Dietary Intake, Prevalence, and the Effect of Anemia on Various Morphophysiological Variables of Postmenopausal Women of North India.

CONTEXT: Anemia has a high prevalence among postmenopausal Indian females. AIM AND
OBJECTIVE: The aim of this study was to evaluate dietary intake, prevalence, and the effect of anemia on various morphophysiological variables among postmenopausal women. SETTING AND
DESIGN: This was a community-based sample survey.
MATERIALS AND METHODS: A total of 250 postmenopausal women aged 45-80 years from various parts of North India participated in the study. Anthropometric measurements, hemoglobin concentration, and bone mineral density (BMD) (using dual-energy X-ray absorptiometry) of each participant were assessed. A 24-h dietary recall method for three consecutive days was employed. STATISTICAL ANALYSIS: The Statistical Package for the Social Sciences version 20 was used for statistical considerations.
RESULTS: An age-associated decline in the mean values of hemoglobin concentration and the prevalence of anemia was reported to be 85.2% among postmenopausal women. Anemic women were lighter and had lesser circumferential measurements as well as lower BMD than their nonanemic counterparts. The intake of nutrients such as protein, calcium, and iron and energy was lower among anemic women than nonanemic women. Binary logistic regression analysis identified age (odds ratio = 1.04, 95% confidence interval = 1.00-1.09)* as the possible predictor of anemia.
CONCLUSIONS: Anemia was not only the result of aging process but also inadequate and unbalanced dietary intake.

INTRODUCTION

Anemia is a growing public health burden associated with a range of detrimental effects across all age groups. The World Health Organization (WHO)[1] observed that anemia is one of the 10 most important global health concerns and is a major factor for enhancing morbidity and mortality particularly in preschool children and pregnant women. Findings of Chaves et al.[2] also reported poor mobility, increased frailty, and decreased executive functions among women having low levels of hemoglobin concentration. With the rising number of aged and elderly people at the global level, anemia is becoming focus of interest in gerontology, because it is associated with a number of clinical [34567] and socioeconomic burden. Nutrition has a strong influence in the maintenance or development of anemia. The WHO [8] recognized anemia as the most prevalent nutritional problem in the world today. In a developing country such as India, nutritional scenario is not very encouraging. The reports of National Family Health Survey-3[9] observed an increasing prevalence of anemia in women since the National Family Health Survey-2. There are ample data on nutritional status as well as the prevalence of anemia among adolescence,[1011] pregnant women,[1213] and on elderly people,[1415] but the studies on dietary intake and the effect of anemia on various morphophysiological variables among postmenopausal women of North India have been insufficiently recognized. Given the wide range of negative consequences of anemia across all age levels, this escalating problem needs a thorough investigation. Hence, the present study is an attempt to assess the dietary intake, prevalence, and effect of anemia on various morphophysiological variables among postmenopausal women of North India.

MATERIALS AND METHODS

The present cross-sectional study was based on a sample of 250 postmenopausal women ranging in age from 45 to 80 years. The data were collected by purposive sampling method from March 2009 to October 2010 from two neighboring states, that is, Punjab and Haryana of North India and the union territory of Chandigarh.

Inclusion criteria

Women having at least 1 year natural amenorrhea [16] were randomly selected in the present study.

Exclusion criteria

The women who had undergone hormone replacement therapy, hysterectomy, or having physical deformity were not included in the study.

The present study is a part of the research project and got ethical approval from by the Ethical Committee of Kurukshetra University, Kurukshetra (Haryana). A total of four anthropometric measurements height (mm), weight (kg), waist circumference (mm), and hip circumference (mm) were taken on each participant following the standard techniques recommended by Weiner and Lourie.[17] Height (mm) and weight (kg) were measured by anthropometer and weighing machine, respectively. Waist circumference (cm) and hip circumferences (cm) of each participant were measured with Freeman's steel tape. Waist circumference (mm) was taken midway between umbilicus and xiphoid. Hip circumference (mm) was measured at the maximum protuberance of the buttocks. Body mass index (BMI) was calculated as body weight divided by height squared (kg/m2). Handgrip strength (N) of all the postmenopausal women was gauged with dynamometer (Analog model, range 0–100 kg, made in Japan). The participants were encouraged to exert their maximal grip with both dominant and nondominant hand. All the participants performed three handgrip tests, out of which the best result was chosen for analysis. Bone mineral density (BMD) was assessed using dual-energy X-ray absorptiometry (GE Healthcare Lunar enCORE, Madison, USA). Cyanmethemoglobin method using a photoelectric colorimeter with green filter (500–570 nm wavelength) was employed to ascertain the hemoglobin concentration of the participants. According to the WHO,[18] criteria hemoglobin level <12 g/dl in women were designated as anemic. The various categories of anemia were mild (10–11.9 g/dl), moderate (8.0–9.9 g/dl), and severe (<8 g/dl) anemia.

To assess the approximate quantity of dietary intake of all the participants, a 24 h dietary recall method for 3 consecutive days was employed. The amounts of food consumed were measured using standardized spoons, glasses, and bowls for measurement of the foodstuffs and compared with the recommended dietary allowances (RDAs)[19] values for Indian women females. Nutritive value tables for Indian foods were employed to assess nutrient intake.[20] Nutritional status was evaluated on the basis of BMI guidelines [21] with following cutoff points: undernutrition: BMI <18.5 (kg/m2); normal: BMI 18.5–24.9 (kg/m2); and overweight: BMI ≥25.0 (kg/m2). Additional information on frequency (ate two times/day or three times/day) and type (vegetarian or nonvegetarian; intake of fruits) of food consumption as well as awareness about anemia (meaning, symptoms, and effects of anemia) was also recorded.

Statistical analysis

The Statistical Package for the Social Sciences version 20 (SPSS, Inc., Chicago, IL) was used for data analysis. Descriptive statistics including means, standard deviations (SDs) were determined for each variable. Comparisons between the anemic and nonanemic groups were made by Student's t-test. Chi-square test was employed to compare categorical variables. One-way analysis of variance (ANOVA) was obtained to gauge statistical significance of the differences for different variables on the basis of their hemoglobin concentration. Binary logistic regression analysis was performed to identify risk factors for anemia among the postmenopausal women.

RESULTS

General characteristics of the sample

In the present study, the prevalence of anemia was found to be 85.2% among postmenopausal women of North India. General information and dietary habits of the participants are presented in Table 1. Hemoglobin concentration of 37 nonanemic participants was 12.36 + 0.32 g/dl, whereas for 213 anemic participants it was 9.78 + 1.08 g/dl. Out of the total postmenopausal women, 44.4% and 55.6% females ate two times/day and three times/day, respectively. Among nonanemic participants, 64.86% women were vegetarian and 35.13% nonvegetarian, whereas 86.3% and 13.69% anemic females were vegetarian and nonvegetarian, respectively. Most of the anemic females (79.34%) demonstrated irregular intake of fruits. Only 37.6% females were aware of the causes, symptoms, and effects of anemia, while rest of the females (62.4%) were not aware of it. Chi-square test displayed significant differences for the intake of fruits (P < 0.00) and diet (P < 0.00) only.

Table 1

General information and dietary habits of the participants

Hemoglobin concentration as stratified by age

Means, SD values, and ANOVA of hemoglobin levels of the postmenopausal women on the basis of their age are documented in Table 2. The prevalence of anemia was lowest in the younger age groups 45–55 (78.8%) and highest in the oldest age groups 66–80 (89.7%). Maximum mean value for hemoglobin concentration (10.54 g/dl) was in the age group 45–55 followed by a decline in their mean values till 66–80 years. One-way ANOVA demonstrated highly significant age differences for hemoglobin concentration as reflected by their F-value (4.852***).

Table 2

Age wise means, standard deviation values, and analysis of variance of hemoglobin levels of the postmenopausal women

Morphophysiological variables in different categories of hemoglobin concentration

Table 3 demonstrated means, SD values, and ANOVA for various morphophysiological variables in different categories of hemoglobin concentration. Severely anemic females (<8 g/dl) were lighter and shorter than participants in all other categories of hemoglobin levels. Females having normal hemoglobin concentration were heavier than females from moderate (8.0–9.9 g/dl) and mild categories (10.0–11.9 g/dl). Women with normal hemoglobin concentration had highest circumference for waist (844.3 mm) than women in mild (827.9 mm), moderate (819.8 mm), and severe (816.8 mm) categories. Similar trend was witnessed for dominant, nondominant handgrip strength, and BMD, where maximum mean value was reported in normal women and minimum in severely anemic females. Results of one-way ANOVA performed on each variable showed no significant differences except for dominant (14.27***), nondominant handgrip strength (12.67***) as is evident from their F-ratio. Table 4 presented mean, SD, and odds ratio (OR) of various morphophysiological variables of anemic (mild, moderate, and severe categories combined) and nonanemic postmenopausal females. Anemic women were lighter (61.26 vs. 64.86 kg), and had lesser circumferential measurements (waist 823.9 vs. 844.3 mm; hip 910.8 vs. 936.7 mm) than their normal counterparts. Grip strength of both dominant (173.87 vs. 145.33 N, P < 0.01) and nondominant hand (150.23 vs. 125.13 N, P < 0.01) as well as BMD (0.87 vs. 0.83 g/cm2, P < 0.05) of anemic women was significantly lower than the participants having normal hemoglobin concentration. Binary logistic regression analysis revealed that odds of having anemia was 1.00 (95% confidence interval [CI]: 0.94–1.06) for weight, 1.03 (95% CI: 0.97–1.10) for height, and 0.18 (95% CI: 0.09–1.06) for BMD at total femur. Age (OR = 1.04, 95% CI = 1.00–1.09)* was recognized as the risk factor for anemia.

Table 3

Means, standard deviations, and analysis of variance of various morphophysiological variables on the basis of different categories of hemoglobin concentration

Table 4

Mean, standard deviation, and odds ratio of various morphophysiological variables of anemic and nonanemic postmenopausal females

Dietary intake of the postmenopausal women

Anemic and nonanemic females have been classified in their normal, underweight, and overweight categories depending on the WHO criteria of BMI [Table 1]. Among nonanemic participants, about 51.3% of the participants were in the normal range of BMI, 2.7% in underweight, and 45.9% in overweight category. The anemic females have 40.8% of the participants in normal range, 8.45% in underweight, and 50.7% as overweight. As is evident from Table 1 that the overall prevalence of underweight and overweight was higher among anemic participants. Nutrient (energy, protein, fat, calcium, and iron) intake of the anemic and nonanemic participants and their comparison with RDA for Indian women are portrayed in Figure 1. The intake of energy (nonanemic 1544.17 kcal; anemic 1416.1 kcal), protein (nonanemic 44.6 g/d; anemic 42.71 g/d), calcium (nonanemic 311.44 mg/d, anemic 275.28 mg/d), and iron (nonanemic 23.06 mg/d; anemic 22.04 mg/d) was lower among anemic participants as compared to nonanemic participants. Except for fat both the anemic and nonanemic groups exhibited inadequate nutrient intake when compared to the RDA.

Figure 1

Nutrient intake of anemic and nonanemic females with reference to recommended dietary allowances

DISCUSSION

In the present study, the prevalence of anemia was found to be 85.2% among postmenopausal women. The current cross-sectional study reported an age-associated increment in the prevalence of anemia. Binary logistic regression analysis also identified age (OR = 1.04, 95% CI = 1.00–1.09)* as the possible predictor of anemia. Guralnik et al.[22] also stated that the prevalence of anemia in women doubles from 10% to 20% from 75–84 years to 85 years and older age groups. Kim and Lee [23] also observed the lowest prevalence of anemia in age group 60–69 (10.0%) followed by age group 70–79 (15.5%) and the highest among age over 80 (20.7%). The prevalence of anemia was significantly higher in the older age groups as compared to their younger age groups have reported by a number of previous reports.[15242526] The age-related decline in the level of hemoglobin concentrations might be due to a lower erythropoietin secretion [3] or a reduced hematopoietic reserve.[27]

In the present study, severely anemic females were lighter, shorter and had lower circumferential measurements than the participants from all other categories of hemoglobin concentration. Kim and Lee [23] also observed that anemic participants showed lower anthropometric status as compared to their nonanemic counterparts. Considerable literature [282930313233] also documented that participants with anemia showed statistically lower values in weight, height, and BMI than those with normal hemoglobin levels. Manual strength (both dominant and nondominant handgrip strength) was highest in the females with normal hemoglobin concentration as compared to females with mild, moderate, and severe categories of anemia. Kaur and Kochar [31] also witnessed lower handgrip strength of both dominant and nondominant hand of anemic participants as compared to their nonanemic counterparts. Penninx et al.[34] displayed a decreased physical performance and strength among anemic residents of Chianti area of Italy. This is in accordance with the previous reports [3536] that participants with hemoglobin level less than normal had less grip strength than participants with normal hemoglobin concentration. This may be attributed to lower levels of hemoglobin were able to influence oxygen delivery to skeletal muscle and consequently negatively impact muscular strength.[3738] The present study emphasized that anemic females revealed significantly (P < 0.05) lower BMD than the females with normal hemoglobin concentration. Findings of Cesari et al.[29] were also compatible with the present study as they presented that anemic women were also more likely to have lower levels of total bone density than their nonanemic counterparts. A few other studies [3940] also suggested a direct relationship of hemoglobin concentration with BMD. Fujimoto et al.[4] studied the relationship of anemia and hemoglobin levels with bone density and observed that hypoxemia can affect mineral density and participants with low PaO2 demonstrated a decreased BMD.

Previous studies indicated nutrition is an important factor for controlling anemia.[32] In the present study, about 44.4% participants of the present study ate twice a day, and 73.6% had irregular intake of fruits. Out of the total 37 nonanemic postmenopausal women, 64.86% were vegetarian and 35.13% were nonvegetarian, whereas 86.3% and 13.69% anemic females were vegetarian and nonvegetarian, respectively. Intake of energy (nonanemic 1544.17 kcal and anemic 1416.1 kcal), protein (nonanemic 44.6 g/d and anemic 42.71 g/d), calcium (nonanemic 311.44 mg and anemic 275.28 mg), and iron (nonanemic 23.06 mg/d and anemic 22.04 mg/d) was higher in nonanemic participants than their anemic counterparts. Except for fat both the anemic and nonanemic groups of the present study showed inadequate dietary intake as compared to the RDA values.[19] Thomson et al.[32] also described that inadequate nutrient intakes were a significant risk factor for anemia in older women. They further elaborated that among anemic postmenopausal women enhanced access to nutrient-rich foods particularly iron, B-12, and/or folate intake may be required to correct nutritional anemia. As per the WHO [21] criteria of BMI for assessing nutritional status, 51.3% nonanemic and 40.8% anemic participants were in the normal range of BMI while rest were in underweight and overweight categories. In the present study, less women fall in the undernutrition category than women were in overweight category. Similar trend was observed by Kaur [41] among elderly females and reported among rural and urban Brahmin females 11.76% and 1.65% fall in the underweight category, respectively, whereas 39.32% rural and 45.58% urban women were in the overweight category. National Family Health Survey-3[9] also reported a very high burden of nutritional deficiency among Indian women, but the prevalence of overweight and obesity is also on the rise. A study carried out in Chicago by Yan et al.[42] discussed lower quality of life, worse physical performance, and less physical well-being among participants with both overweight and low-weight values as compared to participants within normal range. The postmenopausal women of the present study predominantly had cereal-pulse-based diet with low animal protein as well as fruit intake and this monotonous diet may be attributed to lower nutrient intake.

CONCLUSIONS

The postmenopausal women of the present study demonstrated age-associated decline in hemoglobin levels accounting for lighter individuals with reduced grip strength as well as BMD among anemic participants. The magnitude of anemia has been further compounded by insufficient nutrient intakes among postmenopausal women. Hence, the present study highlighted that anemia among postmenopausal women was not only associated with aging process but also further enhanced by inadequate dietary intake.

Financial support and sponsorship

This study was financially supported by the Department of Science and Technology, New Delhi, India.

Conflicts of interest

There are no conflicts of interest.