prevalence of anemia among adult males noted may be attributed to the high iron intake in the form of meat as reported in countries of this region. Rawat et al. (2001) in his study found that 174 (34.5%) of the 504 adolescent girls were anaemic. In his study he also found that the prevalence of anemia was significantly higher (45.2%) among adolescent girls from joint families as compared to those from nuclear families (28.3%), which may be related to household food security.

Kotech P.V., et al. (2002) conducted a study on sample of 804 girls for serum ferritin and found a proportion of girls had serum ferritin levels less than 12 g/ml, indicative of poor iron storage. Deeksha Agarwal et al. (2002) in their study revealed that the prevalence of nutritional anemia in India show that 65% infant and toddlers, 60% children 1–6 years of age, 88% adolescent girls (3.3% had haemoglobin < 7.0 g/dl; severe anemia) and 85% pregnant women (9.9% having severe anemia) were anaemic. The prevalence of anemia was marginally higher in lactating women as compared to pregnancy S.N. Massawe et al. (2002) examined that anemia (Hb<105 g/l) was highly prevalent in adolescent primigravidae (75.5%). Adolescent girls were more anaemic (Hb<120 g/l) than boys (14.5 vs. 7.9%). Iron deficiency and hookworm infestation were predominant in both groups of adolescents; however, malaria contributed more to anemia in the primigravidae. Nearly 40% of the anaemic primigravidae had indication of infection, and S-ferritin was less useful as a marker of iron deficiency in this group. STFR identified iron deficiency in both pregnant and non-pregnant adolescents. In another study by Shah et al. (2002) concluded that the prevalence of anemia declined from 68.6% and 70.1% in groups A and B to 20% and 13.4%, respectively, post supplementation ,whereas the prevalence in group changed little. There was a significant rise in the mean hematocrit of both supplemented groups but no appreciable change in controls. Net change in mean hematocrit in both the supplementation groups was comparable. Hence the prevalence of anemia in adolescent Nepalese girls is high. Supervised iron and folic acid therapy once a week is an effective alternative to daily administration and helps lower the prevalence of anemia in adolescent girls. Similarly Gowrikar et al. (2002) reported that the mean haemoglobin was 9.80 g/dl and overall prevalence of anaemic was 96.5% in 459 girls of 10-18 years of age in Ujjain. Leela et al. (2002) conducted a study on iron status and morbidity pattern among 120 school children in Coimbatore. The results revealed that mean haemoglobin level was 12.5, 11.03 and 9.17 g/dl for the non-anaemic, mild and moderate anaemic, respectively. A study by Indian Institute of Health and Family Welfare, Hyderabad (2002) carried out study on Prevention and Control of Anemia in adolescent girls utilizing school system in rural areas of Andhra Pradesh and found that out of 1811 girls enrolled from 16 selected schools, 1516 subjects studying in Classes VI to X were covered. Iron deficiency anemia was found to be the most common nutritional problem encountered by 81% of respondents. Mild, moderate and severe grades of anemia was observed in 63.2%, 12.5% and 5.3% of respondents respectively. Only 19% of respondents had normal haemoglobin (Hb) levels of 12g / dl or above.

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