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Department of Foods and Nutrition, M. S. University of Baroda, Vadodara, India
3To whom correspondence should be addressed.
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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KEY WORDS: • adolescent girls • growth • iron • folic acid • India
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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). A review of Indian studies on anemia in
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%)
(Kanani and Ghanekar 1997
).
Iron requirements are increased during adolescence, reaching a maximum
at peak growth, and remaining almost as high in girls after menarche to
replace menstrual losses. Adolescent iron requirements are even higher
in developing countries because of infectious diseases and parasitic
infestations that cause iron loss, and because of low bioavailability
of iron from diets limited in heme iron. Low iron status among
adolescents may limit their growth spurt (Brabin and Brabin 1992
). Anemic girls are at risk of compromised physical and
mental functions, and they may also be at increased obstetric risk,
once pregnant. In India, to combat the pervasive problem of anemia,
initiation of iron supplementation early in the adolescent years has
been recommended (Gopalan 1989
), but is not yet being
implemented.
According to Gillespie (1998)
, iron and folic acid
supplementation is one of the most important nutritional interventions
for adolescent girls. Folic acid is included within the iron supplement
to prevent folate deficiency, which is implicated in the etiology of
anemia and associated with neural tube defects of the newborn.
Supplementation with folic acid before pregnancy offers a better chance
of preventing neural tube defects than if given during pregnancy
(Gillespie 1997
).
Iron-folic acid (IFA) supplementation has been shown to enhance
adolescent growth. In Kenya, Lawless et al. (1994)
supplemented 87 primary school children with 55 mg elemental iron per
day for 14 wk and reported a positive effect on growth and appetite
that was significantly better than that in children receiving the
placebo. The positive effect of iron supplementation on growth of their
subjects was likely due to their improved appetite and increased food
intake. If iron does enhance growth, it can be promoted in programs
instead of food supplementation, which is more expensive and less
feasible.
To confirm the results of Lawless et al. (1994)
in the
South Asian context, we undertook an intervention study to investigate
the feasibility, compliance and effect of giving daily IFA supplements
for 3 mo on Hb levels, perceived hunger and growth of unmarried, urban,
low income adolescent girls in Vadodara (Baroda), Gujarat, India.
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SUBJECTS AND METHODS |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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This study was conducted in three low income communities of Vadodara, a community in which the first author has worked closely with adolescent girls for 7 y on community-based youth projects implemented by a voluntary organization, the Baroda Citizens Council. Because many girls marry before the age of 18, and this study enrolled only unmarried girls, the sample of 15- to 18-y-old girls was considerably smaller than the sample of 10- to 14-y-old girls. For feasibility reasons and to ensure similar sample sizes, the two smaller communities were combined with respect to the intervention. Through random allocation, the larger community became the experimental group and the two smaller ones became the control group. All unmarried girls 10–18 y of age, residing in the three communities, were considered eligible for the study and agreed to participate (n = 210). Pre- and postintervention data were available for 203 girls for anthropometry and 180 for hemoglobin.
Study design.
This was an experimental placebo control study. Girls in the experimental group received iron folic acid tablets for 3 mo (60 mg of elemental iron + 0.5 mg folic acid per day); the control group received a similar-looking placebo tablet according to the same protocol. Girls were given 15 tablets in a sachet and asked to consume one tablet daily after the evening meal. Every 15 d, the leftover tablets, if any, were counted and the balance replenished for the next 15 d. If a girl was irregular in consumption, she was counseled on the importance of the tablets and (if needed) on how to cope with side effects.
Data collection.
Weight and height were measured before and after the intervention with
the use of standard techniques (Gibson 1989
), and body
mass index (BMI) was calculated. Blood hemoglobin was estimated by the
cyanmethemoglobin method (Oser 1979
) before and after
intervention.
How the girls perceived their own hunger was assessed as a proxy for
anorexia, which causes poor food intakes and therefore poor growth, and
is associated with iron deficiency anemia. One objective of this study
was to explore whether improving the iron status of adolescent girls
would lead to their improved appetite and increased growth. Improved
appetite is likely to induce a feeling of increased hunger as perceived
by the girls, which, if satisfied through increased food intake, could
lead to a more favorable energy balance, thus contributing to better
weight and height gains. Because assessment of appetite in terms of
increased food intake was not possible, two scales were developed to
evaluate perceived hunger as reported by the girls before and after
intervention (see Fig. 1
). Methodological development of the scales was based on the visual
analog scale for the perception of pain (Mottola 1993
,
Stratton et al. 1998
). Data for the two scales were as
follows: a checklist of questions regarding hunger, from which the
answers were scored and added into a composite score; and a rating
scale (1–10) of the degree of hunger as perceived by the subject,
i.e., the lower the score, the lower the feeling of hunger (Fig. 1)
.
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RESULTS |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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).
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Table 2
summarizes the effect of the intervention on Hb levels, hunger scores,
weight gains and BMI in the experimental compared with the control
group. There was an increment of 17.3 g/L Hb in the group that received
IFA supplementation, whereas the controls showed a slight decrease in
Hb levels. Increase in perceived level of hunger was consistently and
significantly higher in the experimental group after intervention
compared with the control group. Spontaneous responses from several
experimental group subjects as well as their parents indicated that the
food intake of the girls had increased during the study period. Some
girls specifically stated that they ate more food than before the
study. A significant weight gain of 0.83 kg was seen in the
experimental group, whereas the controls showed little weight gain. The
experimental group also had a significantly better BMI response to
supplementation than the control group. In the case of BMI, however,
the experimental group exhibited no change, whereas the control showed
a decrease. This may have occurred because the m2
term (denominator of BMI) was increasing at a faster rate than weight
(numerator). Differences in the change in height-for-age were not
analyzed because they were not expected to be significant, although
height gains in both groups were anticipated.
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). Among the experimental subjects, the increments in mean Hb levels and
weight-for-age were more pronounced in the younger than in the older
girls, and they were also significantly higher than the increments of
the controls. In addition, at postintervention, there was a more
pronounced increase in the hunger scores in the younger girls by the
checklist compared with the older girls (+0.92 vs. + 0.75). This is
perhaps because the younger girls were more anemic and were less hungry
than the older girls before the intervention (Hb 108 vs. 112 g/L,
respectively). Among the older girls, although Hb levels and hunger
scores improved significantly compared with the controls, the weight
and BMI changes were not significantly higher than controls. This could
also be because of the smaller sample size of the older girls. Thus,
the effect on growth in the overall group was explained by the
significant difference seen in the younger age group. The
age-related trends in Hb levels, perceived hunger and
weight-for-age were not seen in the control group, with the initial and
final values being similar in both age groups.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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The mechanism by which supplemental iron and folic acid improve growth
has not been clearly delineated. Improved appetite and subsequent
improvement in food intake could be a factor as suggested by
Lawless et al. (1994)
and in this study. Although
appetite was not assessed (as was done by Lawless and co-workers) with
ad libitum intake of food, the indirect measures of improved appetite
used in this study, i.e., perceived hunger scores and the feedback from
the girls and parents that they consumed greater amounts of food than
they had earlier, suggest that appetite had improved after the IFA
supplementation.
The younger age group (10–14 y) experienced greater increases in
growth in weight and BMI than did the older group (15–18 y). This was
expected because the younger ages correspond with the adolescent growth
spurt and the highest iron needs (Brabin and Brabin 1992
, Srikantia 1989
). In addition, the younger
adolescents are easier to reach than the older ones because more of
them will still be in primary school. IFA supplementation is
recommended for girls throughout schools in India, especially for its
growth-promoting benefits. It appears to have the potential for
maximum benefit at minimum cost.
In addition to improving hematinic status and growth, IFA
supplementation to adolescent girls has other added benefits such as
improved cognition. This was observed in a study among American
adolescent girls who were iron deficient yet not anemic (Bruner et al. 1996
). Even in the absence of anemia, oral ferrous
sulfate (650 mg twice daily) for 8 wk improved some aspects of
cognitive functioning compared with placebo controls. Improved
cognition may lead to better academic performance, which may be an
incentive for girls to remain in school.
The strong association between anemia and reproductive health is well
known and it is being realized increasingly that it is usually too late
to begin to address anemia in pregnancy, given the large prepregnancy
iron deficits and the added demands of pregnancy for iron. Thus, as
Gopalan (1989)
suggests, opportunities provided by the
precious years of adolescence before marriage and the childbearing that
usually follows soon thereafter should not be wasted by the health
system. Adolescent girls should be supplied regularly with IFA
supplements so that they can enter pregnancy with no serious iron
deficiency handicaps.
What about compliance? Our experience with adolescent girls and our compliance data clearly reveal that most adolescent girls are enthusiastic about consuming iron tablets and continue until the necessary supplementation duration, provided they are counseled about the benefits of IFA, are reassured in case of side effects and parental support is sought. Compared with pregnant women, girls are usually less anxious about tablets being "hot" or having deleterious effects, and they are also more willing to consume the tablets.
Thus, iron-folate interventions hold the potential for not only improving Hb levels, but also enhancing growth among disadvantaged adolescent girls. Further epidemiologic and programmatic research is called for to gain understanding of the iron-growth relationships in adolescence and the mechanisms by which iron improves growth.
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FOOTNOTES |
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2 This publication was made possible in part through support provided by the Office of Health and Nutrition, USAID, under terms of contract no. HRN-C-00-93-00038-00, and the MotherCare Project, John Snow, Incorporated (JSI). The contents and opinions expressed herein are those of the authors and do not necessarily reflect the view of USAID or JSI.
4 Abbreviations used: BMI, body mass index; Hb, hemoglobin; IFA, iron-folic acid.
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REFERENCES |
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1.
Brabin L., Brabin B. J. The cost of successful adolescent growth and development in girls in relation to iron and vitamin A status. Am. J. Clin. Nutr. 1992;55:955-958
2. Bruner B. A., Joffe A., Duggan K. A, Casella F. J., Brandt J. Randomised study of cognitive effects of iron supplementation in non-anemic iron-deficient adolescent girls. Lancet 1996;348:992-996[Medline]
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6. Gopalan, C. (1989) Women and nutrition in India: general considerations. In: Women and Nutrition in India (Gopalan, C. & Kaur, S., eds.) Nutrition Foundation of India Special Publication series no. 5, New Delhi, India.
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13. Stratton R. J., Stubbs R. J., Hughes D., King N., Blundell J. E., Elia M. Comparison of the traditional paper visual analogue scale questionnaire with an Apple Newton electronic appetite rating system (EARS) in free living subjects feeding ad libitum. Eur. J. Clin. Nutr. 1998;52:737-741[Medline]
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