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Beneficial Effects of ragi (Finger Millet) on Hematological Parameters, Body

Mass Index, and Scholastic Performance among Anemic Adolescent High-
School Girls (AHSG)

Article in Comprehensive Child and Adolescent Nursing · March 2018

DOI: 10.1080/24694193.2018.1440031

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Beneficial Effects of ragi (Finger Millet) on

Hematological Parameters, Body Mass Index, and
Scholastic Performance among Anemic Adolescent
High-School Girls (AHSG)

Suja Karkada, Sharmila Upadhya, Subramanya Upadhya & Gopalakrishna

Bhat

To cite this article: Suja Karkada, Sharmila Upadhya, Subramanya Upadhya & Gopalakrishna
Bhat (2018): Beneficial Effects of ragi (Finger Millet) on Hematological Parameters, Body Mass
Index, and Scholastic Performance among Anemic Adolescent High-School Girls (AHSG),
Comprehensive Child and Adolescent Nursing, DOI: 10.1080/24694193.2018.1440031

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COMPREHENSIVE CHILD AND ADOLESCENT NURSING
https://doi.org/10.1080/24694193.2018.1440031

Beneficial Effects of ragi (Finger Millet) on Hematological

Parameters, Body Mass Index, and Scholastic Performance
among Anemic Adolescent High-School Girls (AHSG)
Suja Karkada, PhDa, Sharmila Upadhya, MBBS, MD, DNBb, Subramanya Upadhya,
MMBS, MD, DNBb, and Gopalakrishna Bhat, PhDc
a
College of Nursing, Sultan Qaboos University, Muscat, Oman; bSchool of Medicine, St. George’s
University, Grenada, Grenada; cSchool of Life Sciences, Manipal University, Manipal, India

ABSTRACT KEYWORDS
Adolescence is a period characterized by rapid physical, emo- Adolescence; anemia; body
tional, and mental growth and changes potentially resulting in mass index; finger millet
health challenges. Anemia, which is a fairly common complica- (ragi); girls; hematological
tion in this age group, is reported to negatively affect the parameters; scholastic
performance
cognitive ability of adolescents. Traditionally, ragi (Finger
millet: Eleusine coracana), a cereal available in India, has been
recommended as nutritional supplement to combat anemia
because of its high protein and mineral content as well as
anti-microbial property. This study sought to establish the
effect of ragi in improving hematological parameters, body
mass index, and scholastic performance among adolescent
school girls. Sixty adolescent girls were randomly selected
and divided into intervention (n = 30) and control groups
(n = 30). The effect of dietary supplementation of ragi porridge
on hematological parameters was evaluated on the interven-
tion group at 45 and 90 days. Both groups were monitored for
changes in body mass index and scholastic performance. A
statistically significant increase in hemoglobin levels was
observed in the intervention group after 90 days (from a
mean of 11.3 g% to 12.54 g%; t (29) = 7.514, p < .0001), with
no significant changes in the control group. No statistically
significant differences between the two groups were observed
for mean corpuscular hemoglobin, mean corpuscular hemoglo-
bin concentration, mean corpuscular volume, red cell distribu-
tion width, body mass index, and scholastic performance. The
data show that daily dietary supplementation with ragi por-
ridge has a positive effect on hemoglobin levels in adolescent
high schools girls. A well planned nutrition education with
dietary supplementation is thus recommended for better
outcomes.

Introduction
Adolescence, the period of transition from childhood to adulthood is char-
acterized by a spurt in physical, emotional, and mental growth. These

CONTACT Suja Karkada, PhD [email protected] College of Nursing, Sultan Qaboos University,
PO Box 66, Al Khoud, Muscat 123, Oman.
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/icpn.
© 2018 Taylor & Francis
2 S. KARKADA ET AL.

complex changes during puberty often pose challenges including iron defi-
ciency becomes more prevalent due to the onset of menstruation. Yet iron
deficiency has been shown to affect cognitive achievement of adolescents and
young children in mathematics (Dallman, Siimes, & Stekel, 1980; Halterman,
Kaczorowski, Aligne, Auinger, & Szilagyi, 2001), thus necessitating nutri-
tional intervention to address this health challenge.
Globally, the prevalence of anemia among adolescent girls varies widely. For
instance, in Iran, 85.7% of adolescent girls were found to have mild anemia
(Ramzi et al., 2011) and 51.3% in Nepal (Kanodia, Bhatta, Singh, Bhatta, &
Shah, 2016). In India, the prevalence of iron deficiency anemia was 23.9%
among adolescent girls in Chandigarh (Basu, Basu, Hazarika, & Parmar, 2005),
89.4% in Northern India, 91.4% in Eastern India, 91.8% in Southern India and
87% in Western India (Toteja et al., 2006). The prevalence of anemia was
76.29% in Chhattisgarh (Gupta, Chavhan, Singh, & Umate, 2017) and 90% in
Maharastra (Upadhye & Upadhye, 2017). Similarly, Moretti et al. (2006)
reported the prevalence of iron deficiency and iron deficiency anemia in
Bangalore, India was 78% and 29%, respectively. Other studies show that the
prevalence of anemia among adolescent girls was 41.1% in Belgaum (Biradar,
Biradar, Alatagi, Wantamutte, & Malur, 2012) and 57.1% in Udupi (Karkada,
Upadhya, Upadhya, & Bhat, 2011) district in Karnataka, India.
These reports from various parts of India which indicate iron deficiency as
being widespread motivated the investigator to test a nutritional intervention
strategy to combat anemia in this high-risk group using finger millet (ragi), a
cereal indigenous to India and Africa that is rich in calcium, iron,and other
minerals. Ragi was chosen because it is widely available and is nutritionally
dense because every 100 g of ragi contains 375–500 mg of calcium and 3.7–
6.8 mg of iron in addition to other health benefits (Barbeau & Hilu, 1993).
The objectives of the study were to test the effectiveness of ragi supple-
mentation in terms relation to hematological parameters, body mass index
(BMI),and scholastic performance, among anemic adolescent high school
girls. We tested the hypothesis: Regular use of ragi as a nutritional supple-
ment increases the hematological parameters, BMI, and scholastic perfor-
mance among anemic adolescent high school girls.

Materials and methods

Design
This quasi-experimental study was conducted in selected high schools in
Udupi district in India located in semi-rural settings. The schools were
selected using a two-stage cluster sampling method. Ethical clearance was
obtained from the ethical committee of the hospital and university. The
researchers obtained informed consent from parents and assent from
 COMPREHENSIVE CHILD AND ADOLESCENT NURSING 3

adolescent girls prior to the study. Furthermore, permission to conduct the

study was obtained from Deputy Director of Public Instructions (DDPI) and
the Headmasters of the selected schools. After preliminary survey to measure
hemoglobin (Hb) levels at the selected schools using cyanmethemoglobin
method, the experimental group consisted of anemic adolescent girls with Hb
levels ranging between 10 and 11.9 g%. As recommended by ethics commit-
tee, the control group had normal Hb levels ranging from 12 to 12.5 g%.

Inclusion criteria
Participation in the study was voluntary. Participants had to consent to main-
tain a diary for monitoring intake of ragi supplement, and the mothers of these
adolescent girls had to be willing to prepare the ragi porridge as a supplement.

Sample
The study sample size (n) was calculated using the following formula for
which the standard values were calculated from the preliminary survey:
 
Zα þZβ 2
n¼2
d=s
s is the standard deviation of the study = 0.58 rounded to 0.6; Zα is the con-
fidence interval = 1.96; Zβ is the power of the study = 0.84 and d is the 1
(expected increase in Hb after intervention)
 
1:96 þ 0:84 2
n¼2 ¼6
1=0:6
As the calculated sample size was small, 30 participants were considered in
each group.

Intervention
Mothers and their adolescent girls in the intervention group were trained to
prepare ragi porridge to be included in their everyday diet. A demonstration
was performed on the day of the parent-teacher meeting at the selected
schools by the investigator. The mothers were instructed to provide the
girls with the porridge prepared from 1 to 2 tablespoons of ragi powder
twice a day. Each adolescent in the intervention group was provided with a
total of 5 kg (2.5 kg on Day 1 and 2.5 kg on Day 45) ragi powder during the
study. The girls were taught to maintain a diary regarding consumption of
the porridge. The compliance to regimen of the supplements was ensured
with the help of the diary kept by the girls. Adolescent girls in the control
4 S. KARKADA ET AL.

group were not given any nutritional supplements, rather their diet consisted
of usual foods with no other supplements through any other programs.
On Day 1 the BMI and scholastic performance were assessed. The scho-
lastic performance was the percentage of the scores obtained by the adoles-
cent girls in the examination prior to data collection. A blood sample was
collected for analysis of hematological parameters. The researchers followed
both groups up to their homes on Day 45 and 90 for data collection. Data
was analyzed using SPSS software (Version 21.0) for both descriptive and
inferential statistical analysis. Participant flow is presented in Figure 1.

Results
The demographic characteristics of the two groups show that most of the
adolescent girls belonged to the age group of 13–14 years (76.7%, 63.3%) with
normal BMI (60%, 56.7%) in the intervention group and control groups
respectively (Table 1).
As presented in Table 2, the data show improvement in hemoglobin levels
from Days 1 to 90. In the intervention group, there was an improvement of
Hb to normal levels among 80% of the mild anemic adolescent girls.

Preliminary survey (n= 410)

Eligible for study Excluded from study

Intervention
1. group (Mild anemia): (n=177) Normal (n=96)
Control group (normal Hemoglobin): (n=80) Moderate and severe anemia; (n=57)
2.

Intervention group Consented (n=104) Control group Consented

Randomly selected 30 samples Randomly selected 30 samples

Follow up for 3 months

Completed the trial (n=30) Completed the trial (n=30)

Figure 1. Schematic representation of the selection of participants.

 COMPREHENSIVE CHILD AND ADOLESCENT NURSING 5

Table 1. Frequency and percentage distribution of AHSG according to sample characteristics.

Day 1 Day 90
f (%) f (%) f (%) f (%)
No Sample characteristics I (n = 30) C(n = 30) I(n = 30) C(n = 30)
1. Age in years
11 to 12 8 (26.7) 18 (60) 5 (16.7) 11 (36.7)
13 to 14 21 (70.0) 12 (40) 23 (76.7) 19 (63.3)
15 to 17 1 (3.3) 0 2 (6.7) 0
2. BMI
≤ 5th percentile (malnourished) 12 (40.0) 13 (4443.3) 13 (43.3) 14 (46.7)
5th to 85th percentile (normal) 18 (60.0) 17 (56.7) 16 (53.3) 16 (53.3)
85th to 95th percentile (overweight) 0 0 1 (3.3) 0
I = Intervention group; C = Control group

Table 2. Frequency and percentage distribution of AHSG according to haemoglobin category.

Intervention group Control group
Hb1 Hb2 Hb3 Hb1 Hb2 Hb3
(n = 30) (n = 30) (n = 30) (n = 30) (n = 30) (n = 30)
Hb category f % f % f % f % f % f %
Moderate anaemia — — — — 1 3.3 — — — — — —
Mild anemia 30 100 22 73.3 5 16.7 — — 3 10.0 6 20.0
Normal — — 8 26.7 24 80.0 30 100 27 90.0 24 80.0

Incidentally, about 20% of the adolescent girls with normal Hb in the control
group regressed to mild anemia by the end of the study.
As shown in Figure 2, the results shows improvement in the Hb levels in
the intervention group, from a mean of 11.3 g% on Day 1 to 12.54 g% on
completion of 90 days of intervention. In comparison, the slight change in

15

14.5

14
Haemoglobin levels (g%)

13.5

13 ns 12.71
12.5 12.21 12.24
12
** 12.54

11.5
11.52
11
11.03
10.5

10
Day 1 Day 45 Day 90

Interventional group Control group

Figure 2. Graph of the distribution of hemoglobin during the study period in the ragi supple-
mentation group. **p < .0001, significant in the interventional group, between Day 1 and Day
90; ns = nonsignificant in the control group, between Day 1 and Day 90.
6 S. KARKADA ET AL.

Table 3. Comparison of the mean scores & standard deviation and t-test for haemoglobin.
Group Mean Mean deviation SD t-test df p value
Intervention group (n = 30)
Hb 1 11.03 −1.51 0.57 −7.514 29 .0001*
Hb 3 12.54 0.98
Control group (n = 30)
Hb 1 12.21 −.50 0.15 −1.533 29 .136
Hb 3 12.71 1.73
Total (n = 30 + 30)
Intervention group 12.54 −.17 0.98 −0.469 58 .641
Control group 12.71 1.73
df = degree of freedom; Hb1 = haemoglobin levels on day1; Hb3 = haemoglobin levels on day 90;
SD = standard deviation.
*Statistically significant

the values of hemoglobin levels from 12.21 g% to 12.71 g % observed in the

control group was not statistically significant.
As shown in Table 3, there is statistically significant increase in mean
hemoglobin levels on Day 90 compared to Day 1 in the intervention group
(t (29) = 7.514, p < .0001) who consumed ragi porridge every day for 90 days.
Table 4 represents the frequency distribution of various hematological
parameters in both groups on Day 1 and Day 90. Statistical tests were

Table 4. Frequency and percentage distribution of AHSG according to all haematological

parameters.
Categories of haematological parameters
Groups and Measures Below normal f (%) Normal f (%) Above normal f (%)
Intervention group (n = 30)
MCV 1* 1 (3.3) 28 (93.3) 1 (3.3)
MCV 2** 1 (3.3) 28 (93.3) 1 (3.3)
Control group (n = 30)
MCV 1* 3 (10.0) 26 (86.7) 1 (3.3)
MCV 2** 3 (10.0) 25 (83.3) 2 (6.7)
Intervention group (n = 30)
MCH 1* 1 (3.3) 29 (96.7) 0 (0)
MCH 2** 0 (0) 30 (100.0) 0 (0)
Control group (n = 30)
MCH 1* 3 (10.0) 26 (86.7) 1 (3.3)
MCH 2** 3 (10.0) 26 (86.7) 1 (3.3)
Intervention group (n = 30)
MCHC 1* 1 (3.3) 29 (96.7) 0 (0)
MCHC2** 1 (3.3) 23 (76.7) 6 (20.0)
Control group (n = 30)
MCHC 1* 0 (0) 30 (100.0) 0 (0)
MCHC2** 1 (3.3) 26 (86.7) 3 (10.0)
Intervention group (n = 30)
RDW 1* 5 (16.7) 25 (83.3) 0 (0)
RDW 2 5 (16.7) 24 (80.0) 1 (3.3)
Control group (n = 30)
RDW 1* 9 (30) 20 (66.7) 1 (3.3)
RDW 2** 3 (10.0) 24 (80.0) 3 (10.0)
1* = Levels on day 1; 2** = Levels on day 90; AHSG = anaemic high school girls; f: frequency; MCH = Mean
Corpuscular Haemoglobin; MCHC = Mean Corpuscular Haemoglobin Concentration; MCV = Mean
Corpuscular Volume; RDW = Red Cell Distribution Width.
 COMPREHENSIVE CHILD AND ADOLESCENT NURSING 7

Table 5. Mean and standard deviation of scholastic performance of intervention and control
group.
Performance Level by Group Mean SD
Scholastic Performance 1 (n = 30 + 30) Day 1
Intervention 51.23 16.14
Control group 58.01 17.75
Scholastic Performance 2 (n = 30 + 30) Day 90
Intervention 54.80 15.61
Control group 59.14 15.64

performed to find the effectiveness of ragi supplement on MCV, RDW,

MCHC and MCH and BMI. There was no statistically significant difference
between Day 1 and Day 90 when these parameters were analyzed. Hence, the
effect of ragi supplement on BMI and scholastic performance was also not
statistically significant. Table 5 shows a marginal increase in scholastic
performance in intervention group that was 3.57% above Day 1 scores. In
the control group, there was a marginal increase of 1.14% in the scores.

Discussion
In the present study, the majority of adolescent girls (76.7% in the interven-
tion and 63.3% in control group) were between the age group of 13–14 years
as this group is at a high risk for anemia. High prevalence of anemia in this
age group has been reported in various states of India (Jolly, Rajaratnam,
Asokan, & Jonathan, 2000; Kaur, Deshmukh, & Garg, 2006; Sen & Kanani,
2006), as well as in different geographical locations across south Asia and
globally (Bondevik, Ulstein, Lie, Rana, & Kvåle, 2000).
The mean hemoglobin levels in the intervention group were 11.03 g% ±
0.57 at the start of the study and the selected girls had mild anemia. Similar
Hb levels were reported by Kaur et al. (2006), 11.35 ± 1.67 g%; Jolly et al.
(2000), 11.63 ± 1.5 g%; Sen and Kanani (2006), 11.32 g% and Bulliyya,
Mallick, Sethy, and Kar (2011), 9.7 ± 1.4 g%, further illustrating the pre-
valence of anemia across India.
In the intervention group, the hemoglobin levels increased from 11.03 g%
to 12.54 g%, which was statistically significant (t (29) = 7.514, p < .0001). This
increase was consistent from Day 1 to Day 45 and through Day 90. Inclusion
of mothers for nutritional education may also have contributed to this rise as
they were consistent in providing their adolescent girls with the ragi por-
ridge. There was a mean gain of 1.5 g% during the 3-month period of the
study. Bansal, Toteja, Bhatia, Vikram & Siddhu, (2016) reported that the
mean hemoglobin increased from 106.7 ± 11.2 g/l and 108.9 ± 8.91 g/l in
Group A (iron and folate) and Group B (iron, folate and B12) to 116.4 ± 10.8
g/l (p < .001) and 116.5 ± 10.26 g/l (p < .001) post-intervention, respectively.
Hyder et al. (2007) showed that regular consumption of multiple-
8 S. KARKADA ET AL.

micronutrient-fortified beverage for 6 months by adolescent girls signifi-

cantly increased the Hb concentration and improved iron levels. Our find-
ings are consistent with that of Patil, Durgawale, Kakade, and Dighe (2014)
who reported in their study that the rise in the mean Hb level of girls in the
group that received iron and folic acid tablets was higher in comparison to
the mean Hb level of girls in groups that only received nutritional education
without supplementary food (F2,49 = 11.259, p < .001).
As the bioavailability of iron in Indian foods is comparatively less (Nair &
Iyengar, 2009), long-term approaches like nutritional education along with
dietary interventions will be an effective strategy to fight against anemia in this
vulnerable group of adolescent girls. In future, they will practice the same in
their family which will be an added advantage. The improvement in hemoglo-
bin levels with ragi supplement indicates that the public and community can
be educated about the benefits of its use. The ragi porridge was also observed
to generate good compliance in the intervention group, unlike iron tablets
which have been reported to have lower compliance due to its gastrointestinal
side effects (Joshi & Gumashta, 2013). Apart from iron, ragi contains calcium
and other minerals and carbohydrate. This is a food grain grown in most parts
of India and people from all walks of life can afford to buy. Involvement of
mothers in this study had additional advantages such as improvement in the
dietary compliance and nutritional education. Additionally, nutrition educa-
tion of the mothers is likely to benefit the health status of the entire family.
The hematological parameters and BMI in the intervention group were not
significantly changed from Day 1 to Day 90. This may be partly because the
group selected had mild anemia and the hematological parameters were some-
what close to the normal range at the beginning of the study (Table 4). The
scholastic performance assessed the scores obtained on the examinations prior
to and during the study period and these may not be the best indicator of
cognitive ability in this age group. Future studies may incorporate other tests
for a more reliable evaluation (Bruner, Joffe, Duggan, Casella, & Brandt, 1996).

Recommendation
In this community, since finger millet (ragi) is one of the widely available
food sources in India, its use as a supplement food to counter the high
prevalence of anemia is recommended. In order to ensure success, a follow
up of up to 6 months is recommended to aid nutritional education and to
evaluate the long-term effect of ragi supplementation.

Limitation
The comparison of control group and the intervention group is limited as the
control group had normal Hb levels. Another limitation is that the serum
 COMPREHENSIVE CHILD AND ADOLESCENT NURSING 9

ferritin levels and serum iron panel were not included and their inclusion for
study is recommended for future studies.

Conclusion
The results of this study have indicated that Finger Millet (ragi) can be
supplemented in the diet of adolescent girls with mild anemia to improve
their Hb levels. In order to ensure better outcomes, nutrition education of
mothers is further recommended as a strategy to improve their compliance to
dietary supplementation to their adolescent girls.

Acknowledgments
We acknowledge the participation of each adolescent girl and their mothers in the study.

Declaration of interest
The authors report no conflict of interest.

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