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Indian Journal of Medical Sciences
Medknow Publications on behalf of Indian Journal of Medical Sciences Trust
ISSN: 0019-5359 EISSN: 1998-3654
Vol. 58, Num. 9, 2004, pp. 389-393

Indian Journal of Medical Sciences, Vol. 58, No. 9, September, 2004, pp. 389-393

Original Article

Iron deficiency amongst nursing students

Hematology Department, Nanavati Hospital, Mumbai
Correspondence Address:Dr. J. C. Patel Medical Research Department, BSES MG Hospital, SV Rd, Andheri (W), Mumbai - 400 058 labmed@ghrc-bk.org

Code Number:ms04067

ABSTRACT

CONTEXT: Iron deficiency anemia (IDA) is widely prevalent in India. IDA is preceded by a stage of latent iron deficiency (ID) where serum ferritin is reduced but hemoglobin is normal.AIMS: Present study was undertaken (1) to find prevalence of IDA and ID amongst nursing students; (2) to observe effect of hematinic therapy on Hb and red cell indices. SETTINGS AND DESIGN: Nursing students were taken up for study after they gave a written consent. METHODS AND MATERIAL: Subjects were given a written questionnaire to elicit anemia related symptoms. Blood counts were done on electronic counter and serum ferritin was assayed by Elisa. Hematinic capsule was given once at bedtime for a period of three months, after which, participants again answered the same questionnaire and blood count was done. STATISTICAL ANALYSIS USED: Students' t test was used to compare the results. RESULTS: There was no significant difference in Hb, MCV and MCH of normal and ID group. Differences in Hb, MCV and MCH between normal and IDA groups and between IDA and ID groups were highly significant (p < 0.001). Symptom score did not show significant difference in three groups. Ferritin levels of ID and IDA groups were significantly lower than that of normal group (p < 0.001) whereas there was no significant difference in ferritin levels of ID and IDA groups. IDA group showed highly significant improvement in Hb, MCV and MCH as a result of treatment. ID and normal groups did not show increase in Hb level after treatment but increase in MCV and MCH in both groups were highly significant. CONCLUSIONS: IDA and ID were found in 20.3% and 27.5% subjects respectively. Significant rise in MCV and MCH in normal group indicated that even this apparently normal group had iron deficient erythropoiesis.

Key Words: Iron deficiency anemia, Latent iron deficiency, iron deficient erythropoiesis, anemia related symptoms, ferritin.

INTRODUCTION

Iron deficiency anemia (IDA) is widely prevalent especially amongst women in India.[1],[2],[3] As a result, some workers considered hemoglobin (Hb) level of 10-11 g/dl as normal.[4],[5],[6] IDA is an end stage of negative iron balance. It is preceded by a stage of latent iron deficiency (ID) where serum ferritin is below 15.0 ng/ml with normal Hb level.[7] It would be interesting to see the prevalence of ID in addition to IDA. Mild anemia is asymptomatic or cause non-specific symptoms. It would be of interest to find out whether such non-specific symptoms can identify ID and IDA from normal group and whether iron therapy has any effect on these symptoms. In IDA, besides Hb, MCV and MCH are also reduced. In ID, while Hb is normal, it is not known whether MCV and MCH are normal or reduced but in normal range. We report here a study of newly admitted nursing students to find the prevalence of IDA and ID, and observe the effect of iron therapy on Hb, MCV and MCH.

SUBJECTS AND METHODS

Seventy-two newly admitted nursing students were taken up for study after obtaining their informed consent. Study was approved by the institutional ethics committee. None of the subjects included in the study had been on any hematinics in last six months or had any infection in past one month. They were given a written questionnaire to assess anemia related symptoms. Arbitrary score was assigned according to the response to the questionnaire (see annexure). Blood counts with red cell indices were done on electronic cell counter. Serum Ferritin was assayed by Elisa method. After the blood test, irrespective of results of blood tests, all students were given one capsule containing ferrous fumarate 350 mg (elemental iron 112 mg), 1.5 mg folic acid, 15 mcg vitamin B12 and 150 mg vitamin C, everyday for the period of three months. At the end of the three months subjects were asked to fill up the same questionnaire again and blood counts with indices were done again. Serum ferrritn was not estimated again after iron therapy. Every month, when students came for collection of hematinic, check was made for compliance and side effects.

Baseline values of various parameters in three groups of subjects were compared using students t test; and change in values of various parameters as a result of treatment were compared within each group using t test for paired comparisons.[8]

RESULTS

Of 72 students entered in the study, 69 completed the study and were available for repeat blood test. Data of these 69 subjects is analyzed. All subjects were female. Mean age was 19.5 years (range 18-23). Subjects were divided into three groups; (1) Normal group with Hb 12.0 g /dl or more and serum ferritin 15.0 ng/ml or more, (2) ID group with Hb 12.0 g/dl or more and ferritin less than 15.0 ng/ml; and (3) IDA group with Hb less than 12.0 g/dl and ferritin less than 15.0 ng/ml. There were 36 subjects in normal group, 19 in ID group and 14 in IDA group.

Results of baseline studies are shown in [Table - 1]. There was no significant difference in Hb, MCV and MCH of normal group and ID group. Differences in Hb, MCV and MCH between IDA group and normal group, and between IDA group and ID group were highly significant (p < 0.001). Symptom scores did not show any significant difference in three groups. Ferritin levels of ID group and IDA group were significantly (p < 0.001) lower than that of the normal group, whereas there was no significant difference in ferritin levels of ID group and IDA group.

Effect of treatment with hematinic for a period of three months on various parameters is shown in [Table - 2]. IDA group showed highly significant (p < 0.0001) increase in Hb, MCV and MCH as a result of treatment. While there was no significant change in the Hb levels of ID group and normal group as a result of treatment, there was highly significant (p < 0.0001) increase in MCV and MCH in these groups as a result of treatment. Symptom scores of IDA group and ID group showed no significant change as a result of therapy while the change in symptom score in normal group showed significant improvement (p < 0.05).

DISCUSSION

IDA was detected in 20.3% of apparently healthy females aged 18-23 years. High prevalence of IDA amongst apparently healthy Indians has been reported.[9],[10],[11] Hb estimation of 2294 apparently healthy women who came for ′health check′showed the range of 10.9 - 14.5 g/dl, indicating that proportion of them had Hb below 12.0 g/dl.[9] In apparently healthy normal individuals, free stainable iron can seldom be demonstrated in bone-marrow smears.[10] 20% of female college students were found to be anemic.[11] Latent iron deficiency (low serum ferritin, <15.0 ng/ml, with normal Hb, 12.0 g/dl or more) was found amongst 19 (27.5%) subjects. Prevalence of ID was higher than that of IDA. Subjects with ID are likely to develop IDA over a period of time and should receive iron therapy to correct their ID and prevent/delay the development of IDA. Although 15.0 ng/ml of ferritin level is taken as cut off level for diagnosis of ID, there are reports to suggest that even at higher levels of ferritin, there is evidence of iron deficient erythropoiesis.[12],[13],[14]

As expected Hb, MCV, and MCH were significantly lower in IDA group as compared to ID group as well as normal group. There was no significant difference in HB, MCV and MCH of ID group and normal group. Ferritin level of ID and IDA group was comparable but significantly lower than that of the normal group. Symptom score did not show significant difference between three groups indicating that symptoms are non-specific and perhaps unrelated to iron or hemoglobin status.

Three months of hematinic therapy, which included 112 mg elemental iron, 1.5 mg folic acid, 15 mcg vitamin B12 and 150 mg vitamin C, resulted in significant increase in HB, MCV and MCH in IDA group. ID and normal groups, while not showing significant increase in Hb level, showed a significant increase in MCV and MCH values. Reduction in MCV and MCH is an early evidence of iron deficient erythropoiesis.[14] Increase in MCV and MCH values in response to iron therapy, therefore, can be considered as an evidence of iron deficient erythropoiesis. While there could be no difficulty in accepting iron deficient erythropoiesis in ID group, same cannot be said for the normal group. However, in a population with widespread nutritional iron deficiency, as in India,[9],[15] many individuals with ferritin in low normal range and having iron deficient erythropoiesis[12],[13],[14] would respond to iron therapy with increase in MCV and MCH.

In conclusion, iron deficiency is widespread amongst females in India as shown by this study- 20.3% have IDA, another 27.5% have ID and remaining 52% have iron deficient eryhropoiesis as indicated by significant rise in MCV and MCH after three months of oral iron therapy. Need for public health measures to address this problem cannot be overemphasized.

[Annexure]

REFERENCES

1.Gopalan C. Women and nutrition in India. J Nutri Dietet 1999;36:95-107.   Back to cited text no. 1    
2.Udipi SA, Ghughre P, Antony U. Nutrition in pregnancy and lactation. J Indian Med Assn 2000;96:548-57.   Back to cited text no. 2    
3.Roy S, Ray S. Prevention of malnutrition. J Indian Med Assn 2000;98:510-11.   Back to cited text no. 3    
4.Gajwani BW, Patel BL, Mehta AS, Bhatt RV, Pande RS, Venugopal. Anemias of pregnancy. In Iron deficiency anemia- Prevalence and problems in India. Eds. Mehta BC, Patel JC. Research Society, KEM Hospital & Seth GS Medical College, Bombay 1970. p. 53-9.   Back to cited text no. 4    
5.Kothari BC, Bhende YM. Hematological and other findings in normal pregnant women. Indian J Med Res 1950;38197-202.   Back to cited text no. 5    
6.Menon MKK, Chandrasekharan K, Anemia in Pregnancy with special reference to treatment. Indian J Obst Gynecol 1954;4:17-23.   Back to cited text no. 6    
7.Mehta BC. Iron deficiency anemia. In API Textbook of Medicine, 7th Ed, editor Shah SN. Association of Phyicians of India, Mumbai 2003. p. 930-4.   Back to cited text no. 7    
8.Hill AB. A short textbook of medical statistics. Hodder and Stoughton, London. 10th Ed. 1977. p. 127-33.   Back to cited text no. 8    
9.Ashavaid TF, Todur SP, Dherai AJ. Health status of Indian population - current scenario. J Assn Phys India 2004;52:363-9.  Back to cited text no. 9    
10.Cowan B, Bharucha C. Iron deficiency in tropics. Clinics Hematol 1973;2:353-62.  Back to cited text no. 10    
11.Das KVK. Nutritional anemias in India. J Assn Phys India 1980;28:521-33.  Back to cited text no. 11    
12.Nelson R, Chawala M, Conolly P, LaPorte J. Ferritin as index of bone marrow iron stores. Southern Med J 1978;71:1482-84.  Back to cited text no. 12    
13.Holyoake TL, Stott DJ, McKay PJ, Hendry A, MacDonald JB, Lucie NP. Use of plasma ferritin concentration to diagnose iron deficiency in elderly patients. J Clin Pathol 1993;46:857-60.  Back to cited text no. 13  [PUBMED]  
14.Hallberg A, Bengtsson C, Lapidus L, Lindstedt G, Lundberg PA, Hulten L. Screening for iron deficiency: An analysis based on bone marrow examinations and serum ferritin determination in a population sample of women. Brit J Hematol 1993;85:787-98.   Back to cited text no. 14    
15.Hershko C, Bar-Or D, Gaziel Y, Naparstek E, Konijn AM, st al. Diagnosis of iron deficiency anemia in a rural population of children. Am J Clin Nutrition 1981;34:1600-10.  Back to cited text no. 15    

Copyright 2004 - Indian Journal of Medical Sciences


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