Main content
Makunda Christian Leprosy & General Hospital (MCL&GH) is situated in the picturesque landscape of Assam in the Northeast of India. The region’s stunning tea plantations host some of the poorest and most marginalised patients: the tea garden workers. Their poor living and working conditions are the cause of several poverty-related conditions, such as anaemia. [1-4] Research shows that poor nutritional status, resulting in iron, folate and vitamin B12 deficiencies, contribute to the prevalence of anaemia in poorer populations. [3,5] To tackle this problem, the Indian government started implementing a programmeme in 2013 to supplement iron and folate in vulnerable populations, such as children and women in the reproductive age. [6] Vitamin B12 is not included, despite shortages of this nutrient being similarly infamous for causing anaemia in India. [5,7] MCL&GH is therefore investigating the prevalence of anaemia caused by vitamin B12 deficiency among tea garden workers and their family members, to inform possible changes in the government’s food supplementation policy. This article reports on a pilot study.
Methods
The prevalence of vitamin B12 deficiency among tea garden patients was investigated by means of a retrospective study done in the fall of 2019, based on hospital data collected over a two-year period in 2017-2018. This was compared with the prevalence in the non-tea garden patients. Since vitamin B12 levels are not tested in MCL&GH (due to expenses), the cases were defined as hospitalised patients with macrocytic anaemia (Hb <7g/dL, MCV >110FL), a typical feature of vitamin B12 deficiency. [8-10] To make the diagnosis more likely, all charts of patients with macrocytic anaemia were screened for possible other causes, such as parasitic infections and postpartum haemorrhage. [10] If another diagnosis was more plausible, these patients were excluded from analysis.
To gain insight in the possible causes of vitamin B12 deficiency in tea garden patients, a qualitative study was undertaken. Previous research had shown that vitamin B12 deficiency in low- and middle-income countries is most often caused by an inadequate intake of products that contain vitamin B12, in particular animal products. [7,11,12] The aim of the current study was therefore to investigate the dietary habits and socioeconomic status of these patients. A small sample of ten tea garden patients with macrocytic anaemia was interviewed on their dietary habits and socioeconomic status. The results were compared with an equal number of non-macrocytic anaemic tea garden patients.
Table 1: Baseline characteristics.
| GENDER | AGE | MEAN (STANDARD DEVIATION) | RANGE | |
|---|---|---|---|---|
| Male | 11 | 33.8 (±16.9) | 13-78 | |
| Female | 25 | AGE YEARS | NUMBER OF PATIENTS | PERCENTAGE |
| Pregnant | 8 | 12-20 | 9 | 25.0% |
| Not pregnant | 17 | 21-30 | 12 | 33.3% |
| 31-40 | 5 | 13.9% | ||
| 41-50 | 3 | 8.3% | ||
| 51-60 | 4 | 11.1% | ||
| >60 | 3 | 8.3% | ||
| TOTAL | 36 | 100% |
Table 2: Laboratory results.
| VARIABLES (*) | MEAN (STAND. DEV.) | RANGE |
|---|---|---|
| Hb (>10 g/dL) | 4.2 (±1.90) | 1.2-6.9 |
| MCV (80-96 fL) | 113.4 (±13.04) | 100-151.7 |
| RDW-SD** (40.0-55.0 fL) | 79.3 (±20.35) | 52.7-130.7 |
| RDW-CV (11.5-14.5%) | 22.5 (±6.81) | 13.9-37.5 |
| Platelets (150-450) | 132 (±120.03) | 0-481 |
| WBC (4.5-11.0 x 109) | 8.5 (±6.32) | 0.93-29 |
* Normal values
** Increased RDW-values, as well as bi- and pancytopenia, in combination with increased MCV is typical for vitamin B12 deficiency [13]
Table 3: Socioeconomic status and dietary habits of tea garden patients.
| SUBGROUP MACROCYTIC ANAEMIA | SUBGROUP NON-MACROCYTIC ANAΕΜΙΑ | ||
|---|---|---|---|
| DEMOGRAPHICS | Male | 5/10 | 3/10 |
| Female | 5/10 | 7/10 | |
| Age | 39 (6-75) | 27 (13-57) | |
| Mean Hb + range (mg/dL) | 5.3 (1.8-7.8) | 6.2 (3.2-8.9) | |
| Mean MCV + range (fL) | 109 (100-124) | 77.9 (61-91) | |
| SOCIOECONOMIC STATUS OF THE FAMILY | Monthly income p.p. (in Indian rupees, INR) | 635 (208-1240) | 1467 (375-3571) |
| Monthly expenditure p.p. (INR) | 900 (187-2476) | 1010 (229-1839) | |
| Insurance | 8/10 | 7/10 | |
| Above poverty line | 0/10 | 2/10 | |
| Below poverty line | 8/10 | 5/10 | |
| Food subsidies | 8/10 | 8/10 | |
| 24-HOUR RECALL OF INTAKE | Kilocalories | 890 (270-1545) | 1496 (1068-1892) |
| Carbohydrates | 152.9 (51.2-255) | 241.9 (195.5-320) | |
| Proteins | 27.9 (13.4-40.9) | 42.9 (26.3-61.3) | |
| Fats | 22.97 (1.15-44.9) | 34.9 (11.02-40.18) | |
| Any source of vitamin B12 | 1/10 | 3/10 | |
| WEEKLY AND MONTHLY INTAKE OF ANIMAL PRODUCTS | WEEKLY | MONTHLY | |
| Beef | 0/10 | 0/10 | |
| Chicken | 5/10 | 8/10 | |
| Fish | 4/10 | 8/10 | |
| Egg | 2/10 | 4/10 | |
| Cheese | 0/10 | 0/10 | |
| Milk | 2/10 | 3/10 | |
| INTAKE OF SUPPLEMENTS | Iron | 0/10 | |
| Folate | 0/10 | ||
| Vitamin B12 | 0/10 | ||
| Other | 0/10 |
Results
In the period 2017-2018, 54 patients with macrocytic anaemia were admitted to MCL&GH, of which forty (74.1%) were from tea gardens. In comparison, tea garden workers represent only 35% of the total hospital population. In four of the forty included patients no paper charts were available, so these patients were excluded for further analysis. Baseline characteristics and laboratory results are summarised in Table 1 and Table 2. All patient charts were analysed thoroughly to check for possible causes of the anaemia; in all cases vitamin B12 deficiency seemed the most plausible diagnosis.
The results of the dietary and socioeconomic interviews investigating the causes of vitamin B12 deficiency are presented in Table 3. Although the sample was too small to produce statistically significant differences, a few interesting results were seen. First, patients with macrocytic anaemia seemed generally poorer than their non-macrocytic counterparts. This was the case in terms of actual income, but also as number of persons below the poverty line. Furthermore, the macrocytic anaemia patients tended to have a lower overall food intake, as well as a lower weekly intake of products that contained vitamin B12.
Discussion and plans for future research
This pilot study showed that, compared to the non-tea garden population in MCL&GH, both severe macrocytic anaemia and vitamin B12 deficiency seem to be more prevalent among tea garden patients. Moreover, compared to non-tea garden patients, tea garden patients with macrocytic anaemia are generally poorer and report lower intake of products that contain vitamin B12, suggesting that 1) vitamin B12 deficiency might be causing the anaemia, and 2) these patients are less able to afford these expensive animal products, which is in line with previous research. [3,5,7,11]
Although these findings could have serious implications for governmental food supplementation policies, some limitations should be considered when interpreting the results and designing future studies. One limitation is the weak case definition, which could give both an overestimation (by including patients with folate deficiency that also present with macrocytic anaemia) and underestimation (by excluding the patients with a combined nutritional deficiency that present with normocytic anaemia) of the actual prevalence. Additionally, the weak case definition could cause a distorted picture of the causes of vitamin B12 deficiency. Concerning the investigation of possible causes, although previous research has shown that a lack of intake is the most common cause of vitamin B12 deficiency in LMICs, one could argue that other causes should be studied so as to reduce confounding. Lastly, although the present study provides implications for future research, the sample size was too small to draw firm conclusions.
Based on this pilot, plans have been made to conduct a comprehensive study that doesn’t have the above limitations and thus could confirm the preliminary results. A larger sample size of tea garden patients with macrocytic and normocytic anaemia (to catch solitary vitamin B12 deficiencies, as well as combined deficiencies) will be prospectively studied, with determination of vitamin B12 levels being an essential part. To effectively rule out other causes of vitamin B12 deficiency (e.g. alcohol abuse, parasitic infection), the interviews will be expanded with questions on alcohol use and hygiene, among others, and stool tests will be added to the analysis. In addition, patients will be treated with vitamin B12 supplements and followed up, to assess the effect of vitamin B12 on their Hb-levels and consequent general health.
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