Exactly How Anaemic Are Teenage Girls In India?

Recently, a report by Naandi Foundation – `What it means to be a teenage girl in India’ – came up with figures that conveyed both good news and bad.

The good news was to do with education: The survey found that 81 per cent of teenage girls were currently studying; 70 per cent wanted to pursue higher studies, 74 per cent had specific careers in mind, and 73 per cent wanted to marry only after age 21. Encouragingly, rural girls’ figures came close to those of their urban counterparts.

The bad news, as chairman of the foundation, Anand Mahindra tweeted, “is largely related to health matters. One in two girls has anemia and low BMI. Menstrual hygiene is still abysmal and half still defecate in the open…”

The ‘bad news’, all over again, led to everyone worrying about the “abysmal state of female health in India”, with teenage issues as the peg. Anaemia and malnutrition in India are usually attributed to “gender-based nutritional discrimination”, “poverty” and “poor education levels”. “Vegetarianism” is also a favourite whipping boy.

The survey covered over 74,000 girls in 30 states and six cities (Mumbai, Kolkata, Bengaluru, Ahmedabad, Chennai and Hyderabad). Because the findings of this report have provided a database that can provide vital inputs for advocacy, interventions and policies specifically targeted at teenage girls, it is important that well-founded conclusions be drawn.

We examined some figures from the TAG report: The report found that 48.2 per cent girls have no anaemia; 41.2 per cent have mild anaemia; 9.7 cent have moderate anaemia, and 0.9 per cent have severe anaemia. Overall, more than half (51.8 per cent) of teenage Indian girls are anaemic - alarming figures for any nation.

But let us see what constitutes ‘mild’, `moderate’ and `severe’ categories. India follows the WHO-defined parameters for the diagnosis of anaemia and assessment of its severity. Accordingly, the determining haemoglobin (Hb) levels, for age groups 12-14 and 15-and-above, are:

No Anemia – Hb > 12
Mild Anemia – Hb 11-11.9
Moderate Anemia – Hb 8-10.9
Severe Anemia – Hb < 8

So, putting these values against the TAG findings, we find that a picture that is not so dismal. With 48.2 per cent teenage girls at Hb above 12, and 41.2 per cent with Hb between 11 and 11.9, this actually means that 89.4 per cent girls have Hb above 11! This is actually good news.

Why then has India historically been at the bottom of the anaemia international-comparisons table?

The answer to this may lie in the fact that India uses the WHO cut‐off points for reporting anaemia (for surveys, for the sake of global comparisons), as given above. However, not all countries follow the WHO norms. For instance, this report ‘Anemia Testing in Population-Based Surveys’ of the USAID-funded DHS Program (Demographic and Health Surveys) - after long-drawn reasoning about what constitutes normal reference range - says: “Severe anemia is diagnosed when hemoglobin concentration is less than 7.0 g/dl; moderate anemia when the hemoglobin concentration is 7.0 to 9.9 g/dl, and mild anemia when hemoglobin concentration is between 10.0 g/dl and cutoff points.

That `normal’ haemoglobin levels vary across age-groups, gender, smoking patterns and altitude, is well known. But they also depend on races and ethnic backgrounds, as this paper in The Journal of Nutrition demonstrates; it argues that “the general world-wide application of the common cut-off for anemia may be questioned.” For illustration, “individuals of African extraction in the US have hemoglobin concentrations that are on average 8 g/L lower than those of European extraction”; similarly, for healthy Vietnamese in Vietnam, who have Hb lower than Caucasian population. “More information is therefore required on the validity of the use of hemoglobin cut-off values as a screening for iron deficiency because the frequently-used WHO cut-off may not be universal.” Could it be that India is being too harsh on itself by adhering to WHO norms? Perhaps, we need to re-establish anaemia norms, based on renewed understanding of our own local conditions, changed environmental factors and functioning.

What’s more, estimation of Hb is not sacrosanct and discrepancies may result from using different methods of estimation. Apparently, there are two methods - Hemocue versus Cyanmethaemoglobin; and going deeper we found that there were actually studies in the US that found within the Hemocue method, one more accurate Hemocue method and one less-accurate Hemocue method. In a paper on `Standards for Diagnosis of Anemia’, Dr Prema R, then director, Nutrition Foundation of India in 2011, had listed out a plethora of problems related to accurate estimation of anaemia in India. She argued that often the methods used to measure Hb and other factors are “variable and of poor quality. Furthermore, results have not always been comparable, since they have been expressed in different ways”.

All in all, could India’s “unrelenting problem of Anemia” may, in fact, just be an exaggeration?

After this broad question, we look at the usual conclusions drawn.

The first is about gender norms – “girls are discriminated against, and hence have greater anemia incidence”. While it is true that in the Indian tradition, the woman “eats last”, fact is, this may apply less to young girls, and more to women of the households. The figures also show that before puberty sets in, anaemia figures for girls and boys are comparable in India; if at all, it is the boys in the age nine-11 category who have higher anaemia!

The following figure taken from a 2014-paper in Hindawi journal, titled, ‘Prevalence and Severity of Anaemia Stratified by Age and Gender in Rural India’ (by Gerardo Alvarez-Uria et al), illustrates this fact.

It is clear that till around age 10, incidence of anemia in males and females is comparable, with males often showing higher incidence in all three categories viz. mild, moderate and severe.

It is only around age 11, that girls’ anaemia overtakes that in boys.

Doctors tell us that the higher incidence of anaemia after age 11 is accounted for by menstruation and hormonal changes. Which incidentally, is a world-wide phenomenon, and a cause of worry even in the developed world. The incidence in those countries is lower, but again, as we have argued above, the lower cut-offs and ethnicity probably account for the huge difference.

Usual quick-conclusion #2 is that anaemia in Indian females is attributable to poverty.

So yes, the TAG report figures tell us that 53.2 per cent girls from low-wealth quintile are anaemic. But then so are 48.8 per cent from the high-wealth quintile! The chart below from the TAG report demonstrates this:

Then, poverty is not the causal factor for anaemia, it seems, given the low difference of only 5 per cent, by wealth quintile. The survey had taken the top 40 per cent households as the “high wealth” category and the bottom 60 per cent clubbed into the “low wealth” quintile.

Again, there was not much difference between urban and rural girls: 48.5 per cent urban girls also had anaemia, if 53.2 per cent rural girls did.

We found similar trends in malnutrition, as determined by BMI (body mass index or weight-for-height). Normal BMI was found in the case of 43.9 per cent girls in low-wealth quintile, but also only 49.9 per cent girls in the high-wealth quintile! Also, low BMI in rural areas, at 55.4 per cent, but also low BMI in urban areas at 49.5 per cent. Thus, there is not much difference by wealth or place of residence.

Could we again conclude, for BMI, that a different set of standards are applicable in India, to judge the `underweight/malnourished phenomenon’? The TAG report has used the normal as “Normal BMI is between 18.5 and 24.9” as defined by IIPS in its NHFS-4.

The latter seems to have blindly applied the WHO standard, ignoring the evidence - and consequent lowering of cut-off points - for BMI based on ethnicity in Asian countries, as this article informs us. Along with China and Japan, India had also changed its definition of `overweight’ to >23 BMI. It is unclear why a similar logic was not applied to the lower cut off of 18.5, below which constitutes ‘underweight’. How many of us have known grandmothers who would technically fall in the “stunted” or “underweight” category by WHO standards, and yet gave life to perfectly healthy progeny, and lived to age 95, with all systems functioning perfectly?

These are some points worth pondering, which may actually change the picture - and with it, the narrative.

Instead of dissipating our energies worrying about “patriarchy” and “gender and social norms” being the causal factors of poor health outcomes in the country, what if we collectively applied ourselves to finding exemplary, actionable and scalable health solutions?

The TAG report also acknowledges that difference in anaemia and normal BMI is not large between rural-urban areas and different wealth quintiles. We found above, from our quick analysis, that boys are equally anaemic in the years preceding girls’ menarche. The results would likely be the same were we to carry out studies regarding number of BMI-determined, underweight teenage boys.

And Yet…

All of the above said, exemplary and scalable health solutions are needed, in order that even the last-mile teenager in India has health parameters that fall in the “normal” category.

Having 10-per cent teenage girls in the moderate to severe anaemia categories is worrisome in itself. To that end, girls’ health and nutrition throughout the lifecycle need to be given more importance than boys – for the sole reason that severe deficiencies lead to inter-generational cycles of illness. We must leave behind the high rates of maternal and infant mortality that India has the ‘distinction’ of having.

For teenage girls, the broad progress-snapshot is:
- Education outcomes have improved, as the TAG report found.
- Open defecation - acknowledgedly avoidable, irrespective of whether it is practised by girls or boys - is being worked on: as of 15 November, the swachhbharatmission.gov.in website showed 8,85,13,795 toilets built since Oct 2014; 5,23,560 ODF-free villages and 25 ODF-free states. Of course, more needs to be done in terms of improving water access and changing social norms, mostly gender-neutral.
- Menstrual hygiene needs improvement; but again, we may choose to reconsider the TAG definition, where cloth and cloth pads are unqualifiedly dismissed as “unhygienic” methods. After all, there has been discussion internationally, about the safety of chemicals used in the manufacture of sanitary napkins also, and about environmental hazards of their disposal.

Nutrition is the one area that undisputedly needs careful planning at the policy level. Malnutrition owing to imbalanced diet, wrong food choices, ready-to-eat food and “zero-waist” and “six-pack-abs” aspirations has assumed menacing proportions more in the urban, high-wealth categories – and which is now beginning to spread to rural areas, as nutritionists inform us. This is the bigger threat. Perhaps, India now needs a new, comprehensive food policy that addresses these issues. The goal should be – strong and well-nourished workforce, and strong and healthy mothers.

In the next article, we will discuss some innovative methods for improving nutrition and addressing issues like anaemia.