Abstract Iron deficiency anemia (IDA) is one of the most prevalent nutritional deficiencies in the world. Adolescence, a period of rapid growth and development, is considered the most nutritionally vulnerable group. To combat these problems, a Nutrition based video game (Snakes and ladders) is developed to create an awareness on Iron Deficiency Anemia. An intervention study was conducted among 180 adolescent girls and boys in Government school and Private School with an objective to study the effect of a change in dietary behaviors for reduction of iron deficiency Anemia. Anthropometric measurements and hemoglobin estimations were collected from the subjects. Socioeconomic status was collected using pretested and Post tested questionnaires. Results showed that majority of low- income groups (Non-heme iron consumption) subjects shows low Hemoglobin percentage (35%) compared middle and high-income (Heme Iron consumption) groups. It is observed that knowledge and awareness on Anemia was increased significantly among school children. In conclusion, considering the effectiveness of the intervention on Iron Deficiency Anemia should be started and dietary behaviors should be improved in adolescents for the control and prevention of Anemia and IDA in this population.
Keywords: Iron Deficiency Anemia, Iron Studies on Adolescents.
When our body doesn’t have enough iron, Iron deficiency anemia occurs. In Iron deficiency anemia condition, the patient doesn’t get enough oxygen throughout the body. The body uses iron to make hemoglobin. Hemoglobin is a part of red blood cells. Oxygen is carried throughout the body by Hemoglobin. Lack of iron in the body, makes fewer and smaller red blood cells resulting in lower hemoglobin, and inadequate oxygen levels.
This publication is focused on Iron Deficiency Anemia and comparison between Heme Iron (meat consumption) and Non-Heme Iron (Plant based Iron rich food consumption) in subjects. It also provides information on how to prevent Iron Deficiency Anemia in Adolescents.
Intestinal mucosal cells in the duodenum and upper jejunum absorb the iron. The iron is coupled to transferrin (Tf) in the circulation which delivers it to the cells of the body. Phytates, tannins and antacids block iron absorption. Vitamin C rich foods will enhance the dietary iron absorption in the body. Calcium is found in foods suchas milk, yogurt, cheese, sardines,cannedsalmon, tofu, broccoli, almonds, figs, turnip greens and rhubarb and is the only known substance to inhibit absorption of both non-heme and heme iron. Eat non-heme iron foods (Plant
sources: legumes, grains, Nuts and seeds, vegetables) with vitamin C foods, and absorption can increase as much as five times.
Mucosal transfer of iron into the body occurs competitively with dietary iron that entered the absorptive cell as inorganic iron because they both share a common pathway within the intestinal cell.
Total iron-binding capacity (TIBC) is most frequently used along with a serum iron test to evaluate people suspected of having either iron deficiency or iron overload. This test helps your doctor know how well that protein can carry iron in the blood. Normal range of ferritin levels should be 20 to 500 nanograms per milliliter in men. 20 to 200 nanograms per milliliter in women. Over-consumption of Iron in diet leads to acute toxicity that causes severe mucosal damage in the gastrointestinal tract, among other problems. Deficiency of Iron leads to Damage to the intestinal lining. Inflammation leading to hepcidin-induced restriction on iron release from enterocytes.
High levels of ferritin can indicate an iron storage disorder, such as hemochromatosis, or a chronic disease process. Low levels of ferritin are indicative of iron deficiency, which causes anemia.
2. PURPOSE OF THE STUDY: The purpose of this study is to assess the effect of Nutrition games on knowledge and attitudes of adolescents on Iron deficiency anemia.
2.1 SIGNIFICANCE OF THE STUDY: Iron deficiency anemia is highly prevalent particularly among adolescents in developing countries. Adolescents are mainly suffering from anemia especially girl’s due to menstrual blood loss and improper nutrition. So, there is a need to give nutrition education for better awareness on Iron intake among adolescent girls in urban areas.
2.1.2. IRON DEFICIENCY ANEMIA SYMPTOMS
· Extreme fatigue
· Pale skin
· Shortness of breath
· Chest pain
· Frequent infections
· Dizziness or lightheadedness
· Cold hands and feet
· Inflammation or soreness of your tongue
· Brittle nails
· Fast heartbeat
To identify the contributing factors of Iron deficiency anemia in adolescent children.
To create awareness and knowledge on Iron deficiency in adolescent children.
To develop a Nutrition game on Iron rich foods.
To educate adolescent children through computer game on anemia.
To compare the Iron deficiency status among the school children with or without computer educational Intervention.
2.1.4. Review Of Literature
Health risks of Iron Deficiency Anemia:
Anuradhashekar (2011) reported that
Low iron stores in throughout childhood may delay the age at menarche.
· Severe anemia may lead to neurological abnormalities including head ache, irritability, generalized muscle weakness and ischemic attack.
· Anemia may also impair immune response. Lower verbal learning and memory. Decreased mood and ability to concentrate.
· International Journal of Obesity (2003) concluded Greater prevalence of iron deficiency in overweight and obese children and adolescents.
· Fogarty, et al, (Aug 2016) reported Iron-deficiency anemia (IDA) is the most common nutritional disorder observed in adolescent girls in India.
2.1.5. CLASSIFICATION OF ANEMIA:
As Anemia is classified into three degrees according to WHO:
• Mild Anemia
• Moderate Anemia and
• Severe Anemia
Hb cut-off values of Anemia are as follows
• 10.0-11.9 g/dl (mild),
• 7.0-9.9 g/dl (moderate) and
• <7.0g/dl(severe). Table-1: prevalence of iron deficiency anemia in adolescents Age group Sex Total Prevalence rate (%) Female Male 10-11 years 55 (5.2%) 74 (7.02%) 129 12.2 12-13 years 90 (8.5%) 112 (10.63%) 202 19.2 14-15 years 135 (12.8%) 133 (12.62%) 268 25.4 16-17 years 111 (10.5%) 52 (4.93%) 163 15.5 18-19 years 210 (19.9%) 82 (7.78%) 292 27.7 · India has the world's highest prevalence of iron deficiency anemia among women, with 60 to 70 percent of the adolescent girls being anemic. The pre-pregnancy nutritional status of young girls is important as it impacts on the course and the outcome of their pregnancy. · The prevalence of anemia was found to be 35.1% a significant association of anemia was found with the socioeconomic status of parents. Mean height and weight of subjects with anemia were significant. · Prevalence of anemia was 81.8% and significant association with variables such as the occupation of father, habits of post meal consumption of green leafy vegetables and body mass index among. Among girls (16-18yrs). less than subjects without anemia on adolescents. Fogarty, et al, (Aug 2016) reported Iron-deficiency anaemia (IDA) is the most common nutritional disorder observed in adolescent girls in India. Deficiency of iron in early life may increase the risk of psychiatric morbidity (Mu-Hong Chen, Tung-Pin, et al, (May2012)). Susan (2008) stated that the most severe consequence of iron depletion is iron deficiency anemia (IDA), and it is still considered the most common nutrition deficiency worldwide. Cynthia and Thomson (2011) reported that in an adequate nutrition is linked to a greater risk of anaemia in postmenopausal women. The prevalence of anaemia was found to be 35.1% a significant association of anaemia was found with socio-economic status of parents. 2.1.6TESTS AND DIAGNOSIS OF ANEMIA: Physical Examination: • Pale Conjunctive • Spoon shaped nails • Pale tongue • Brittle nails • Frequent infections Bio-chemical Tests: Blood test (Hemoglobin Levels). RECOMMENDED ALLOWANCES OF IRON: As per ICMR (1994) guidelines during adolescence, Age Iron Requirement (RDI) per day Girls 13-18 years 15 mg/day Boys 13-18 years 11 mg/day 2.1.7 PREVENTION OF IRON DEFICIENCY ANEMIA: We can prevent anemia by eating foods that contain iron every day. Iron-rich foods include meats, vegetables, and whole grains such as iron-fortified cereals. If the Iron deficiency is not cured by the food in early stage, the patients will be kept on medication. 2.1.8 TREATMENT: Dietary modification: In mild anemia which is asymptomatic, diet rich in iron such as spinach, beetroot, dates, figs, Jaggery, Ragi, eggs, meat etc are advised. In mild to moderate anemia Oral iron supplementation is advised. Heme iron is the most efficiently absorbed form of iron. The absorption rate of non-heme iron supplements, such as ferrous sulfate and ferrous fumarate, is 2.9% on an empty stomach and 0.9% with food. Injectable iron: In severe anemia or with severe symptoms, intolerance to oral iron etc, injectable iron dextrose is advised. Packed cell transfusion: Severe symptoms like shock or heart failure, Blood loss packed red cell transfusion is advised. Treatment of primary cause such as helminths, peptic ulcer disease etc. Erythropoietin injections in patients with kidney failure. 3. Materials & Methods: Sample Selection of area: Hyderabad (West) urban was selected as the study area. Nizampet and Hydernagar are the two areas identified where two schools private and Government schools are selected for the study. Where computer facility is available. Ninety students were selected from each school randomly, age group 13-19 years of age. The names of the two schools are 1. Z.P High school, Nizampet (Govt. School) 2. Bhaskar model school, Hydernagar (Private School) 3.1. EXPERIMENTAL DESIGN 3.2 SELECTION OF THE SAMPLE The students of 13-19yrs of age studying at the schools were assessed regarding their knowledge of anemia. The total number of children part of the activity were 180 and their knowledge and attitude after intervention were assessed. 3.3 METHOD OF DATA COLLECTION Small activity was conducted at the premises. Questionnaires were used to do the survey and their knowledge attitude on anemia. The questions were selected to highlight the importance of nutrition and anemia, maintenance of health and prevention of anemia. Food frequency 24hour dietary recall method was used to know the frequency of preference of iron rich foods in terms of daily, weekly, monthly and never. 3.4. DEVELOPMENT OF QUESTIONNAIRE 3.5 ANTHROPOMETRIC MEASUREMENTS: • Height • Weight • BMI (Body Mass Index) BMI = Weight (kg) / Height (m2) 3.6 BMI CLASSIFICATION: • <= 18.5 under weight • 18.5 – 25 – normal • 25.5 – 29.9 – over weight • 30-40 obese Figure 1: Measuring Height of the student Figure 2: Measuring Weight of the student 3.7 BIOCHEMICAL ANALYSIS: Under the supervision of Dr. Namrata and lab technician Ms. Priya, the estimation of hemoglobin was done by Hemoglobin colour strip. It helps to determine the hemoglobin percentage of a person whether it is sufficient of non-sufficient. Figure 3 : Hemoglobin colour strip (pictures) Figure 5: Hemoglobin colour strip (pictures) 3.8 PRE-ASSESSMENT OF KNOWLEDGE & ATTITUDE: Before conducting the final study, a pre-assessment study was conducted by giving the questionnaire to the school children. 45 minutes were taken for filling the questionnaire. Collected the sheets for analysis. 3.9 INTERVENTION: Computer game and power point presentation designed on Iron Deficiency Anaemia Awareness. Figure 6: Snakes and Ladder's computer game: 4. RESULTS & DISCUSSION: Figure 7: Classification of the subjects according to BMI From the above bar graph, the distribution of subjects according to the BMI. It was seen that majority of the subjects (42.78%) were in below normal BMI. Figure 8: Distribution of the subjects according to the food habits The pie chart represents the distribution of the subjects according to the food habits majority of the subjects (62.78%) were Non-Vegetarians and the remaining (37.22%) are vegetarians. Even if the 62.2% of the subjects were non-vegetarians, their frequency of consumption and like to consume iron rich foods are not quite satisfactory. In general, vegetarian diets are lacking vitamin B12 and folic acid (Sri Lakshmi, 1993). Figure 9: Frequency of food intake of Iron rich foods of the selected subjects: Figure 10: Classification of the subjects according to the Haemoglobin percentage: The above bar graph represents the distribution of the subjects according to the Haemoglobin levels. Majority of the subjects (35%) had below <8gm/dl of Haemoglobin 31.11% followed by 33.89% had 9-11 gm/dl and 12-14 gm/dl levels of Haemoglobin respectively. Figure 11: Classification of the subjects according to the clinical signs and symptoms of subjects: The above bar graph represents the subjects according to the clinical signs and symptoms of anemia. Majority of the subjects had the signs of Pale conjunctiva 33.32% followed by Frequent infections (23.89%) respectively. Figure 12: Classification of the subjects according to the General symptoms of subjects Figure 13: Classification of the subjects according to the regularity of periods: The above bar graph represents the sample according to the regularity of periods. It is clear that 18.89% girls had regular periods and 31.11% girls had irregular periods. Figure14 Comparison between control and experimental in Govt. school using t-test: Figure15: Comparison between control and experimental in Pvt. school using t-test: Figure 16: Comparison between pre-and post in control groups using Paired t-test: Govt.& Pvt.School Mean N Std. Deviation t-value p-value Knowledge Pre 5.51 90 1.921 10.83** 0.000 Post 7.64 90 2.309 Attitude Pre 7.77 90 1.246 6.2546** 0.000 Post 9.10 90 1.622 ** significant at 1% level It was clear that the comparison between pre-knowledge and post-knowledge group t-value is significant at 1% level. After giving the educational intervention the knowledge levels in the control group were improved. Similarly, the pre-attitude and post-attitude groups after education intervention the comparison between the subjects were improved. Hence the paired t-test is significant at 1% level. Figure 17: Comparison between pre-and post in Experimental group using Paired t-test: Govt. & Pvt.School Mean N Std. Deviation t-value p-value Knowledge Pre 5.59 90 1.754 12.638** 0.000 Post 7.84 90 2.055 Attitude Pre 7.72 90 1.263 7.1034** 0.000 Post 9.18 90 1.555 ** significant at 1% level It was clear that the comparison between pre-knowledge and post-knowledge group t-value is significant at 1% level. After giving the educational intervention the knowledge levels in the experimental group were improved. Similarly, the pre-attitude and post-attitude groups after education intervention the comparison between the subjects were improved. Hence the paired t-test is significant at 1% level. 5. SUMMARY AND CONCLUSION: Adolescent girls and young women can be considered as nutritionally vulnerable persons of the population. Various surveys conducted and indicated that iron deficiency Anemia is high among females. Various Anemia prophylaxis programs launched by Government of India (1990) is aimed to improve the health status of pregnant, lactating women and children. The present study conducted on180 adolescent school children in the age group of 13 to 16 years were studied. It is observed that Iron Deficiency Anemia is more in Non-Heme Iron (Plant based dietary iron) consumption subjects compare with Heme Iron consumption subjects. The percentage of Anemia was observed among 35% of the subjects.