Archives of Medicine and Health Sciences

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 7  |  Issue : 2  |  Page : 201--205

Profile of nutritional anemia and its correlation with serum iron, Vitamin B12, and folic acid level among the tribal population of northern districts of West Bengal, India


Ankita Dhanuka1, Bidyut Krishna Goswami1, Sarama Banerjee Goswami2, Sudipta Chakrabarti3,  
1 Department of Pathology, North Bengal Medical College and Hospital, Darjeeling, West Bengal, India
2 Department of Regional Blood Transfusion Centre, North Bengal Medical College and Hospital, Darjeeling, West Bengal, India
3 Department of Pathology, ESI PGIMSR Manicktala, Kolkata, West Bengal, India

Correspondence Address:
Dr. Bidyut Krishna Goswami
Department of Pathology, North Bengal Medical College and Hospital, Sushrutanagar, Darjeeling, Kolkata, West Bengal
India

Abstract

Background and Objective: Nutritional anemia is the most common and easily preventable cause of anemia. No comprehensive data regarding the magnitude of this problem are available in the literature in northern regions of West Bengal where a significant number of tribals inhabit. The present study was undertaken to assess the magnitude of anemia and the status of iron, Vitamin B12, and folic acid deficiency in tribals of North Bengal and to analyze their red blood cell (RBC) morphology. Materials and Methods: A descriptive study done on the individuals during a period of 1 year at North Bengal Medical College. Serum iron, ferritin, total iron-binding capacity, Vitamin B12, and folic acid were measured along with other relevant investigations. Results: Forty-eight out of 88 (54.51%) of the cases were found to be anemic. Thirty-four out of 48 (70.83%) of them had at least one of the nutritional deficiencies. Iron deficiency was most common, seen in 18 (37.5%) of cases. Abnormal hemoglobin was seen in 7 (14.58%), two of which also had nutritional deficiency. In combined iron and folate deficiency, 7 out of 10 (70%) showed microcytic hypochromic morphology and 3 (30%) were dimorphic. Conclusion: Iron and folic acid deficiency is quite common among the tribals of northern region of West Bengal. RBC morphology alone lacks the specificity for the diagnosis of causes. Furthermore, nutritional deficiencies may coexist with abnormal hemoglobin variants, complicating their diagnosis further. A proper clinical, hematological, and biochemical correlation is required for the accurate diagnosis and effective treatment of anemia, highlighting the need for a screening for the causes of anemia in this population.



How to cite this article:
Dhanuka A, Goswami BK, Goswami SB, Chakrabarti S. Profile of nutritional anemia and its correlation with serum iron, Vitamin B12, and folic acid level among the tribal population of northern districts of West Bengal, India.Arch Med Health Sci 2019;7:201-205


How to cite this URL:
Dhanuka A, Goswami BK, Goswami SB, Chakrabarti S. Profile of nutritional anemia and its correlation with serum iron, Vitamin B12, and folic acid level among the tribal population of northern districts of West Bengal, India. Arch Med Health Sci [serial online] 2019 [cited 2020 May 28 ];7:201-205
Available from: http://www.amhsjournal.org/text.asp?2019/7/2/201/273071


Full Text



 Introduction



Anemia is a major public health problem in India, especially in the rural and tribal population. More than 1.6 billion people, almost a quarter of the world's population, are anemic.[1] The prevalence of anemia in all age groups is higher in India as compared to other developing countries.[2],[3]

Iron deficiency accounts for about half the world's anemia burden.[4] Forty-seven percent of Asian Indians had Vitamin B12 deficiency showing a high prevalence of this magnitude in Indians.[5] Folate deficiency has traditionally been linked to poverty, which (by Indian standards) afflicts around 33% of the population of India.[6]

Tribal population constitutes significantly to Indian population (8.19%).[7] The tribal community is one of the most vulnerable sectors of the population of a country in terms of social development. They are expose to many health hazards as their residence is usually located in isolated places, embrace rigid customs, high illiteracy and separation from modern amenities.[8]

No comprehensive data of the prevalence of nutritional deficiencies among tribals are available, especially in northern districts of West Bengal where a significant number of population are tribal.

The present study was undertaken to evaluate the magnitude and severity of anemia and iron, Vitamin B12, and folic acid deficiency in tribal population of northern districts of West Bengal.

 Materials and Methods



During the period of 1 year from April 2015 to March 2016, a total of 88 tribal patients exclusively from northern districts of West Bengal attending for pallor or weakness at the Thalassemia Control Unit (TCU) of North Bengal Medical College (NBMCH) for screening and from the camps arranged by TCU were selected for this study. Permission from the Institutional Ethical Committee was obtained for the present study.

Informed consent was obtained from all the individuals who participated in this study. The sample size was calculated by the formula of sample size estimation in cross-sectional studies: N =4pq/d^2 (p – prevalence of the condition, q – expressed as 100 − p, and d – the precision of the estimate). Diagnosed patients of hematologic malignancies or any chronic illness, patients receiving hematinics or any other marrow stimulating agents, patients who received blood transfusion recently, and pregnant females were excluded from this study. Clinical history was taken and complete clinical examination was done for each individual. Blood sample was drawn using disposable syringes and collected in vials containing disodium salt of ethylenediaminetetraacetic acid as anticoagulant as well as in plain vials. Hematological indices were measured using automated cell counter (Sysmax K × 21E-210, Japan). Peripheral blood smear study and reticulocyte count were also performed. Those who were found to be anemic based on their hemoglobin levels were graded as mild, moderate, or severely anemic using the WHO criteria for anemia.[9]

In all cases, serum ferritin, Vitamin B12, and folic acid were measured automated immunofluorescence assay method using TOSOH AIA System Analyzers. Serum iron and total iron-binding capacity were detected by ferrozine method using automated biochemical analyzer according to the manufacturer's instructions. Simultaneously, the presence of abnormal hemoglobin variants was assessed by cation-exchange high-performance liquid chromatography principle, using Variant 2 (Bio-Rad, USA) automated HPLC. Quality control for the tests was assessed by the internal quality control program of the institution's laboratory.

Standard statistical techniques (Chi-square test and t-test) were used for calculation, using Microsoft™ Excel.

 Results



Out of 88 tribal persons, 48 (54.51%) were found to be anemic. Majority of them were in the 20–29 years' age group (20 out of 48, 41.68%), with a mean age of 33.37 year (median: 29.5 years; mode: 26 years).

In the present study, the nonanemic population was predominantly male (25 out of 40, 62.5%), with a male-to-female ratio of 1.67:1, whereas the anemic population was predominantly female (30 out of 48, 62.5%), with a male-to-female ratio of 1:1.67. However, these demographic data depict only cases who attended TCU of NBMCH.

The most common presenting complaint among the anemic patients was weakness, which was present in 14 out of the 48 anemic patients. An equal number of cases were asymptomatic [Table 1]. All cases of the study population were nonvegetarians. Out of 48 anemic patients, only 15 (31.25%) did not have any pallor on clinical examination. Among these cases, 13 (86.67%) were found to be suffering from mild anemia. Rest two cases had moderate grade of anemia as per the WHO criteria of grading of anemia [Table 2]. All patients who were found to be severely anemic showed clinical pallor.{Table 1}{Table 2}

In the present study, the females had slightly lower average hemoglobin levels (9.83 g/dl). The number of females suffering from moderate and severe anemia was higher as compared to that of the males, as shown in [Table 3]. However, the results were not statistically significant in Chi-square test [Table 3]. Overall, 56.25% of the total 48 anemic patients had mild anemia, 31.25% had moderate, and 12.5% had severe.{Table 3}

Out of 48 anemic population, 34 (70.83%) had at least one nutritional factor deficiency [Figure 1]. Only 14 (29.17%) anemic patients showed no deficiency of these factors. Two cases (4.17%) had coexisting nutritional deficiency as well as abnormal hemoglobin.{Figure 1}

Iron deficiency was the most common among these, seen in 18 out of 48 (37.5%) of the total anemic population [Table 3] and [Table 4]. Seven (14.58%) out of 48 anemic patients showed abnormal hemoglobin, five were beta-thalassemia carriers, and two were sickle cell carriers. Out of the five, two of the beta-thalassemia carriers had coexisting either iron or folic acid deficiency, respectively.{Table 4}

Fourteen of 18 (77.78%) of iron-deficient population showed microcytic hypochromic red blood cells (RBCs). Only 2 of 6 (33.33%) of folic acid-deficient population showed macrocytic RBCs. In combined iron and folate deficiency, 7 of 10 (70%) showed predominantly microcytic hypochromic morphology and 3 of 10 (30%) were dimorphic [Table 4]. A statistically significant difference was observed between RBC indices of iron and folic acid deficiency in respect of Mean Corpuscular Volume (MCV) and Mean Corpuscular Hemoglobin {MCH} but not in Mean Corpuscular Hemoglobin Concentration (MCHC) and Red cell Distribution Width (RDW) by t-test [Table 5].{Table 5}

 Discussion



Although the Indian tribals are a heterogeneous group, most of them remain at the lowest stratum of the society due to various factors such as geographical and cultural isolation, low levels of literacy, primitive occupations, and extreme levels of poverty.[10]

The state of West Bengal is home to 38 scheduled tribes (ST) constituting 5.5% of the total population of the state (numbering 80,176,197). The Santal represent more than half of the total ST population of the state (51.8%) which includes Oraon, Minj, Lakra, Kujur, Tigga, Ekka, Kaka, and Toppo, Other constituent of ST population are Munda, Bhumij, Kora, Lodha, Mahali, Bhutia, Bedia, and Savar. More than half of the total ST population of the state are concentrated in four districts, namely Medinipur, Jalpaiguri, Purulia, and Barddhaman.[7]

The present study included 88 tribal people, of which 48 (54.51%) were found to be anemic, which is similar to a study on prevalence of anemia in tribal women in Udupi taluk, Karnataka, by Kamath et al., which showed 55.9% to be anemic.[11]

There are major deficiencies in the coverage and quality of anemia monitoring data for indigenous population worldwide, as indicated by the results of a study done at Royal North Shore Hospital, New South Wales, Sydney, Australia, in which 50 studies published from 13 countries including India using PubMed/MEDLINE and Embase were analyzed.[12]

A study for coexistence of hemoglobinopathies and iron deficiency in tribal population of East India by Chatterjee et al. shows that 39.92% and 76.4% of tribal populations are anemic in Assam and West Bengal, respectively.[13]

In the present study, it was seen that, out of the 48 anemic patients, 30 (62.5%) were females. Apart from overall poverty, the health status of women in India reflects gender discrimination from birth, inequitable distribution of health resources, and early and frequent reproductive cycles. The high rates of anemia among Indian women, therefore, reflect their social and biological vulnerability both within society and the household.[14] Furthermore, it was found that the severity of anemia was higher in females as compared to that of males.

A study on malnutrition and anemia in tribal population of Purnia district, Bihar, by Rao and Vijay, showed that only 21.9% of tribal children had normal hemoglobin level. Thirty-six percent of Munda and 16.11% of Oraon children had moderate anemia. Overall, 78.1% of children were found to be anemic.[15]

The most common presenting symptom in this study was weakness, noted in 14 (29.16%) out of 48 cases. This is similar to a recent study done in a tertiary care center by Prakash et al.[16]

However, 14 cases with anemia were asymptomatic. It had been argued that patients would adapt to low hemoglobin levels if anemia developed slowly. This has led to the concept of asymptomatic anemia. In truth, asymptomatic reflects the fact that impairments in physical condition, quality of life, and cognitive function may be unrecognized by both patients and their doctors.[17]

In this study, iron deficiency was found in 18 (37.5%) anemic cases, folic acid in 6 (12.5%), and combined iron and folic acid deficiency in 10 (20.83%). Data regarding the prevalence of these deficiencies among the tribal population of Northern regions of West Bengal were not yet available for comparison.

In this study, none of the cases suffering from anemia were found to be having Vitamin B12 deficiency. It may be because all the cases studied were nonvegetarians and studies have established that dietary Vitamin B12 deficiency is not prevalent in Asia, except in vegetarians.[18]

In the present study, abnormal hemoglobin variants were found in seven out of 48 (14.58%) cases. A study on spectrum of hemoglobin variants in northern region of West Bengal showed a high prevalence of hemoglobinopathies in this region, especially among the ethnic races.[19]

In the present study, two cases were such who had both hemoglobinopathy and nutritional deficiency. According to a study on coexistence of hemoglobinopathies and iron deficiency in the development of anemia in the tribal population in East India, HbE was the most common hemoglobinopathy among the studied groups of the Northeast. The prevalence of beta-thalassemia (1.6%) was almost nil in the tribal groups.[20]

In this study, cases having iron deficiency showed microcytic hypochromic RBC morphology in 14 out of 18 cases. According to a study by Viswanath et al. on iron deficiency anemia, peripheral smear showed microcytosis and hypochromia in all cases with severe anemia, 61.5% and 22.5% of those with moderate and mild anemia, respectively.[21]

In the present study, one of the most important and distinguished observations was combined iron and folic acid deficiency, which showed microcytic hypochromic RBCs in 70% of cases and dimorphic in the rest 30%. No definite published literature with this type of observation in this part of the country has been found.

In this study, out of 48 cases of anemia, 15 (31.25%) of them did not have any clinical pallor. Thirteen (86.66%) out of these 15 had mild anemia and two had moderate anemia. The current evidence suggests that conjunctival pallor may be a more accurate indicator of the presence or absence of anemia than pallor of the palms or nail beds. In addition, conjunctival pallor has been documented to appear more frequently in patients with severe anemia and hence may be more sensitive than other signs.[22]

 Conclusion



Anemia due to nutritional deficiency, especially of iron and folic acid either in isolation or in combination, is very common among the tribal population of northern districts of West Bengal, with a higher severity in females. Vitamin B12 deficiency is not common in this population. Although microcytic hypochromic RBC morphology is an important observation in iron deficiency anemia, alone it lacks the specificity for the diagnosis of causes. Even in association with folic acid deficiency, microcytic hypochromic anemia may be seen. Furthermore, these nutritional deficiencies may coexist with abnormal hemoglobin variants, complicating their diagnosis further. A proper clinical, hematological, and biochemical correlation is required for the accurate diagnosis and effective treatment of anemia, thus highlighting the need for a screening for the causes of anemia in this population.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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