CHAPTER 11 ANEMIA. Almaz T. Sharmanov, Duishe K. Kudayarov and Kalia K. Toguzbaeva Introduction Anemia Measurement Procedures

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1 CHAPTER 11 ANEMIA Almaz T. Sharmanov, Duishe K. Kudayarov and Kalia K. Toguzbaeva 11.1 Introduction Anemia is a condition which is characterized by a reduction in the red blood cell volume and a decrease in the concentration of hemoglobin in the blood. Commonly, anemia is the final outcome of a nutritional deficiency of iron, folate, vitamin B 12 and some other nutrients. Although many other causes of anemia such as hemorrhage, infection, genetic disorders, and chronic disease have been identified, nutritional deficiency, due primarily to a lack of bioavailable dietary iron, accounts for the majority of cases of anemia (INACG, 1979, 1989; DeMaeyer et al., 1989; Hercberg and Galan, 1992; Yip, 1994). Anemia is known to have detrimental health implications, particularly for mothers and young children. Compared with nonanemic mothers, unfavorable pregnancy outcomes have been reported to be more common in anemic mothers (INACG, 1989). Women with severe anemia can experience difficulty meeting oxygen transport requirements near and at delivery, especially if significant hemorrhaging occurs. This may be an underlying cause of maternal death and antenatal and perinatal infant loss (Fleming, 1987; Omar et al., 1994; Thonneau et al., 1992). Iron-deficiency anemia among children has been demonstrated to be associated with impaired cognitive performance, motor development, coordination, language development and scholastic achievement (Scrimshaw, 1984; Lozoff et al., 1991). Anemia increases morbidity from infectious diseases because several immune mechanisms are adversely affected. Anemia due to iron deficiency is recognized as a major public health problem throughout the world. According to the epidemiological data collected from multiple countries by the World Health Organization, some 35 percent of women and 43 percent of young children in the world are affected by anemia. In developing countries, about 50 percent of women and young children are anemic. In the U.S. and Europe, the prevalence of anemia is 7 to 12 percent among women and children. The highest overall rates of anemia are reported in southern Asia and certain regions of Africa (DeMaeyer et al., 1989). Anemia has been considered to be among the leading public health problems in the Kyrgyz Republic for decades. Nevertheless, prior to the KRDHS, no nationally representative data on the prevalence of anemia were available Anemia Measurement Procedures Testing of women and children for anemia was a major part of the 1997 KRDHS. This was the first anemia study in the Kyrgyz Republic done on a nationally representative sample. The study involved hemoglobin testing for anemia to determine the prevalence and severity of anemia among women and children, and to identify demographic, socioeconomic, nutritional and other risk factors for anemia by residence, region, education, and other subgroups of population. This chapter presents findings of the anemia study. Anemia testing was done on 3,760 women age and 980 of their children age three and under. Prior to participating in the study, each respondent was asked to sign a consent form giving permission for the collection of a blood droplet from her and her children. 127

2 For hemoglobin measurement, capillary blood was taken from the finger using Tenderlett lancets (i.e., sterile disposable instruments that allow a relatively painless skin puncture). Hemoglobin was measured in the blood using the Hemocue system that allows the detection of the level of hemoglobin within a minute. This system consists of a battery-operated portable photometer and a disposable cuvette which serves as both a blood collection device and the site where reaction occurs. The procedure was performed by specially trained medical personnel and was determined to be suitable for the field conditions of the survey. Levels of anemia were classified as severe, moderate, and mild based on the hemoglobin concentration in the blood and according to criteria developed by the World Health Organization (DeMaeyer et al., 1989). Severe anemia was diagnosed when hemoglobin concentration was less than 7.0 g/dl, moderate anemia when hemoglobin concentration was g/dl, and mild anemia when the hemoglobin concentration was g/dl ( g/dl for pregnant women and children under age three). The hemoglobin concentration in the blood is negatively regulated by the level of saturation of arterial blood with oxygen. The decline in the oxygen partial pressure with altitude is accompanied by a decline in the saturation of arterial blood with oxygen and increased concentration of hemoglobin in the blood. Based on these relationships Hurtado et al. developed altitude hemoglobin level adjustments for the CDC Pediatric Nutrition Surveillance System. The population of the Kyrgyz Republic lives at altitudes ranging from 488 meters (1,600 feet) in the Ferghana Valley to more than 3,000 meters (10,000 feet) in some areas of Narynskaya oblast. High altitude can affect the level of hemoglobin in the blood and, therefore, should be taken into consideration in the calculation of anemia rates. For this reason, in the KRDHS, the anemia rates were calculated using high altitude adjustment equations: Adjusted level of altitude = observed level adjustment coefficient Adjustment coefficient is calculated as follows: Altitude is measured as Adjustment coefficient = (altitude) (altitude 2 ) [altitude in meters/1,000] Anemia Prevalence Among Women Table 11.1 presents anemia rates for women. Thirty-eight percent of the women in the KRDHS survey suffer from some degree of anemia; 9 percent have moderate anemia, and 1 percent have severe anemia. Among age groups, the highest rate of (combined) moderate and severe anemia was diagnosed among women age (14 percent), and the lowest rate among women age (7 percent). A high rate of moderate/severe anemia was found among women living in the South (13 percent), while only 6 percent of women in Bishkek City were diagnosed as having moderate or severe anemia. Women with higher education are less frequently anemic than women with primary or secondaryspecial education. The rates of moderate and severe anemia are higher among rural women compared with urban women, and among ethnic Kyrgyz and Uzbek women compared with ethnic Russians or women of other ethnic groups. 128

3 Table 11.1 Anemia among women Percentage of women classified as having anemia, by background characteristics, Kyrgyz Republic 1997 Percentage of women with: Background Severe Moderate Mild Number characteristic anemia 1 anemia 2 anemia 3 measured Age Residence Urban Rural Region Bishkek City North East South Education Primary/Secondary Secondary-Special Higher Ethnicity Kyrgyz Russian Uzbek Other , , , , , , , Total ,767 1 Hemoglobin level less than 7g/dl 2 Hemoglobin level g/dl 3 Hemoglobin level g/dl ( g/dl for pregnant women) When iron deficiency is the main etiologic factor of anemia, population groups with high iron requirements are disproportionately affected and develop anemia more frequently. Negative iron balance due to an imbalance of iron requirements versus iron intake often occurs during pregnancy and growth. For this reason, when iron deficiency is highly prevalent in a population, pregnant women, who provide the fetus with a considerable amount of iron, are at greater risk of developing anemia than nonpregnant women. Figure 11.1 shows the prevalence of moderate anemia among pregnant, breastfeeding, and nonpregnant, nonbreastfeeding women. Among pregnant women in the Kyrgyz Republic, moderate anemia is almost twice as prevalent than among nonpregnant women (breastfeeding or nonbreastfeeding). 129

4 Figure 11.2 illustrates hemoglobin distributions of pregnant women, breastfeeding women, and nonpregnant, nonbreastfeeding women. The entire hemoglobin distribution for pregnant women is shifted downward (to the left) compared with the distribution for nonpregnant women. The hemoglobin distribution for breastfeeding women is also shifted downward compared with the distribution for nonpregnant and nonbreastfeeding women, but to a lesser extent than the distribution for pregnant women. There is sufficient evidence to suggest that the majority of cases of anemia among women in the Kyrgyz Republic are due to a nutritional deficiency of iron. Testing blood for hemoglobin, which is an ironcontaining conjugated protein occurring in red blood cells, can be used as a screening procedure for iron deficiency. However, anemia represents only the severe end of iron deficiency, and the real magnitude of iron deficiency in a population is greater than that reflected by hemoglobin measurement alone. Iron deficiency results primarily from low consumption of food products containing bioavailable iron and promoters of iron absorption, such as animal protein and ascorbic acid. It has been shown that the mean monthly menstrual blood loss increases from 30 ml for women who are not using contraception to 50 ml for those who rely on the IUD (INACG, 1989). The chronic use of the IUD can lead to iron depletion and iron deficiency anemia (Palomo et al., 1993). Based on the KRDHS data, 28 percent of currently married women in the Kyrgyz Republic are using an IUD. The prevalence of anemia among women according to whether or not the respondent is currently using an IUD as a method of contraception is presented in Figure The rates of both severe and moderate anemia among IUD users are higher than among nonusers. 130

5 131

6 11.4 Anemia Prevalence Among Children Table 11.2 presents anemia rates for children. Fifty percent of the children under the age of three suffer from some degree of anemia; 24 percent have moderate anemia, and 1 percent are severely anemic. Table 11.2 Anemia among children Percentage of children under three years classified as having anemia, by background characteristics, Kyrgyz Republic 1997 Background Severe Moderate Mild Number of characteristic anemia anemia anemia children Sex Male Female Residence Urban Rural Region Bishkek City North East South Education of mother Primary/Secondary Secondary-special Higher Ethnicity Kyrgyz Russian Uzbek Other Total ,021 a Hemoglobin level less than 7g/dl b Hemoglobin level g/dl c Hemoglobin level g/dl Differences in overall rates of anemia by sex of the child, ethnicity, residence and education of the mother were relatively minor. However, as was the case with women, differences by region are substantial. Thirty-two percent of the children living in the North Region and 24 percent of children living in the South and East Regions were diagnosed as having moderate or severe anemia. In Bishkek City, the prevalence of moderate anemia among children was relatively low (13 percent). Certain relationships are observed between the prevalence of anemia among mothers and their children. Table 11.3 shows the prevalence of anemia for children according to the anemia status of their mothers. Among children of mothers with moderate anemia, 0.5 percent have severe anemia and 37 percent have moderate anemia. The proportion of moderate anemia among these children is almost twice as high as among children of nonanemic mothers. 132

7 Table 11.3 Anemia among children born to anemic mothers Percent distribution of children under three years by anemia status according to mother's anemia status at the time of the survey, Kyrgyz Republic 1997 Child's anemia status Number Severe Moderate Mild Not of Mother's anemia status anemia 1 anemia 2 anemia 3 anemic Total children Severe anemia 1 Moderate anemia 2 Mild anemia 3 Not anemic * * * * * Total ,019 Note: An asterisk indicates that a figure is based on fewer than 25 unweighted cases and has been suppressed. 1 Hemoglobin level less than 7g/dl 2 Hemoglobin level g/dl 3 Hemoglobin level g/dl ( g/dl for pregnant women and children under age three) 133

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