Young People and Anemia

Senderowitz, 1998

Anemia afflicts an estimated two billion people worldwide, mostly due to iron deficiency. It primarily affects women.¹ Yet among adolescents, prevalence rates of anemia are closer for males and females in some parts of the world. The prevalence of anemia is disproportionately high in developing countries, due to poverty, inadequate diet, certain diseases, pregnancy and lactation, and poor access to health services. Young people are particularly susceptible because of their rapid growth and associated high iron requirements.

Anemia is a critical health concern because it affects growth and energy levels. In pregnancy it is associated with premature births, low birth weight, and perinatal and maternal mortality.

Adolescence is an opportune time for interventions to address anemia. In addition to growth needs, girls need to improve iron status before pregnancy.^2,3 And both boys and girls are more accessible to information about anemia through schools, recreational activities, and via the mass media than they will be later in their lives.

Is anemia a significant problem for young adults?

A significant percentage of adolescents in the developing world are anemic, causing considerable health consequences for this age group.

About 27% of adolescents are estimated to be anemic in developing countries, compared to 6% in developed countries.⁴ Regional figures, although varying by country within the region,

suggest the following prevalence rates for anemia: ⁵

• In Africa, 45% for girls and 57% for boys
• In Oceania, 45% for girls and 43% for boys
• In Latin America and the Caribbean, 12% for girls and 22% for boys
• In Asia, 19% for girls and 17% for boys

In studies conducted by the International Center for Research on Women, country findings on adolescent anemia among both males and females include:⁶

• High rates of anemia in Nepal (42%), India (55%), and Cameroon (32%)
• Moderate rates in Ecuador (17%) and Jamaica (16%)
• Similar rates in studies which included both genders (India and Cameroon)
• Significantly more boys than girls in Ecuador (20% versus 15%)

A 1997 survey of 12-18 year old girls in rural India found an anemia prevalence rate of 82.9% among girls in school and 92.7% among girls not in school.⁷ In a baseline survey conducted in Indonesia in October 1996, students showed a mean anemia prevalence of 29% for girls and 23% for boys.⁸

Body growth slows down late in adolescence, at which point the iron status of boys appears to improve. Adult men, therefore, typically have larger iron stores than women.

The health consequences of anemia in children and adolescents are well documented. In children, anemia affects physical growth and mental development. Other consequences—including reduced levels of energy and productivity and impaired immune system function—develop as children mature.^9,10,11 Boys and girls both need iron for growth during adolescence, and girls have a continuing need to replace iron lost during menstruation.^12,13

Girls often enter their active reproductive years in late adolescence with poor iron status. A great many girls in the world (at least 25%) will have had their first child by age 19, and great more shortly afterward.¹⁴ Because pregnancy requires more iron for increased blood production, an iron deficit can result in negative reproductive consequences.¹⁵

• An estimated 47% of women of reproductive age in developing countries are anemic.¹⁶
• During pregnancy, 59% are estimated
  to be anemic.¹⁷
• Anemia during pregnancy is associated with prematurity and low birth weight.^18,19
• Anemia is also related to perinatal and maternal mortality.²⁰

In what ways can adolescents be reached in order to improve their iron status?

Early adolescence is a critical period for addressing anemia in both girls and boys. Adolescents can often be reached through educational and social activities. Existing settings such as schools and health facilities may offer opportunities to integrate nutrition education and actual services to reduce anemia. Nutrition awareness and education are particularly important given adolescents' poor knowledge of anemia, diet and health generally and of iron-rich foods specifically.^21,22 Channels for reaching youth include:

Educational settings - schools can incorporate nutrition education into family life education, health education, AIDS prevention courses, vocational training activities as well as organize sessions for out-of-school youth.

Health facilities - health centers, clinics and hospitals can offer information about improving iron status. They can also provide services for anemia screening, reducing blood loss, and increasing iron intake (see actions below).

Community outreach - peer education projects, workplace educational sessions, and social/ recreational activities can incorporate nutrition education into their programs.

Media and public information - practical information about nutritional needs can be communicated to young people through all forms of mass media (TV, radio, print materials, movies) as well as by traditional media (plays, folk drama, fairs, puppet shows).

In practice, nutritional education can be addressed within any setting or program that deals with reproductive and other health issues.

What actions should be taken to reduce anemia?

Education is fundamental to anemia reduction projects because adolescents have poor know-ledge about its causes and adverse effects. In a survey of adolescent girls in rural India, for example, more than one-half of the respondents did not know that diet is related to anemia and less than 5% mentioned excessive menstrual bleeding as a cause of anemia. Furthermore, 29% of the schoolgirls and 43% of the out-of-school girls had no knowledge of anemia's adverse effects.²³

The following actions to reduce anemia in adolescents can be combined to fit different settings.²⁴

• Reducing unwanted pregnancy (because pregnancy itself contributes to anemia)
• Educating and motivating young people about nutritional needs in schools,

community settings, health venues, and through the media

• Increasing the iron content of food through dietary intake
• Increasing the iron content of food through fortification
• Increasing iron intake through supplement-ation
• Reducing blood loss by treating for parasites
• Reducing blood loss from hemorrhage by improving birthing or abortion practices and post-abortion care

Is there evidence that interventions are successful?

Iron supplementation projects have been tried in several types of settings. In the International Center for Research on Women's Guatemala metabolic study, researchers found that hemoglobin levels increased during iron supplementation but fell when a placebo was taken. This confirms the finding that while supplementation can rapidly improve iron status, continued interventions are necessary to maintain this improved status.²⁵ Other studies/interventions showed some promising results.

A MotherCare-supported study in India using a nutrition communication strategy to improve dietary intake and reduce anemia and undernutrition in early adolescent school girls was implemented over six months. A one-year post intervention evaluation showed significant increases in growth velocity, mean hemoglobin levels, anemia-related knowledge, and dietary behavior in the experimental, compared to the control, group.²⁶

In Peru, a study supported by MotherCare comparing daily and intermittent supplement-ation in a group of adolescent girls showed that the prevalence of anemia significantly decreased with daily supplements, but there was no decrease among those receiving the intermittent dosage (2 days/week).²⁷

In an U.S. clinical trial assessing the effects of iron deficiency on cognitive function, iron supplemented adolescent girls performed better on a test of verbal learning and memory than the control group.²⁸

A birth survey in Nigeria found that pregnant adolescents who received antimalarial drugs and iron and folic acid supplements in the second half of pregnancy gained in height. Increased height is usually associated with a reduced incidence of cephalopelvic disproportion.^29,30

In the U.S., a group of pregnant adolescents who received calorie, protein, vitamin and mineral supplements gave birth to infants with significantly higher mean weight than a group that received no supplements; larger effects were observed among girls under 16.³¹

A Helen Keller International project in Indonesia begun in 1996 will assess the impact of various strategies of improving iron status in girls. Three independent interventions—supplementation, a dietary approach and education—will be tested. The school setting will be assessed for its appropriateness as a channel for addressing adolescent nutritional problems.³²

MotherCare is looking at effective ways to improve iron status among youth in India and Peru, and it is addressing anemia across broader age groups in many other countries.³³

References

1. World Health Organization (WHO). 1991. National Strategies for Overcoming Micronutrient Malnutrition.
2. Helen Keller International Girls. 1996. Gizi: Intervensi Kepada Remaja Lokal di Sekolah.
3. Kurz, K.M. 1997. Personal communication.
4. DeMaeyer E, and M. Aaiels-Tegman. 1985. "The Prevalence of Anemia in the World." World Health Statistics Quarterly 38: 302-316. 1985.
5. ⁵ Ibid.
6. Kurz, K.M., and C. Johnson-Welch. 1994. The Nutrition and Lives of Adolescents in Developing Countries: Findings from the Nutrition of Adolescent Girls Research Program. International Center for Research on Women.
7. Survival for Women and Children (SWACH) Foundation. 1997. Anemia in Pregnant Women and Adolescent Girls in Rural Areas of Haryana, India. Quarterly Progress Report: April to June 1997. Sumitted to MotherCare Project, John Snow, Inc.
8. Helen Keller International, op. cit.
9. Lawless, J.W., M.C. Latham, L.S. Stephenson, et al. 1994. "Iron Supplementation Improves Appetite and Growth in Anemic Kenyan Primary School Children." Journal of Nutrition. 124: 645-654.
10. Levin, H., E. Pollitt, R. Galloway, et al. 1993. "Micronutrient Deficiency Disorders." In Jamison D, H. Mosley, A. Measham, et al, eds., Disease Control Priorities in Developing Countries. New York, Oxford University Press.
11. Pollitt, E. 1987. "Effects of Iron Deficiency on Mental Development: Methodological Considerations and Substantive Findings." In Johnston, F., ed., Nutritional Anthropology. New York, Alan R. Liss.
12. Brabin, L., and B.J. Brabin. 1992. "The Cost of Successful Adolescent Growth and Development in Girls in Relation to Iron and Vitamin A Status." American Journal of Clinical Nutrition 55: 955-958.
13. Kurz et al., op. cit.
14. Senderowitz, J. 1995. Adolescent Health: Reassessing the Passage to Adulthood. World Bank Discussion Paper #272. Washington DC: The World Bank.
15. Kurz et al., op. cit.
16. DeMaeyer et al., op. cit.
17. Ibid.
18. Levin et al., op. cit.
19. Scholl, T.O., and M.L. Hediger. 1994. "Anemia and Iron-Deficiency Anemia: Compilation of Data on Pregnancy Outcome." American Journal of Clinical Nutrition 59 (suppl.): 4925-5015.
20. Levin et al., op. cit.
21. Creed-Kanashiro H, M. Bentley, M. Fukumoto, et al. 1997. "Relationship of Anaemia to Dietary Intake and Feeding Patterns in Women of Fertile Age and Adolescent Girls Participating in Community Kitchens in Peri-Urban Lima, Peru." In Improving the Quality of Iron Supplementation Programs. MotherCare Project/USAID/John Snow, Inc.
22. Raina, N., A. Gupta, M. Sharma, et al. 1997. "Operational Study on Nutritional Anemia in Pregnant Women, Lactating Women and Adolescent Girls in a Rural Community in India." In Improving the Quality of Iron Supplementation Programs.. MotherCare Project/USAID/ John Snow, Inc.
23. Survival for Women and Children (SWACH) Foundation. 1996. Anemia in Pregnant Women and Adolescent Girls in Rural Areas of Haryana, India. Quarterly Progress Report:
24. October to December 1996. Submitted to MotherCare Project, John Snow, Inc.
25. Kurz, K.M. 1997. Personal communication.
26. Kurz et al, op. cit.
27. Kanini, S., and V. Agarwal. 1997. "Reducing Anemia and Improving Growth in Early Adolescence- Nutrition Education Alone Can Make a Difference." In Improving the Quality of Iron Supplementation Programs. MotherCare Project/USAID/ John Snow, Inc.
28. Zavaleta, N., G. Respicio, and T. Garcia. 1997. "Efficacy of an Intermittent Iron Dose Compared to Daily Iron Supplementation in Adolescent Girls." In Improving the Quality of Iron Supplementation Programs. MotherCare Project/USAID/ John Snow, Inc.
29. Bruner, A.B., A. Joffe, A.K. Duggan, et al. 1996. "Randomised Study of Cognitive Effects of Iron Supplementation in Non-Anaemic Iron-Deficient Adolescent Girls." Lancet 348: 992-961.
30. Harrison, K.A. 1990. "Predicting Trends in Operative Delivery for Cephalopelvic Disproportion in Africa." Lancet 335: 861-862.
31. Harrison, K.A., A.F. Fleming, N.D. Briggs, et al. 1985. "Growth During Pregnancy in Nigerian Primigravidae." British Journal of Obstetrics and Gynecology. 5 (suppl.): 32-39.
32. Rosso, P., and S.A. Lederman. 1982. "Nutrition in the Pregnant Adolescent." In Winick M., ed., Adolescent Nutrition. New York, John Wiley & Sons.
33. Helen Keller International op. cit.
34. MotherCare Project/USAID/John Snow, Inc. July 1997. Improving the Quality of Iron Supplementation Programs.

The In FOCUS series summarizes for professionals working in developing countries some of the program experience and limited research available on young adult reproductive health concerns. This issue was prepared by Judith Senderowitz and was reviewed by the FOCUS Editorial Board, some outside experts and the staff of the FOCUS Program. The author is particularly indebted to Kathleen Kurz at the International Center for Research on Women (ICRW) for her assistance in the preparation of this issue of In Focus.