The status of iron deficiency anaemia among the adolescents
Iron deficiency anaemia is a public health concern due to the fact that it solely contributes to approximately 50% of the global anaemia cases [28,34]. And adolescents are not excluded as they are highly susceptible to iron deficiency anaemia due to rapid growth spurt and onset of menstruation (particularly the girls), which consequently leads to increased nutrient demands [35]. To ascertain the status of iron deficiency anaemia among adolescents, the haemoglobin levels were measured using the hemocue system [11]. Accordingly, we found that in the present study, the average haemoglobin (Hb) level for the adolescent girls and boys in Gulu district was above the cut-off point established by WHO [32] (Table 3). This implies that generally, adolescents in the study areas had normal haemoglobin level. However, the boys had significantly higher haemoglobin levels (p<0.05) than the girls (Table 3). This finding is similar to a study in India where the haemoglobin level of rural boys was found to be higher than that of girls [36]. The finding of the current study further, agrees with previous studies [11-12, 37-40] that reported a higher prevalence of anaemia among adolescent girls than the boys. This could be attributed to the physiological differences between boys and girls and is consistent with the girls’ experience of menstruation (Table 2). It was acknowledged that girls lose blood monthly through menstruation [7,13]. Our study suggests that adolescent girls are more prone than boys to irreversible negative effects of anaemia such as poor growth and cognitive function [1,15], poor work performance [15], low immune system [1], neurological development disorders [16]. On the other hand, the prevalence of anaemia among the adolescent girls and boys in the current study (Table 3) is quite lower than the findings of the previous studies which involved both male and female adolescents as study participants [39]. Similarly, the findings of the present study also report a lower prevalence of anaemia among adolescent girls in the study area than in several other previous studies [13, 16, 41-43]. Despite that, anaemia should not be underestimated because Acholi sub-region has the highest prevalence among women of reproductive age and children below five years of age [10]. It is against this background that efforts to address anaemia among adolescents should be considered on public health agenda in Gulu district and city in particular and Acholi sub-region in general although the prevalence still falls under mild category according to public health significance [33]. This is because mild anaemia was reported to have health consequences on the adolescent girls such as reproductive age; risk of low birth, preterm delivery, perinatal mortality, and postpartum haemorrhage [44]. Furthermore, although the results of the current study cannot be generalised to other parts of Uganda and the rest of the world, the findings of the current study still provide an important information that can give insight into a large-scale study and provoke mechanisms for addressing iron deficiency anaemia.
The status of dietary quality and micronutrient adequacy among adolescent girls and boys
Individual dietary diversity is defined as the type and number of food groups consumed by an individual over 24 hours. It is reflective of an individual’s ability to access a variety of foods and is a proxy of micronutrient adequacy [30, 45-46]. Dietary diversity score (DDS) for adolescents were calculated based on 9 food groups [30]. Adolescents who consumed at least four (4) out of the 9 recommended food groups were categorized as having high dietary diversity whereas those who consumed less than four (4) food groups were categorized as having a less diversified diet. Based on the findings of the present study (Table 5), dietary diversity was not significantly different between girls and boys (p>0.05), but girls consumed slightly more diverse diet than boys. Nonetheless, a high proportion of both adolescent girls and boys had low dietary diversity as assessed by the average number of food groups consumed (Table 5). The finding in the study is not in agreement with previous studies [26,47] that reported a low proportion of adolescents with low dietary diversity. In addition, the mean dietary diversity for the current study was lower compared to previous studies [47-49]. Low dietary diversity is associated with a high risk of micronutrient deficiencies such as anaemia [12, 24-26].
The results (Table 4) further indicate that among the food groups, animal source foods (milk and its products, fish, meat, eggs and meat from animal organ), vitamin A rich fruits and vegetables, and other fruits and vegetables were the most consumed among girls compared to boys. Consumption of iron rich foods was also higher among adolescent girls than boys (Figure 2). Similarly, consumption of food groups such as starchy staples, legumes/seeds/nuts, green leafy vegetables, oils/fats, sweets and beverages was high amongst adolescent girls compared to the boys (Table 4). The findings of the present study with respect to adolescent girls is in agreement with [25, 47] who reported high consumption of plant-based diets dominated by starch staples (cereals, roots and tubers), but not with respect to consumption of animal source foods, fruits and vegetables as indicated in Table 4. Moreso, the present study indicates that there were significant differences in consumption of starchy staples, milk and its products and Vitamin A rich fruits and vegetables between the adolescent girls and boys (p<0.05). This is in agreement with a previous study in India [50] among adolescent with regard to consumption of milk and meat, attributed to puberty, school enrolment, time use and dietary behaviours. Levin [51] also affirmed that consumption of fruits and vegetables was higher among girls than boys in Scotland. Consumption of a diversified diet, which is low in starchy staples and high in animal source foods is associated with both adequate macronutrient and micronutrient intake [30, 45-46,,48], which consequently reduces the risk of nutritional deficiency diseases and chronic diseases later in life such as obesity, diabetes, cardio vascular and renal diseases [24]. In the Eastern Mediterranean Region (EMR), it was reported that malnutrition among adolescent has implications for health, which can be serious and wide ranging [52]. Consistent with this, the same authors [52] reported that iron deficiency was one of the leading determinants of adolescent disability-adjusted life years, especially in low- and middle-income countries, contributing to 20% of maternal deaths. In another study in India, females aged 15–49 years who appeared to have consumed nutrient-rich foods less frequently were twice more likely than men to suffer from anaemia, a non-communicable condition often caused by nutritionally inadequate diets [50]. Moreover, malnutrition in girls in their adult age or reproductive age is one of the causes a vicious cycle of undernutrition and poverty [53]. However, despite that fact that in the current study, the adolescent girls had better dietary quality than boys (Table 4), the prevalence of anaemia was significantly higher among the girls than boys (Table 3). First because, generally, that dietary diversity for both the adolescent girls and boys was low in the study area (Table 5). Secondly, women as well as adolescent girls are vulnerable to micronutrient deficiencies on account of their cyclical loss of iron during menstruation and childbearing [53].
Therefore, future interventions should focus on how to increase the number of foods that can be prepared and consumed by adolescents while at either school or home. Such interventions can include promotion of agricultural diversification, promotion of iron fortified and biofortified foods. In addition, there is need to investigate level of knowledge, awareness and attitude towards the consumption of iron-rich foods among adolescents.
Socio-economic and demographic factors associated with dietary quality and micronutrient adequacy, and anaemia among adolescent girls and boys
Previous authors [44] reported that differences in magnitude of anaemia could be due to differences in economy, socio-culture, and dietary practices. In our study, socio-economic and demographic factors of the adolescents like age of respondent, caretaker of the respondent, class of the respondent, highest level of education of the parent/guardian, household size, occupation of the parent/guardian, nature of the menstrual flow, and duration of menstruation (days) were considered and tested whether they had association with dietary quality and micronutrient adequacy. Interestingly, none of these socio-economic and demographic parameters showed significant relationship (p>0.05) (Table 6). This therefore implies that the dietary diversity among the adolescent girls and boys in Gulu district is independent of the socio-economic and demographic factors stated above. The findings of the present study are not consistent with previous studies [ 26, 47, 49, 54-55] that reported socio-economic and demographic factors such as weak economic situation of households, maternal education, maternal employment, monthly income, staying with a single parent, educational level of adolescents as predictors of dietary diversity amongst adolescents.
For the prevalence of anaemia (Table 7), only education level of the parent/guardian and nature of menstruation were significant predictors of anaemia among the girls (p<0.05). This could partly explain why haemoglobin concentration of adolescent girls was below that of boys (Table 3) despite them consuming more animal food groups than boys (Table 4). The findings of the current study are in agreement with [39, 56] where education status of the parent/guardian was a positive predictor of anaemia. A highly educated parent/guardian is able to influence intake of micronutrient foods such as meat, fish, fruits and vegetables which consequently reduces the risk of anaemia amongst adolescents [16]. Furthermore, the results of the current study correlate with previous studies [57,58] that reported menstruation as a predictor of anaemia amongst adolescent girls. Menstruation is associated with blood loss and hence reduces on the iron stores in the body. Should there be no replacement of the lost iron, then anaemia manifests. Our study has shown that even with moderate levels of intake of animal products, adolescent girls are still prone to anaemia compared to boys whose diet was dominated by plant-based foods. Therefore, preventing anaemia among adolescents should take into consideration strengthening the already existing health interventions at schools such as regular deworming and timely diagnosis and treatment of malaria. In addition, consideration should be given to iron supplementation programs to adolescent girls in order to reduce anaemia, and health and nutrition education. Further study is required to understand the effect of iron supplementation and its cost-effectiveness, health and nutrition promotion among adolescents.