Chapter I : Introduction

1..-on
deficiency

____

Total
population

INTRODUCTION

Health and nutrition are the two things that go hand in hand. Good nutrition is
essential for good health. Imbalance of proper nutrients in food causes
deterioration in health. Imbalance can be both over intake of nutrients i.e. over
nutrition and under intake of nutrients i.e. under nutrition. Over nutrition and obesity
is a major concern in developed countries as it increases the risk for diseases like
diabetes mellitus, cardiovascular disease, hypertension, stroke and various
cancers. 1
On the other hand under nutrition is a major health issue in developing countries.
The World Health Organization (WHO) long back in 1972 considered under
nutrition as the gravest single threat to the world's public health and declared
anemia as one of the top ten serious health problems in the world. 2 In a recent
report (2005) WHO reconfirmed anemia as the most serious global public health
problem 3 and reported that globally 41.8% pregnant females and 30.2 % of
nonpregnant females are anemic. 4
Anemia is a clinical condition characterized by reduction in the number of RBCs or
their Hemoglobin content below the accepted normal range depending upon age
and sex. Hemoglobin cut off levels for determining anemia as per WHO guidelines
are for adolescent girls and women in reproductive age group < 12 gm% and for
pregnant women< 11 gm%. 5

WHO technical report in 1968 defined nutritional anemia as a condition in which

the hemoglobin content of the blood is lower than normal as a result of a deficiency
of one or more essential nutrients regardless of the cause of such deficiency. 6
After more than 30 years the same definition holds true for defining nutritional
anemia? World Health Organization (WHO) coordinated a series of studies in
pregnant women and after assessing transferrin saturation, serum folate and
serum B-12 levels concluded that iron deficiency was present in 40-99% of the
pregnant women and was undoubtedly responsible for the major proportion of
anemia. Associated folic acid deficiency may be present in pregnant women. Other
nutrient deficiency e.g. vitamin B-12, pyridoxine and copper play an insignificant
role. 8 9 Even today iron deficiency and specifically iron deficiency anemia remains
one of the most severe and important nutritional deficiencies in the world. 5 Iron
deficiency is considered one of the ten leading global risk factors in terms of its
attributable disease burden. 10
In adolescent girls and women of reproductive age menstruation every month
causes iron deficiency. Over and above adolescent girls need more iron for their
growth requirement. Adolescents gain upto 50% of their adult weight, more than
20% of their adult height and 50% of their adult bone mass during this period. 11
For pregnant women each pregnancy approximately require 1000 mg of extra
iron. 12
Socially females are little different in our country due to varying culture, economic
factors and education. All females including students, house wives, working
women- labourers or professionals suffer from various grades of nutritional

anemia. The factors responsible for nutritional anemia vary in each class. Even in
literate class proper awareness is lacking regarding dietary rich sources of iron and
anemia. In housewives typical Indian culture matters. In most of the Indian families
women are last to eat and least bothered about the quantity and quality of food
they eat. Labourers spend more energy due to their strenuous work and do not
usually take

adequate diet. Females engaged in office type of work or

professionals are mentally and physically strained, give less attention to food due
to time constraints and like adolescents consume more junk foods which can
supply calories but not micronutrients. Bioavailability of iron in pure vegetarian food
is less than non vegetarian food. 13
Generally female child gets second priority in all aspects of nutrition including
balanced diet. Gender bias is highly prevalent in all the castes and all socioeconomical classes across the country. 14 In lower socio-economic class economic
constraints also play an important role. Paradoxically in higher socio-economic
class adolescent girls are very conscious about their body figure, hence do forced
dieting and suffer from nutritional anemia. 15 Earlier mainly cooking was in iron
utensils, while at present the cooking is in microwave, non-stick, stainless steel
and aluminium. Cooking in iron utensil can supply 5-10 mg iron/day. 16
In India prevalence of anemia in different studies is varying from 35.1% to 90.1% in
adolescent girls 171819 and 57.8% to 96.0% in pregnant women. 131920 21 Bentley
ME et al 22 reported that prevalence of anemia was high among all women. Even in
high socio economic class the prevalence of anemia was > 40% and there was not
much difference between rich or poor, fat or thin and urban or rural. While there

are regional differences prevalence rates across the states are remarkably
similar. 23 24
Adolescent girls with nutritional anemia are prone to many health hazards. It
affects growth, concentration, 25 school performance and capacity to perform
physical work. There is decreased immunity and inadequate preparation for
motherhood. Adult females with nutritional anemia suffer from weakness, easy
fatiguability,

reduced

work

capacity, 26

impaired

cognitive

performance,

susceptibility to other infective diseases due to suppression of immune system and

poor obstetric outcome. Even women with mild anemia experience fatigue and
have reduced work capacity. 27
World Bank analysis of the global burden of disease in 1993 ranked iron deficiency
anemia as the leading cause of loss of disability adjusted life years (DALYs) for
females aged 15-44 across the globe. 28 The loss due to micronutrient deficiency
costs India 1 percent of its GOP, which is a huge cost. 29
In pregnant females anemia leads to increased maternal morbidity and
mortality. 30 31 32 Approximately 6,00,000 women die every year from pregnancy and
child birth related conditions in the world. 33 Out of these 90% of these occur in
developing countries. In India anemia is primarily responsible for 20% of total
maternal deaths every yea~9 . Anemia in pregnancy had three times greater risk of
premature delivery, low birth weight babies and nine times higher risk of perinatal
mortality. 34 Anemic mothers give birth to children with low iron reserves. 3536 Such
infants are at risk of long term or permanent impairment of motor and cognitive
development. 37 Barker's hypothesis is - Intrauterine growth restriction in fetus

gives rise to diseases e.g. coronary heart disease, type 2 diabetes and
hypertension in their later life. 38 India was one of the first few countries to start
National Nutritional Anemia prophylaxis program as early as in 1970, yet the
current scenario is not satisfactory. 39 From the prevalence rate of anemia in
pregnant and non pregnant female WHO has put India into category of severe
public health problem group4 (Fig.1, Fig.2). Considering all these facts the present
study was undertaken to assess the health related hazards of nutritional anemia in
Indian females from adolescence to menopause in present times with following
aims and objectives.

AIMS AND OBJECTIVES

General objective : To study the health hazards of nutritional anemia in females

from adolescence to menopause.

Specific objectives :

(1)

To describe the spectrum of nutritional anemia in adolescents and adult

females.

(2)

To determine the effect on health as a whole with emphasis on physical

performance and Intelligent Quotient with cognitive performance.

(3)

To determine the obstetric outcome in pregnant mothers having nutritional

anemia.

(4)

To compare the different modalities of prevention and treatment.