NUTRITION RESEARCH, Vol. 7, pp. 1127-1138, 1987 0271-5317/87 $3.00 + .00 Printed in the USA. Copyright (c) 1987 Pergamon Journals Ltd. All rights reserved. HEMATINIC SUPPLEMENTATION AND HEMATOLOGICAL STATUS OF UNDERPRIVILEGED SCHOOL GIRLS ( 8-15 YRS OF AGE) * PURNIMA KASHYAP, PhD and TARA GOPALDAS Ph D. Department of Foods and Nutrition M.S. University, Baroda 390 002 Gujarat, India. ABSTRACT Effect of hematinic dosing with FeSO 4 ( 60 mg elemental iron), for 60 days at a stretch, twice in a school year on the hematological status was investigated. Eightythree pairs of subjects initially matched for age, Hb status, dietary energy, proteins, iron and ascorbic acid intakes were randomly assigned to either the treatment or placebo group. Data were collected four months apart at baseline( 0 month); mid evaluation (4th month); final evaluation (8th month); and post final evaluation (12th month), following a withdrawal of inputs. Prevalence of anemia was near universal (90Z by WHO norm of 12 g/dl) prior to supplementation and was reduced to 30Z after two prophylactic treatments at the 8th month. Further, RCM examination at the initiation of the study, indicated that anemia was primarily of iron deficiency origin. Mean Hb values of the hematinic supplemented group rose from 10.28• g/dl at 0 mth, to 11.61• g/dl at 4th month, to 12.33• g/dl at 8th month and dropped to i0.66~ 0.12 g/dl at 12th month evaluation. For the placebo group the values remained practically stationary at baseline values. Comparative iron status values measured by serum iron, total iron binding capacity and transferrin saturation for hematinic treated and placebo group subjects at 8th month were 87.93 vs 59.17 mcg/dl; 388.03 vs 435.33 mcg/dl; 23.36 vs 14.47 Z respectively. Results indicated that the prophylactic dose and dosing schedule improved the hematological status of underprivileged school girls. Key words: Anemia~ underprivileged school girls, hematinic supplementation, iron status. Supported by grants from the University Grants Commission, New Delhi, India and forms a part of the doctoral work of Purnima Kashyap. 1127
Transcript
NUTRITION RESEARCH, Vol. 7, pp. 1127-1138, 1987 0271-5317/87 $3.00 + .00 Printed in the USA. Copyright (c) 1987 Pergamon Journals Ltd. All r ights reserved.
HEMATINIC SUPPLEMENTATION AND HEMATOLOGICAL STATUS OF UNDERPRIVILEGED SCHOOL GIRLS ( 8-15 YRS OF AGE) *
PURNIMA KASHYAP, PhD and TARA GOPALDAS Ph D.
Department of Foods and Nutrition M.S. University, Baroda 390 002
Gujarat, India.
ABSTRACT
Effect of hematinic dosing with FeSO 4 ( 60 mg elemental iron), for 60 days at a stretch, twice in a school year on the hematological status was investigated. Eightythree pairs of subjects initially matched for age, Hb status, dietary energy, proteins, iron and ascorbic acid intakes were randomly assigned to either the treatment or placebo group. Data were collected four months apart at baseline( 0 month); mid evaluation (4th month); final evaluation (8th month); and post final evaluation (12th month), following a withdrawal of inputs. Prevalence of anemia was near universal (90Z by WHO norm of 12 g/dl) prior to supplementation and was reduced to 30Z after two prophylactic treatments at the 8th month. Further, RCM examination at the initiation of the study, indicated that anemia was primarily of iron deficiency origin. Mean Hb values of the hematinic supplemented group rose from 10.28• g/dl at 0 mth, to 11.61• g/dl at 4th month, to 12.33• g/dl at 8th month and dropped to i0.66~ 0.12 g/dl at 12th month evaluation. For the placebo group the values remained practically stationary at baseline values. Comparative iron status values measured by serum iron, total iron binding capacity and transferrin saturation for hematinic treated and placebo group subjects at 8th month were 87.93 vs 59.17 mcg/dl; 388.03 vs 435.33 mcg/dl; 23.36 vs 14.47 Z respectively. Results indicated that the prophylactic dose and dosing schedule improved the hematological status of underprivileged school girls.
Key words: Anemia~ underprivileged school girls, hematinic supplementation, iron status.
Supported by grants from the University Grants Commission, New Delhi, India and forms a part of the doctoral work of Purnima Kashyap.
1127
I128 P. KASHYAP and T. GOPALDAS
INTRODUCTION
*
Prevalence of anemia in underprivileged school girls (5-13 yrs) in Baroda city, Gujarat, has been reported to be near universal (90%) by the World Health Organisation(WHO) norm of 12 g/d1(1). Further, a dose of 20 mg elemental Fe/day for 60 days at a stretch, twice in a school year, was unsuccess- ful in improving the Hb status of the preadolescent/adolescent (10-13yrs)girls, probably indicating their need for a higher hematinic dose level. In another study from this department on underprivileged school boys (8-15 yrs), a benefit in Hb status at the end of 4 months was observed on a 30 mg and 40 mg elemental Fe dosage/day for 60 days at a stretch(2).
However, onset of menarche increase the iron requirements in school girls to higher levels than those of boys of the same age group. Thus, to improve the hematological status of these future mothers, it is essential to meet their present iron requirements and build up adequate stores for the future needs. Therefore, a series of hematinic intervention studies were planned for school girls. This study is the first in the series. It investigates the effect of a suitable prophylactic hematinic dose on underprivileged school girls (8-15 yrs), when administered for 60 days at a stretch, twice in a school year. The objectives of the present investigation were to study the impact of hematinic supplementation on (i) percent prevalence of anemia; (ii) Hb status; and (iii) other parameters of iron status, namely, serum iron(SI), total iron binding capacity (TIBC) and transferrin saturation(TS).
METHODS
Sample s e l e c t i o n
Of the 45 primary schools catering exclusively to under- privileged school girls in Baroda city, Gujarat(Western India), four schools were purposively selected for the study. Permission to conduct the study was obtained from the Primary School Board and Principals of the respective schools. Only subjects with recorded birth dates between 8-15 years of age, with family income less than Rs. 500/= (US $42.00) per month and those whose parents gave informed consent for participation in the study, including blood withdrawal, were enrolled. Based on the above conditions, 207 subjects were enrolled for the study. But, the sample was reduced to 166 subjects due to attrition over the one year long supplementation study.
* Underprivileged school children were those of low socio- econmic strata, living in congested slum pockets of the city; in one or two room tenaments without attached toilets. Although, piped water was available to some, the environment in and around the houses was unsanitary; usually with large families, more than 5 members/family with neither parent having more than primary school education, working on dai~[ges"
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Choice of hematinic supplement
There is evidence from this laboratory to indicate absence of folate deficiency in pre schoolers(3) and in school boys (2). Other investigators have also reported that folate and vitamin BI2 deficiencies are relatively uncommon among Indian children(4,5). A predominant microcytic hypochromic red cell morphology of the present study subjects (Table i) indicated that iron deficiency was the primary cause of anemia. Therefore, ferrous sulfate alone was used as our hematinic compound.
TABLE 1
Red Cell Morphology of underprivileged school girls(8-15 yrs)
Figures in parentheses indicate actual number of subjects.
Hematinic dosage selection
Although various levels of ferrous iron have been used to study the response to iron therapy, in hematological studies in school children, no guidelines for the prophylactic dose level of iron for school age populations are available. In order to prevent side effects and to bring about a slow hematological response for mildly anemic cases, the Interna- tional Nutritional Anemia Consultative Group,INACG(6) suggested, a single dose of 36 to 74 mg ferrous iron/day. WHO(7) suggested a dose of 3 mg elemental iron as ferrous ascorbate/kg body weight/day for infants and preschoolers. Accordingly, a prophylactic dose of 60 mg elemental Fe as FeSO 4 was calculated on the basis of the mean weight (21 kg, range 14.0 to 36.0 kg) of the study group. However, chemical analysis of the Fe tablets by Wong's thiocyanate method (8) gave an analysis value of 62 mg elemental iron/tablet. No side effects at this dosage were observed in the hematinic treated group.
Dosing procedure
INACG has suggested that the Hb response is virtually completed after two months of appropriate therapy although dosing for a longer duration is desirable for accumulation of storage iron (9). Hence, a distribution period of 60 days duration was decided upon for feasibility and convenience.
1130 P. KASHYAP and T. GOPALDAS
The subjects were stratified by age, using one year age intervals. Within each category the subjecgs were pair matched for initial Hb levels and nutrient intakes for calories, proteins, iron and ascorbic acid. One subject from each pair was then randomly assigned to either the experimental or placebo group. The two groups did not differ in any of the matching criteria (Table 2). The experimental group received a daily hematinic dose of 60 mg elemental iron as FeSO 4 while the placebo group received sugar tablets , as a single dose, twice in a school year, at the commencement of each school term of about 4 months duration, for 60 days at a stretch. The experimental design was such that data was collected every four months ie. baseline (0 month), at the initiation of the study; mid evaluation (4 th month), at the end of the first school term; final evaluation (Sth month), at the end of the second school term; and post final evaluation (12th month), following a withdrawal of inputs.
TABLE 2
Matching criteria for the hematinic treated and placebo group of underprivileged school girls (8-15 yrs) at baseline evaluation
Hematinic Placebo Independent Criteria treated group group 't' values
Difference in means of the various criteria between the two groups was non significant, thereby indicating that the two groups were well matched prior to the hematinic supplementation trial.
Data collection
Seven ml of venous blood was collected at the 8th month ie. final evaluation for SI, TIBC and TS estimations. All blood samples were collected between II.00 am to 2.00 pm. to avoid diurnal variations.
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Parameter Data collection time(month) Method 0 4 8 12
Red cell Morphology v/ - - -
(RCM)
Hemoglobin / v/ J J (Hb)
Diet survey for nutrient intake
SI, TIBC and TS
Leischman's stain (i0)
Cyanmethemoglobin method, filter paper technique (11)
Means and standard errors were calculated for both the groups,for all parameters. The independent 't' test was used to compare the experimental and placebo groups at each evalua- tion. The paired 't' test was used to study the changes over time in Hb in both the groups.
RESULTS
Impact of hematinics on the prevalence of anemia
Table 3 depicts the changes in the prevalence of anemia on intervention over the entire study period.
Near universal (90%) prevalence of anemia was observed using the WHO norm of 12g/dl for anemia(15). Using the more modest cut off point suggested by $ingla and Agarwal (16) for anemia, in Indian school age children (i.e Hb~ll g/dl)nearly three quarters (70%) of the subjects were still found to be anemic. On dosing the prevalence figures by the WHO norm were reduced to 59% at the 4th month and to 31% at the 8th month indicating that prevalence of anemia was reduced to a third by the above prophylactic dose and dosing schedule.
Impact of hematinic supplementation on Hb status
Table 4 indicates changes in mean Hb values of subjects in the experimental and placebo group over one year.
Comparison of each group over the entire study period ( in columns) indicated a highly significant (p< 0.001) improvement in the mean Hb values of the hematinic treated group, following each intervention. On withdrawal of the hematinic supplement (12th month) a significant (p < 0.001)
1132 P. KASHYAP and T. GOPALDAS
drop in the values from those at the 4th and 8th month evaluation was observed. A marginal change (+0.32 g/dl) was observed in the Hb values of the placebo group over the study period. This was stastically significant (p< 0.001) and could perhaps be attributed to a variation in the dietary intakes due to seasonal availability of certain iron rich foods like fenugreek (Trigonello foenum@raecum), spinach (Spinacia oleracea), amaranth (Amaranthus gangeticus)etc. However, this could not be substantiated as the dietary survey was conducted only at the initiation of the study( 0 month). Significantly (p<0.001) higher Hb values were observed in the hematinic treated against the placebo group at 4th (11.61 vs 10.71 g/dl) and at 8th month (12.33 vs 10.68 g/dl) evaluations. Hb values dropped significantly from the 8th month values, resulting in a non significant difference between the experimental and placebo groups ( I0;65 vs 10.37 g/dl).
TABLE 3
Impact of intervention on the prevalence of anemia in under- privileged school girls, 8-15 yrs of age.
Groups Cut off point taken
as < ii g/dl % prevalence(83)
Cut off point taken as < 12 g/dl
Z prevalence(83)
Base- Mid Final Post- Base- Mid Final Post- line 4th 8th final line 4th 8th final 0mth mth mth 12 mth 0 mth mth mth 12 mth
Iron 70 25 1 58 90 59 31 89 treated group (58) (21) (I) (48) (75) (49) (26) (74)
Note: Figures in parentheses indicate actual nuber of subjects.
Fig. 1 illustrates the changes in the Hb values for the Fe treated subjects over one year indicating a shift in Hb values from the lower to the higher ranges. Nearly 70% of the subjects had attained Hb values greater than 12 g/dl at the 8th month evaluation. Hb values for the placebo group however remained virtually stationary (Fig. 2).
The inference appears to be that hematinic dosing at the level and duration of dosing used~ reduces prevalence of anemia and brings about an elevation in the Hb status of the majority of the population under study.
ImpaCt of hematinic supplementation on Fe status
The placebo group values could be considered to be the baseline values as they were simply carried over time with sugar tablets. Thus a comparison with the hematinic group would
HEMATINIC SUPPLEMENTS FOR GIRLS 1133
indicate the benefit of Fe supplementation in the study popula- tion over 8 months.
A comparative profile of the measures of iron status at the 8th month in the hematinic supplemented and placebo groups are depicted in Table 5. Significantly(p4 0.001) higher SI and TS values and significantly (p ~ 0.001) lower TIBC values in the hematinic supplemented over the placebo group were observed.
Table 5 also ilustrates the percentage of subjects with inadequate iron stores. Results indicated that 6~ of the supplemented group subjects had a TS value below i0~ ( which is considered as the single best criterion of impairment of Fe supply to the developing red cell in children upto adolescence.
This implied that a dose of 60 mg Fe/day as Fe804 for 60 days at a stretch, twice in a school year alone, may not be sufficient to reduce prevalence of anemia and improve iron stores of every subject in the supplemented group.
TABLE 4
Changes in Hb status over one year study period in the Fe treated and placebo groups.
Group I Group II Independent (Fe treated) (Placebo) 't' values
Baseline (B) i0.28• 0.14 Mid (M) 11,61• 0.14 Final (F) 12.33• 0.09 Post final(PF) 10.65• 0.12
*** ** B Vs M 12.25.** 3.44** B Vs F 16.95.. 3,32NS B Vs PF 3.96*** -0.34** M Vs F 7.78*** -0.63**: M Vs PF -8.65*** -4.03** F Vs PF -15.32 -3.94
NS - Non significant difference between the two groups. Difference between the two groups significant (p ~ 0.01) Difference between the means of the two groups highly significant (p ~ 0.001).
1134 P. KASHYAP and T. GOPALDAS
TABLE 5
Hematological status of hematinic treated and placebo group after intervention for one school year (8th month evaluation)
Parameter Hematinic Placebo 't' treated group group value
The INACG (9, 18) has rightly drawn attention to the need for intervention strategies and iron supplementation programs to eradicate nutritional anemia in the school age populations, where little research has been done inspite of a high prevalence of anemia. In girls, sexual development and attainment of menarche ( onset of menstruation) imposes an extra demand for nutrients, especially iron, which must be met. However, in the underprivileged population this does not happen because of poor availability of iron in the cereal based diets (6). Hence school girls require hematinic supplementation to meet these additional needs.
The hematological data of the present study demonstrated that iron status is less than adequate in a significant proportion of the underprivileged school girls (8-15 yrs). Results on the prevalence of anemia were in conformity with those of various studies conducted all over India (19, 20) and on Baroda school children (1,21).
Absence of folic acid and Vit BI2 deficiency in Indian school children has been reported earlier(4, 5). Our finding that Fe deficiency was the primary cause of anemia, indicated by predominant microcytic hypochromic red cell picture, is in agrrement with a report by Gopaldas et al(2)
1136 P. KASHYAP and T. GOPALDAS
for underprivileged school boys of Baroda. Also, results of the supplementation trial supported the fact that anemia was primarily of the iron deficiency type.
Results of the other iron status parameters (SI, TIBC and TS) indicated a beneficial effect of hematinic therapy on the study population. However, a small proportion of the supplemented subjects had a TS below the normal, even at the end of the second intervention. This could be due to either an insufficient dose to raise it to normal values in all subjects or due to the need for longer duration of supplementation or due to some subjects not being anemic by this criterion.
The need for continued hematinic dosing year after year to these school girls during their school sojourn was indicated by a decline in Hb values, approaching those at baseline, 4 months after withdrawal of therapy.
Consequently, in order to maintain a normal iron status for such girl populations, it would be necessary to continue hematinic supplementation, at the suggested prophylactic dose level of 60 mg elemental iron/day, and a distribution regimen of 60 days per school term for two terms per year, as long as they attend school.
Most of the study subjects came from a socio-economic segment where marriage and motherhood would normally follow early in their lives. Consequently, this study has shown that regular prophylactic hematinic supplementation at the level indicated, for as many years these girls attend school, may result in most of these girls entering motherhood with sufficient iron stores, which in turn may help them to have normal pregnancies and offspring of normal birth weight.
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