Maharashtra Anaemia Study: an investigation of factors associated with adolescent health and pregnancy-related outcomes in women from Maharashtra State, India

Maharashtra Anaemia study (MAS) was conducted as a part of the PhD programme of Dr Anand Ahankari through a joint collaboration of the University of Nottingham, UK and Halo Medical Foundation, India. The main goal of the study was to establish baseline epidemiological data for anaemia research in pregnant women and adolescent girls in Maharashtra state of India. Iron deficiency anaemia is the most common form of anaemia observed in India, and assessed based on haemoglobin (Hb) levels in blood. Clinically, anaemia is categorised in mild, moderate and severe form based on Hb levels. The project had three main sections, a) Adolescent girls cross sectional survey, b) Pregnant women prospective study, and c) Maharashtra state birth registry analysis. The study aimed to investigate individual and village level risk factors of anaemia in adolescent girls (13 to 17 years), and pregnant women (3 to 5 months) living in rural Maharashtra. Data from pregnant women were also used to examine risk factors associated with low birth weight (LBW). A recently introduced non-invasive haemoglobin (Hb) technology (known as NBM 200) was validated in this Indian setting by comparing Hb measurements obtained from the NBM 200 with reference blood measurements. In the adolescent survey, Sahli’s hemometer (finger prick technique) was used to estimate reference Hb values, while in pregnant women venous blood samples were obtained to measure Hb using an automated analyser. Anaemia was defined using Hb levels based on the following cut offs, (a) Hb <12.0 g/dl in adolescent girls, and in (b) Hb <11.0 g/dl in pregnant women. Multivariable regression technique was used to identity risk factors associated with anaemia and LBW. The Maharashtra state birth registry records covering a 32-year period (1980 to 2011) were investigated to assess temporal changes in the sex ratio at birth to investigate impacts of sex determination prevention legislations (known as PNDT 1994 and PCPNDT 2003). The adolescent girls’ survey showed a very high prevalence of anaemia (87%). Of 45 factors assessed in the survey, four were associated with adolescent anaemia. Anaemia likelihood increased significantly with age (Odds Ratio [OR] 1.41 per year, 95% CI: 1.17 to 1.70). Factors associated with decreased risk of anaemia were higher mid upper arm circumference (> 22 cm) (OR 0.51, 95% CI: 0.31 to 0.82), and ≥3 days/week consumption of fruit (OR 0.35, 95% CI: 0.23 to 0.54). At village level piped water supply was associated with higher Hb levels (β coefficient 0.61 g/dl, 95% CI: 0.39 to 0.82). Results from the NBM 200 reported wide agreement levels in the Bland-Altman analysis (mean difference of -2.70 g/dl, 95% CI: -2.84 to -2.55) demonstrating an overestimation of Hb by the NBM 200 compared to Sahli’s hemometer. The NBM 200 showed low sensitivity (23.6%) and moderate specificity (61.8%) for the diagnosis of anaemia in the adolescent population. Findings from pregnant women showed high anaemia prevalence (77%). Of 51 factors assessed in the study, three were associated with maternal anaemia. Increased risk of anaemia was seen in women with consanguineous marriages (OR 2.41, 95% CI: 1.16 to 5.01). Post-delivery data from full-term singleton live births showed the prevalence of LBW babies was 7%. Consanguineous marriage was a major risk of LBW babies in our study population (OR 5.68, 95% CI: 1.58 to 20.32). Village level risk factors showed lower likelihood of maternal anaemia with regular access to government nurses (OR 0.48, 95% CI: 0.25 to 0.93). The NBM 200 validation showed overestimation of Hb levels and underestimation of anaemia. Bland-Altman analysis showed a mean difference of -1.8 g/dl (95% CI: -2.06 to -1.71) indicating a systematic overestimation by the NBM 200 compared to venous Hb measurements. The device showed low sensitivity (33.7%) but high specificity (91.8%) for the diagnosis of anaemia in the pregnant woman population. The 32 years of longitudinal birth registry data showed a significant increase in the sex ratio at live birth from 1980 to 2004, and then a subsequent decrease in sex ratio. The annual state male:female sex ratio of Maharashtra increased from a baseline of 1.11 in 1980 to a maximum value of 1.23 in 2003, before decreasing to 1.16 in 2011. This represented an increase in the annual sex ratio at live birth from 1980 to 2004 of 0.005 units per year (p < 0.001), and a decrease of 0.009 units per year after 2004 (p < 0.01). The increase in the sex ratio was consistent with the hypothesis of both increasing availability and acceptability of ultrasound scanning during this period, enabling foeticide of females in utero. The probable cause for the decrease in sex ratio after 2004 is likely to be due to the strengthening of the legislation banning sex-specific foeticide

Two measures of systemic inflammation are positively associated with haemoglobin levels in adolescent girls living in rural India: A cross‐sectional study

ObjectiveThis study tested the hypothesis that systemic inflammation is inversely associated with haemoglobin levels in adolescent girls in India.MethodsThe study population consisted of adolescent girls aged between 10 and 19 years living in a remote rural region in Maharashtra State, India. Data were collected on anthropometric measures, and a venous blood sample taken and tested for Complete Blood Count and C‐reactive Protein (CRP).ResultsOf 679 individuals who were invited to the research site to participate, data were available from 401 participants giving a response rate of 59%. Median blood CRP was 1.26 mg/L (Range 0.00 to 26.33), and 167 (41.6%) participants had CRP level [less than] 1.0 mg/L. The mean haemoglobin was 12.24 g/dL (Standard deviation [SD] 1.51), and the mean total White Blood Cells (WBC) count was 9.02 x103/μL (SD 2.00). With each g/dL increase in blood haemoglobin, the risk of having an elevated CRP of ≥1 mg/L increased with an odds ratio of 1.16 (95% CI 1.01 to 1.33, p=0.03). Total WBC count was also positively associated with blood haemoglobin, increasing by 0.24 x103/μL (95% CI 0.11 to 0.37, p [less than] 0.001) per g/dL increase in haemoglobin. Both analyses were adjusted for age. ConclusionsIn this population, blood haemoglobin levels were positively associated with two measures of systemic inflammation, contrary to the primary hypothesis being tested. Other unmeasured environmental exposures may modify haemoglobin levels in this population. Understanding this observation may help design better public health interventions to improve the wellbeing of adolescent girls in India

Proceedings of the inaugural International Summit for Medical Nutrition Education and Research

© 2016 The Royal Society for Public Health Medical Nutrition Education (MNE) has been identified as an area with potential public health impact. Despite countries having distinctive education systems, barriers and facilitators to effective MNE are consistent across borders, demanding a common platform to initiate global programmes. A shared approach to supporting greater MNE is ideal to support countries to work together. In an effort to initiate this process, the Need for Nutrition Education/Innovation Programme group, in association with their strategic partners, hosted the inaugural International Summit on Medical Nutrition Education and Research on August 8, 2015 in Cambridge, UK. Speakers from the UK, the USA, Canada, Australia, New Zealand, Italy, and India provided insights into their respective countries including their education systems, inherent challenges, and potential solutions across two main themes: (1) Medical Nutrition Education, focused on best practice examples in competencies and assessment; and (2) Medical Nutrition Research, discussing how to translate nutrition research into education opportunities. The Summit identified shared needs across regions, showcased examples of transferrable strategies and identified opportunities for collaboration in nutrition education for healthcare (including medical) professionals. These proceedings highlight the key messages presented at the Summit and showcase opportunities for working together towards a common goal of improvement in MNE to improve public health at large

Prevalence of iron deficiency anaemia and risk factors in 1,010 adolescent girls from rural Maharashtra, India: a cross-sectional survey

Objective: Iron deficiency anaemia (IDA) is the most common nutritional disorder observed in adolescent girls in India. Our aim was to investigate the prevalence and risk factors associated with IDA in rural Maharashtra, India to address current evidence gaps. Study Design: Cross sectional survey Methods: The study recruited 13 to 17 year old adolescent girls living in 34 villages of Osmanabad district. Data were collected on individual health, dietary, sociodemographic factors, and anthropometric measurements were taken. Haemoglobin (Hb) levels were measured using Sahli’s hemometer. Logistic and linear regressions were used to identify risk factors associated with IDA and Hb level respectively. Results: Among 1,010 adolescent girls (response rate 97.5%), the mean Hb was 10.1 g/dl (standard deviation=1.3), and 87% had anaemia (Hb<12 g/dl). The prevalence of mild (11.0-11.9 g/dl), moderate (8.0-10.9 g/dl) and severe (Hb≤ 7.9 g/dl) anaemia was 17%, 65% and 5% respectively. Anaemia likelihood increased significantly with age (odds ratio (OR): 1.41 per year, 95% confidence interval (CI): 1.17 to 1.70). Factors associated with decreased anaemia risk were mid upper arm circumference (MUAC) ≥22 cm (OR: 0.51, 95% CI: 0.31 to 0.82), ≥3 days/week consumption of fruit (OR: 0.35, 95% CI: 0.23 to 0.54) or rice (OR: 0.39, 95% CI: 0.17 to 0.91), and incomplete schooling (OR: 0.47, 95% CI: 0.24 to 0.91). In the final model lower age, MUAC and fruit consumption were significantly associated with Hb level. Conclusion: Anaemia prevalence was extremely high among adolescent girls in rural areas of Maharashtra. Whilst we identified risk factors that could be used for targeting interventions, there is urgent need of comprehensive preventative interventions for the whole adolescent girl population

Maharashtra Anaemia Study: an investigation of factors associated with adolescent health and pregnancy-related outcomes in women from Maharashtra State, India

Maharashtra Anaemia study (MAS) was conducted as a part of the PhD programme of Dr Anand Ahankari through a joint collaboration of the University of Nottingham, UK and Halo Medical Foundation, India. The main goal of the study was to establish baseline epidemiological data for anaemia research in pregnant women and adolescent girls in Maharashtra state of India. Iron deficiency anaemia is the most common form of anaemia observed in India, and assessed based on haemoglobin (Hb) levels in blood. Clinically, anaemia is categorised in mild, moderate and severe form based on Hb levels. The project had three main sections, a) Adolescent girls cross sectional survey, b) Pregnant women prospective study, and c) Maharashtra state birth registry analysis. The study aimed to investigate individual and village level risk factors of anaemia in adolescent girls (13 to 17 years), and pregnant women (3 to 5 months) living in rural Maharashtra. Data from pregnant women were also used to examine risk factors associated with low birth weight (LBW). A recently introduced non-invasive haemoglobin (Hb) technology (known as NBM 200) was validated in this Indian setting by comparing Hb measurements obtained from the NBM 200 with reference blood measurements. In the adolescent survey, Sahli’s hemometer (finger prick technique) was used to estimate reference Hb values, while in pregnant women venous blood samples were obtained to measure Hb using an automated analyser. Anaemia was defined using Hb levels based on the following cut offs, (a) Hb <12.0 g/dl in adolescent girls, and in (b) Hb <11.0 g/dl in pregnant women. Multivariable regression technique was used to identity risk factors associated with anaemia and LBW. The Maharashtra state birth registry records covering a 32-year period (1980 to 2011) were investigated to assess temporal changes in the sex ratio at birth to investigate impacts of sex determination prevention legislations (known as PNDT 1994 and PCPNDT 2003). The adolescent girls’ survey showed a very high prevalence of anaemia (87%). Of 45 factors assessed in the survey, four were associated with adolescent anaemia. Anaemia likelihood increased significantly with age (Odds Ratio [OR] 1.41 per year, 95% CI: 1.17 to 1.70). Factors associated with decreased risk of anaemia were higher mid upper arm circumference (> 22 cm) (OR 0.51, 95% CI: 0.31 to 0.82), and ≥3 days/week consumption of fruit (OR 0.35, 95% CI: 0.23 to 0.54). At village level piped water supply was associated with higher Hb levels (β coefficient 0.61 g/dl, 95% CI: 0.39 to 0.82). Results from the NBM 200 reported wide agreement levels in the Bland-Altman analysis (mean difference of -2.70 g/dl, 95% CI: -2.84 to -2.55) demonstrating an overestimation of Hb by the NBM 200 compared to Sahli’s hemometer. The NBM 200 showed low sensitivity (23.6%) and moderate specificity (61.8%) for the diagnosis of anaemia in the adolescent population. Findings from pregnant women showed high anaemia prevalence (77%). Of 51 factors assessed in the study, three were associated with maternal anaemia. Increased risk of anaemia was seen in women with consanguineous marriages (OR 2.41, 95% CI: 1.16 to 5.01). Post-delivery data from full-term singleton live births showed the prevalence of LBW babies was 7%. Consanguineous marriage was a major risk of LBW babies in our study population (OR 5.68, 95% CI: 1.58 to 20.32). Village level risk factors showed lower likelihood of maternal anaemia with regular access to government nurses (OR 0.48, 95% CI: 0.25 to 0.93). The NBM 200 validation showed overestimation of Hb levels and underestimation of anaemia. Bland-Altman analysis showed a mean difference of -1.8 g/dl (95% CI: -2.06 to -1.71) indicating a systematic overestimation by the NBM 200 compared to venous Hb measurements. The device showed low sensitivity (33.7%) but high specificity (91.8%) for the diagnosis of anaemia in the pregnant woman population. The 32 years of longitudinal birth registry data showed a significant increase in the sex ratio at live birth from 1980 to 2004, and then a subsequent decrease in sex ratio. The annual state male:female sex ratio of Maharashtra increased from a baseline of 1.11 in 1980 to a maximum value of 1.23 in 2003, before decreasing to 1.16 in 2011. This represented an increase in the annual sex ratio at live birth from 1980 to 2004 of 0.005 units per year (p < 0.001), and a decrease of 0.009 units per year after 2004 (p < 0.01). The increase in the sex ratio was consistent with the hypothesis of both increasing availability and acceptability of ultrasound scanning during this period, enabling foeticide of females in utero. The probable cause for the decrease in sex ratio after 2004 is likely to be due to the strengthening of the legislation banning sex-specific foeticide