Chapter IV Results

RESULTS
Table No.1 :Age distribution of anemic subjects
No. of subjects

No. of subjects

Adolescent

Adult

10-19

108

108 (24.3)

20-29

168

168 (37.7)

30-39

98

98 (22.0)

40-49

71

71 (16.0)

337

445 (100.0)

Age in years

108

Total(%)

More than 1/3rd of anemic subjects were in third decade (37.7 %) , more or less

1/4th of subjects (24.3%) were in the second decade, while less than 1/4th (22.0%)
were in the 4th decade. Mean age of study subjects was 27.19 9.5. At 95 %
Confidence limit Confidence interval was 8.57 to 45.81.

Table No. 2 : Educational Status

Education

Adolescents ( % )

Adults (%)

Graduate or post
graduate

62 (18.4)

High school
HSC/SSC passed

73 (67.6)

79 (23.4)

Primary School

35 (32.4)

126 (37.4)

161 (36.2)

Illiterate

70 (20.8)

70 (15.7)

Total

108 (100.0)

337 (100.0)

445 (100.0)

Total (%)

62 (13.9)
152 (34.2)

The education in adolescents was HSC or SSC in 2/3rd of subjects (67.6 %), while
more or less 1/3rd (32.4%) were studying in schools. One third of adult subjects

42

(37.4%) were having primary school education, while less than 1/41h (23.4%) were
having HSC/SSC level education. Anemia was prevalent in all, adolescent and
adult anemic subjects irrespective of their education.

Table No. 3 : Residence

Residence

Adolescents(%)

Adults(%)

Total(%)

Rural

22 (20.4)

137 (40.6)

159 (35.7)

Urban

86 (79.6)

200 (59.4)

286 (64.7)

Total

108 (100.0)

337 (100.0)

445 (100.0)

Nearly 2/3rd (64.7%) of anemic subjects coming to civil Hospital were from urban
areas while more than 1/3rd (35.7%) of anemic subjects were from rural areas. As
per census of India 2001, 72.2 % of population resides in rural area while 27.8 %
stay in urban areas. Rural:urban ratio in present study is different from the last
census of 2001, because the Civil Hospital is a tertiary care teaching hospital in
the state of Gujarat and the patients are mainly from urban areas (>80%). In the
school and nursing students overall 15 % were from rural areas.

Table No. 4 : Different Communities

Community

Adolescents(%)

Adults(%)

Total(%)

Hindu

90 (83.3)

252 (74.8)

342 (76.8)

Muslim

12 (11.1)

68 (20.2)

80 (18.0)

Christian

6 (5.6)

17 (5.0)

23 (5.2)

Total

108 (100.0)

337 (100.0)

445 (100.0)

43

More than 3/41h (76.8%) number of anemic subjects were hindus, while less than
1/41h (18.0%) were muslims. It is matching with the distribution of various
communities as per census of 2001. As per census of India 2001, 80.5 % are
hindus, 13.5 % are muslims and 2.3 % are christians. Thus religion had no
influence on prevalence of nutritional anemia. All subjects other than Muslim and
Christian like Sindhis and Sikhs were included in Hindus.

Table No. 5 : Diet

Diet

Adolescents (%)

Adults(%)

Total(%)

Vegetarian

82 (75.9)

231 ( 68.5)

313 (70.3)

Non-vegetarian

26( 24.1)

106 (31.5)

132 (29.7)

Total

108 (100.0)

337 (100.0)

445 (100.0)

More than 2/3rd (70.3%) anemic subjects were purely vegetarian. Only less than
1/3rd (29.7%) were taking mixed diet, hence labeled as non-vegetarians. On
detailed analysis it was found that all these 132 (26+1 06) non-vegetarian subjects
were consuming less than one non-vegetarian meal per week.
According to the 2006 survey 156 40 % of population in India is vegetarian. In this
study vegetarians were more than non-vegetarians not matching with the national
data at large because the state of Gujarat is having more vegetarians than other
states.

44

--

---------------------

Table No. 6 : Occupation

Occupation
Student

Adolescents (%)

Adults(%)

108 (100.0)

Housewife

Total(%)
108 (24.3)

157 (46.6)

157 (35.3)

84 (24.9)

84 (18.9)

96 (28.5)

96 (21.5)

108 (100.0)

337 (100.0)

445 (1 00.0)

Working
Office type table work
Labourer
Total

Nutritional anemia was prevalent in all types of females - students, working and
housewives. More than 40 % of anemic subjects were working in present study,
while female working population at large is 25.6 % as per census 2001. As the
anemic subjects were more from urban areas where most of the females also
work, the working anemic subjects were more than the census 2001.
Table No. 7 : Economic status of 445 anemic subjects
Modified Prasad Classification
Socia Economic Class

Adolescents(%)

Adults (%)

Total(%)

Upper

16 ( 14.8)

42 (12.5)

58 (13.0)

Middle

28 (25.9)

80 (23.7)

108 (24.3)

Lower

64 (59.3)

215 (63.8)

279 (62.7)

Total

108 (100.0)

337

445 (1 00.0)

Only three main categories were taken from original six classes of Prasad
classification. Most of the anemic subjects were from lower socioeconomic (SE)
group (62.7%), while approximately 1/4th (24.3%) were from middle SE group. It
shows that economic status of subjects play a role in nutritional anemias. Lower

45

SE group included 154 (34.6%) below poverty line (BPL) and 125 (28.1%) poor
economic class subjects. As per Planning Commission of India population below
poverty line reported is 27% in 2005.
Table No. 8 : Birth Order

Birth order

Adolescents(%)

Adults(%)

Total(%)

1st

33 (30.6)

63 (18.7)

96 (21.6)

2nd

31 (28.7)

75 (22.3)

106 (23.8)

3rd

24 (22.2)

97 (28.8)

121 (27.2)

41h or more

20 (18.5)

102 (30.3)

122 (27.4)

Total

108 (100.0)

337 (100.0)

445 (1 00.0)

Birth order is not showing any important correlation with anemic subjects in the
present study. Nutritional anemia was prevalent whether the study subject was a
first child in the family or second, third, fourth or more in number in her family.
Fig. No. 9 : Knowledge regarding anemia, diet and their Hb
9 A : Knowledge about anemia and dietary sources of iron & folic acid

Category

Adolescents ( % )

Adults (%)

Total (%)

Not knowing

79 (73.1)

206 (61.1)

285 (64.0)

Knowing

29 (26.9)

131 (38.9)

160 (36.0)

Total

108 (100.0)

337 (100.0)

445 (100.0)

Chi Square 5.14

p = 0.023

Overall 64% females (285 out of total 445) had no knowledge about anemia and
dietary rich sources of iron. This was statistically significant. (P < 0.05). It was more
in adolescents (73.1 %) than in adult subjects (61.1 %).

46

9 8 : Knowledge about their Hb

Category

Adolescents ( % )

Adults (%)

Total (%)

No

92 (85.2)

229 (68.0)

321 (72.1)

Yes

16 (14.2)

108 (32.0)

124 (27.9)

Total

108 (100.0)

337 (1 00.0)

445 (1 00.0)

Chi Square 12.08

P = 0.0005

Overall 72.1% females ( 321 out of total 445) were not knowing their own Hb. This
was statistically significant. (P < 0.05). It was quite more in adolescent group
(85.2%) as compared to adults (68.0%). This may be due to adult females might
have undergone Hb estimation during their past pregnancies.
Table No. 10 : Degrees of anemia

Degree
Mild

Hb level

Adolescents.(%)

Adults (%)

Nonpregnant

10 to <12.0 g%

57 (52.8)

67 (19.9)

Pregnant

10 to <11.0 g%

121(35.9)

7 to <10 g%

47 (43.5)

113 (33.5)

160 (36.0)

< 7.0 g%

4 (3.7)

36 (10.7)

40 (9.0)

108 (100.0)

337 (1 00.0)

445 (100.0)

Moderate
Severe
Total

Total (%)
245 (55.0)

Mild anemia is found in more than 50% cases in both the groups. While severe
anemia is more common in adult group. Most of these (33 out of 36) were
pregnant subjects. In moderate anemia group there were 36 patients (out of total
160 subjects) were having Hb less than 8.0 Gm%.

47

Other Investigations :
Fig. No. 1 : Serum iron values

Se.iron ug/dl

80 .-------------. --------------------------------70

1~~~

6o

so"~$~~~!"~*'~
~~. ~~~ ~~~.
~ ....
fi~"
'
.. .

40
~Vi
~
30 r"".
..l~,.
~
~-
20 +
~

-----l

'I
!

Ii

1o

l
0+---------------~----------------,-------~
0

100

200

300

400

500

no. of subjects

Fig.No.1 shows scatter diagram of serum iron values in 445 anemic subjects
Serum iron was ranging from 24 to 68 ).lg/dl in adolescents and 20 to 54 ).lg/dl in
adult subjects (normal range 60-150 ).lg/dl).
TIBC was ranging from 360 to 500 ).lg/dl in adolescents and 380 to 590 ).lg/dl in
adults subjects (normal range 250 to 350 ).lQ/dl). Peripheral smear was done in all
cases and showed microcytic hypochromic ( iron deficiency ) or dimorphic anemia
( iron +folic acid deficiency) picture.

48

!~
Fig. No. 2 : Serum Ferritin values

Se.Ferritin ug/1

90
80

70

60
50
40
30 #.
20

10
0

~--~----~----~---,-----,--------~~--~

50

100

150

200

250

300

350

400

No. of subjects

Fig. No.2 shows scatter diagram of serum ferritin values. It was done in total 362
subjects - all adolescents and 75% of adult subjects. In both the groups it was
ranging from 8 to 80 ug/1. In most of them it was less than 30 ug/1.
Serum Folate and serum Vitamin 812 was done in 71 subjects who were having
either severe anemia or clinical features of their deficiencies or megaloblasts
detected on peripheral smear. 31 anemic subjects were having low folate levels
ranging from 1.2 to 3.0 ng/ml, while Vitamin B 12 levels were in normal range
except three cases they were marginally low ( 190-200 pg/ml ).
Table No. 11 : Symptoms

Leading questions regarding symptoms of anemia like tiredness, weakness,

dizziness, feeling of chromic ill heath were asked to the anemic subjects as well as
controls.

49

------------------

--------

11 A : Adolescents

Symptoms

Gr I A. Anemic
subjects (%)

Gr I B. Controls (%)

Present

64 (59.3)

24 (22.2)

Absent

44 (40.7)

84 (77.8)

Total

108 (100.0)

108 (100.0)

Chi Square 30.6

P = 0.0000

11 B: Adults

Symptoms

Gr II A. Anemic
subjects(%)

Gr II B. Controls (%)

Present

266 (78.9)

114 (33.8)

Absent

71(21.1)

223 (66.2)

Total

337 (100.0)

337 (100.0)

Chi Square 59.1

P = 0.0000

The symptoms were present in 330 (74.1%) of anemic subjects (64 adolescents +
266 adults) while they were present in only 138 (31. 0%) of controls. (24
adolescents +114 adults) . Comparing both the groups of anemic subjects with
appropriate controls this was statistically significant (P<0.05) .

Table No. 12 : Weight

12 A : Adolescents
Weight in Kgs.

Gr I A. Anemic subjects ( % )

Gr I B. Controls ( % )

~40

37 (34.3)

35 (32.4)

41-50

64 (59.3)

63 (58.3)

51-60

6 (5.5)

8 (7.4)

61-70

1 (0.9)

2 (1.9)

Total

108(100.0)

108(100.0)

Chi Square o.68

P = 0.8

50

------------

12 B: Adults
Weight in Kgs.

Gr II A. Anemic subjects ( % )

Gr II B. Controls ( % )

~40

39 (11.6)

38 (11.3)

41-50

44 (13.1)

44 (13.1)

51-60

124 (36.8)

120 (35.6)

61-70

82 (24.3))

86 (25.5)

> 70

48 (14.2)

49 (14.5)

Total

337 ( 100.0)

337 ( 100.0)

Chi Square 0.18

P = 0.9

There was no significant difference (P > 0.05) in anemic subjects and controls as
far as the weight was concerned in both adolescents as well as adult groups. In
Gr I of adolescent subjects there was no student of > 70 Kg weight.

Table No. 13 : Body Mass Index (BMI)

13 A : Adolescents
Body Mass Index ( BMI)

Gr I A. Anemic subjects ( % )

Gr I B. Controls ( % )

< 18.50 Kg/M 2

31 (28.7)

26(24.1)

18.5 - 24.99 Kg/M 2

59 (54.6)

61 (56.5)

~ 25.00 Kg/M

18 (16.7)

21 (19.4)

108 ( 100.0)

108 ( 100.0)

Total

Chi Square 0. 7

p =0.7

13 B: Adults
Body Mass Index ( BMI)

Gr II A. Anemic subjects ( % )

Gr II B. Controls ( % )

< 18.50 Kg/M 2

40 (11.9)

38(11.3)

18.5 - 24.99 Kg/M 2

151 (44.8)

143 (42.4)

~ 25.00 Kg/M

146 (43.3)

156 (46.3)

Total

337 ( 100.0)
Chi Square 0.6

337( 100.0)

P = 0.7

51

----------

There was no significant difference (P > 0.05) in anemic subjects and controls as
far as BMI was concerned in both the groups. BMI categories were made
according to WH0 157 . BMI of< 18.50 Kg/M 2 are considered underweight, 18.50 to
24.99 Kg/M 2 are considered normal and .:::_ 25.00 Kg/M 2 are considered overweight.
This means that anemia can still be there even if other nutrition is not affected.

Table No. 14: Physical Performance

14 A: Adolescents
Gr I A. Anemic subjects ( % )

Gr I B. Controls ( % )

Reduced Capacity

70 ( 64.8)

44(40.7)

Normal

38 ( 35.2)

64 ( 59.3)

Total

108 ( 100.0)

108(100.0)

Chi Square = 12.56

p = 0.0004

14 B: Adults

Gr II A. Anemic subjects ( % )

Gr II B. Controls (%)

Reduced capacity

217 (64.4)

174(51.6)

Normal

120 (35.6 )

163(48.4)

Total

337( 100.0)

337 ( 100.0)

Chi Square

=11.26

p = 0.0008

In both the groups physical capacity was reduced in anaemic subjects as

compared to controls which was statistically significant (P < 0.05) . In adult group
physical capacity was reduced even in 51.6% of control group. This may be due to
physiological changes of pregnancy in pregnant subjects of the group (228 of 337).

52

Table No. 15 : Infections in last 5 years

15 A : Adolescents
Category

Gr I A. Anemic subjects (%)

Gr I B. Controls (%)

No infection

4 ( 3.7)

25 ( 23.1 )

One episode

78 ( 72.2)

66 ( 61.1 )

> 1 episode

26 ( 24.1 )

17 ( 15.8)

Total

108 (100.0)

108 (100.0)

Chi Square= 17.57

=0.00003

15 8: Adults
Category

Gr II A. Anemic subjects(%)

Gr II B. Controls(%)

No infection

36 ( 10.7)

78 ( 23.2)

One episode

211 (62.6)

198 ( 58.7)

> 1 episode

90(26.7)

61(18.1)

Total

337 (100.0)

337 (100.0)

Chi Square = 18.62

p = 0.00002

Infection in last 5 years was assessed by eliciting histories and by checking

available records in anemic subjects as well as controls. In Group I of anemic
adolescents 104 (78+26) had one or more episodes of infection while only 83
adolescents of control group (66+17) had history of infections in last 5 years.
In Group-11 of adults 311 anemic subjects had one or more episodes of infection as
against 259 subjects of controls. In both the groups this was statistically significant
(P< 0.05). In adolescents respiratory and gastrointestinal tract infections were

common while in adults genital tract and urinary tract infections were common. In
pregnant anemic subjects respiratory tract infections was also common.

53

Table No. 16: I Q Testing

16 A : Adolescents
Score

Gr I A. Anemic subjects ( % )

Gr I B. Controls ( % )

40

31 (28.7)

18(16.7)

> 40-80

66 ( 61.1 )

59 ( 54.6)

> 80-120

8(7.4)

18 ( 16.7)

> 120-160

3 ( 2.8)

13 ( 12.0)

Total

108(100.0)

108 ( 100.0)

Chi Square = 13.94

p = 0.003

16 B: Adults
Score

Gr II A. Anemic subjects ( % )

Gr II B. Controls (%)

40

98 ( 29.1 )

52 ( 15.5)

> 40-80

206 ( 61.1 )

200 ( 59.3)

> 80-120

22 ( 6.5)

56 ( 16.6)

> 120-160

11 ( 3.3

29 ( 8.6)

337 ( 100.0)

337 ( 100.0)

Chi Square = 15.54

p = 0.0014

I Q score obtained in both the groups were low in anemic subjects as compared to
controls & this was statistically significant (P < 0.05).
Anemic subjects were slow in completing the test. Time required in anemic
subjects ranged from 17 to 24 minutes with mean of 20.99

. 2.8 minutes ( 95

Confidence interval 18.19 to 23.79 ), while in controls it ranged from 13 to 21

minutes with mean of 16.0
19.78)

.:t

3.78 minutes (95 % Confidence interval 12.22 to

On applying the 'Z' test for comparison of anemic subjects with controls

for IQ test time it was statistically significant . P < 0.05 , Z = 43.85.

54

Table No. 17: Pregnant patients Maternal Outcome

Complications

Pregnant anemic subjects

Gr li.A.1

Controls
Gr II.B.1

Post partum hemorrhage

14

Congestive cardiac failure

Puerperal pyrexia
(includes sepsis)

24

Wound complications

Lactation failure

Total

57 (44)

17 (12)

Chi Square

=20.85

p = 0.00001

Total 44 patients of nutritional anemia had some obstetric complications as against

12 patients of control group. Total number of complications are more as some
patients had more than one complication. This was statistically significant
(P < 0.05).
Complications occurred because anemic subjects who were on treatment either
delivered before treatment was over or they suffered more blood loss during
delivery. Post partum hemorrhage (PPH) is common in anemic subjects as
myometrial oxygenation may be poor, resulting in atony of uterus and PPH.
Moreover moderate amount of blood loss can be detrimental to anemic patients.
Congestive cardiac failure occurred in patients of severe anemia in 2 during
labour, in 1 postpartum and in 1 when she was given Packed cells.
There was no case of maternal mortality in anemic subjects as well as controls in
present study.

55

Table No. 18 : Perinatal Outcome

18 A : Perinatal Morbidity

Complications

Pregnant anemic subjects

Gr II.A.1

Controls

Birth asphyxia

18

Prematurity

22

IUGR

25

10

Neonatal Sepsis

Others

Total

77 (68)

31 (26)

Chi Square= 17.66

Gr 11.8.1

p = 0.00003

Total 68 babies in anemic subjects and 26 babies in control group had one or more
complications. This was statistically significant (P < 0.05) As some of the newborns
had more than one complication total No. of complications is more than the
number of babies. Different complications were nearly 2 to 3 times more common
in anemic subjects as compared to controls.
18 B : Perinatal Mortality
Pregnant anemic subjects
Gr II.A.1

Controls
Gr 11.8.1

SB (Intrapartum)

Neonatal Death

11

4
5
2

2
3
0

11

Cause of Death
Prematurity
Severe birth asphyxia
Septicemia
Total

Chi Square = 2.33

p = 0.13

56

Perinatal deaths were more than double in anemic subjects as against controls but
this was statistically not significant.(P > 0.05) Neonatal deaths were common and
prematurity and severe birth asphyxia were the common causes.

Table No. 19: Treatment

Treatment

Failure

Side effects

Oral Iron

369

31( 8.4%)

108 ( 29.3%)

Parenteral Iron

36 + 31

Packed cells

40

Folic acid

235

All patients of mild anemia were treated by oral iron ferrous sulphate 200 mg tablet
per day. Patients having moderate anemia with Hb more than 8 gm% were also
treated by oral tablets but dose was increased to two tablets I per day. Parenteral
iron in the form of intravenous iron sucrose was given to the patients of moderate
anemia whose original Hb was less than 8 gm% ( 36) and 31 subjects in whom
oral iron therapy failed to raise their Hb at the end of 4 weeks.
Blood transfusion in the form of Packed cells was given to 40 anemic subjects
whose Hb was < 7 gm% i.e. severe anemia.
Folic acid tablets were given to all pregnant patients as supplements 0.5 mg/day
and 5 mg/day was given to all the 31 subjects having their deficiencies. Three
patients of Vit B 12 deficiency were treated by Vit B 12 JIM injections.
108 patients on oral therapy had side effects in the form of gastric upset,
constipation, diarrhoea.

57

-~-----------

Two patients on parenteral iron therapy had side effects of whom one had
induration at injection site and other developed minor allergic reaction to IV iron
sucrose. Two patients of blood transfusion had complications. One had CCF and
other had pyrexic reaction both were tackled effectively.

58