Nutrition & Food Science
Nutritional status of children with sickle cell disease: A study at the Komfo
Anokye Teaching Hospital of Ghana
Tracy Bonsu Osei, Charles Apprey, Felix Charles Mills-Robertson, Agartha N. Ohemeng,
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Tracy Bonsu Osei, Charles Apprey, Felix Charles Mills-Robertson, Agartha N. Ohemeng, (2019)
"Nutritional status of children with sickle cell disease: A study at the Komfo Anokye Teaching
Hospital of Ghana", Nutrition & Food Science, Vol. 49 Issue: 2, pp.232-239, https://doi.org/10.1108/
NFS-03-2018-0100
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NFS
49,2 Nutritional status of children
with sickle cell disease
A study at the Komfo Anokye Teaching
232 Hospital of Ghana
Tracy Bonsu Osei and Charles Apprey
Received 15May 2018
Revised 18 July 2018 Department of Biochemistry, Kwame Nkrumah University of Science
Accepted 19 July 2018 and Technology, Kumasi, Ghana
Felix Charles Mills-Robertson
Kwame Nkrumah University of Science and Technology, Kumasi, Ghana, and
Agartha N. Ohemeng
College of Basic and Applied Science, University of Ghana, Accra, Ghana
Abstract
Purpose – This study aims to assess the nutritional status of children with sickle cell diseases using
anthropometric measurements, biochemical markers and dietary intakes.
Design/methodology/approach – The study was conducted in 100 children of 3-12 years of age with
sickle cell diseases (SCDs) at the Komfo Anokye Teaching Hospital in the Kumasi Metropolis of Ghana. Weight,
height and age of participants were used to calculate body mass index-for-age. The mid-upper-arm-
circumference-for-age, weight-for-age (percentiles) and height-for-age (percentiles) were compared with standards
growth charts for children. Biochemical measures such as serum albumin and ferritin, as well as full blood count,
were assessed. Dietary intake was assessed using 24-h dietary recall and food frequency questionnaire.
Findings – From the study, 73 and 37 per cent of the children with SCD recorded inadequate intake of iron
and vitamin E, respectively, when compared to the recommended daily allowance. Out of the 100 participants,
37 per cent were underweight and 22 per cent were stunted. There was significant difference (p < 0.05) in
underweight (weight-for-age) prevalence by gender. A multiple variate regression showed a significant
association between zinc (r2 = 0.763, p< 0.05) and haemoglobin levels.
Originality/value – The evidence in this paper is relevant for treatment, health education and nutritional
counselling of parents with children who have SCD.
Keywords Nutrition, Children, Sickle cell disease
Paper type Research paper
Introduction
Malnutrition is considered an important risk factor for illness and death in children with a
prevalence of 52.5 per cent (Tette et al., 2015). Undernutrition is associated with low immune
function and considered as the commonest cause of immunodeficiency (Ashaba et al., 2015).
Thus, children who are undernourished have decreased ability to overcome infections and may
have high probability of dying from common diseases (Apprey et al., 2014; Tette et al., 2015).
Sickle cell disease (SCD) is a group of inherited red blood cell disorders that affects
Nutrition & Food Science
Vol. 49 No. 2, 2019 haemoglobin. It is caused by the exchange of nitrogenous bases in the codon of the beta
pp. 232-239
© EmeraldPublishingLimited haemoglobin gene, creating a different haemoglobin S (Hgb-S). Hence, the expression of the
0034-6659
DOI 10.1108/NFS-03-2018-0100 disease mainly lies in the presence of Hgb-S, in which there is replacement of glutamic acid
Downloaded by University of Ghana At 08:16 30 May 2019 (PT)
with valine, resulting in hydrophobic interaction which triggers polymerization molecules Nutritional
when deoxygenated. The red blood cells then form longer and rigid structures which are status of
sickled-shaped (Oliveira et al., 2015). children
Globally, SCD is known as one of the leading causes of death and disability (Piel et al.,
2014). The global burden of SCD varies across different settings. In the USA, it is estimated
that the population affected by SCD each year is about 7,200, of which most are blacks (Piel
et al., 2014). In Africa, where dietary intake is inadequate among a significant proportion of 233
the population, it is hypothesised that undernutrition is a key factor that worsens the
prognosis of SCD. SCD is associated with 50-90 per cent of childhood mortality in Africa
(Ansong et al., 2013). The prevalence is highest in sub-Saharan Africa, especially in West
Africa (Hyacinth et al., 2013). In Ghana, SCD is a major contributing factor to childhood
morbidity and mortality (Magalhaes and Clements, 2011), and it affects 2 per cent of all
babies born (Dennis-Antwi et al., 2008).
In low- and middle-income settings, children with SCD may have increased risk of
developing undernutrition due to poor appetite levels, reduced dietary intake and infectious
complications. Most children with SCD show reduced growth rate, delayed maturity and
poor immunologic functions. These complications are mainly attributable to undernutrition
associated with the disease. (Behera et al., 2012; Hasanato, 2006; Jackson et al., 2012).
While adequate nutritional intake is required for effective child development, there is a
dearth of evidence on the extent of intake among children, particularly those with SCD. This
presents a gap in literature on the nutritional status of children with SCD, something
required to develop interventions. This study therefore sought to assess the nutritional
status of children with SCD presenting at Komfo Anokye Teaching Hospital, a tertiary
hospital setting in Ghana.
Materials and methods
Sampling and sample size
The study was conducted at the Child Health Unit (Sickle Cell Department) of the Komfo
Anokye Teaching Hospital, Kumasi, Ghana. Using the Yamane (1967)[1] formula for
calculating sample size, where N is the population (the total number of registered children
with SCD) and e = 5 per cent (margin of error), the sample size obtained was 98, which was
approximated to 100. A consecutive sampling was used to recruit participants. This
sampling helped to enrol all SCD children presenting at the facility over the period of a
month. All SCD children presenting at the sickle cell unit for review were approached, and
all those who agreed to participate were made to sign a consent form. This process was
repeated for all the prospective participants until a total of 100 participants were reached.
Ethical consideration
Ethical approval was obtained from Committee on Human Research Publication and Ethics
of The School of Medical Sciences, Kwame Nkrumah University of Science and Technology.
All participants of the study signed a consent form in accordance with Committee on Human
Research Publication and Ethics regulations before participating in the study.
Inclusion and exclusion criteria
All children of 3-12 years of age with SCD who did not have any clinical complications and
were in a steady state were included in the study. Participants who did not give consent to
the study and those in crisis were excluded from the study.
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NFS Dietary assessment
49,2 Multiple 24-h dietary recall was used to assess the daily intakes of some macro- and
micronutrients. The participants were made to recall all foods and snacks they had taken the
previous 24 h. The recall was done on a one weekday and one weekend. Household handy
measures were used to help estimate the amount of foods or snacks consumed. Nutrient
analysis template was used to determine the nutrient content of the food consumed. A Food
234 Frequency Questionnaire that had been tested on children with similar age were used to
assess dietary intake of the participants for the previous three months.
Anthropometric assessment
Weight and height were measured and used to calculate body mass index (BMI)-for-age [kg/
height (m2)] (Silva and Viana, 2002). Weight-for-age (percentile) and height-for-age
(percentile) were expressed into percentiles and compared with World Health Organization
growth reference standards (de Onis, 2015).
Haematological and biochemical markers assessment
About 6 ml of venous blood sample was collected from the antecubital fossa of the study
participants. Of the 6 ml, 2 ml of the blood sample was dispensed into ethylenediamine-tetra-
acetic acid anti-coagulated tube and the other 4 ml into a vacutainer plain tube. Assay
parameters included serum ferritin, full blood counts, total proteins and albumin. Serum
ferritin was performed on Mindray® microplate reader MR 96 A (Shenzhen Mindray Bio-
medical electronics Co., Ltd, China), whereas the full blood count was determined using the
Sysmex XP300 autoanalyzer.
Data analysis
Data were entered using SPSS version 20. The study was analysed using descriptive and
inferential statistics. Descriptive statistics such as frequencies, means and standard
deviations were used to present findings. Continuous variables were summarised as means
with their standard deviations. Independent Student’s t-test was used to compare means
between boys and girls. Multiple variate regression was used to determine the association
Parameter n = 100
Age (years)
3-5 35 (35)
6-8 37 (37)
9-12 28 (28)
Gender
Male 57 (57)
Female 43 (43)
Type Of SCD
SCD-SS 65 (65)
SCD-SC 28 (28)
SCD-Sb 0 6 (6)
þ
Table I. SCD-Sb 1(1)
Demographic Notes: Grouped data are represented as frequency with their corresponding percentage in bracket. SCD:
characteristics of sickle cell diseases; SC: sickle cell anaemia; SS: genotype SS; Sb 0: beta-zore thalassemia; Sbþ: beta-zore
study participants thalassemia (plus)
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Nutritional
Boys Girls p-value
Variables Total n = (100) n = (57) n = (43) status of
children
Weigh-for- age
Underweight 37 17 (29.8%) 20 (46.5%)
Normal 54 37 (64.9%) 17 (39.5%) 0.030
Overweight 9 3 (5.3%) 6 (14.0%)
Height-for-age 235
Short stature 22 11 (19.3%) 11 (25.6%)
Normal 71 42 (73.7%) 29 (71.0%) 0.750
Tall stature 7 4 (7.0%) 3 (7.0%)
BMI-for-age
Underweight 40 20 (35.1%) 20 (46.5%)
Normal 50 33 (57.9%) 17 (39.5%) 0.160
Overweight 10 4 (7.0%) 6 (14.0%) Table II.
Notes: Data presented as number of respondents, with the corresponding percentage in brackets. Prevalence of
Proportions were compared using chi-square test. Percentile < 5: short stature/underweight, percentile # 5 malnutrition among
and< 95: normal and percentile> 95 underweight/tall stature children with SCD
Boys Girls p-value
Variable Total n (100) n (57) n (43)
Iron
Low level 73 46 (80.7%) 27 (62.8%) 0.046
Adequate 27 11 (19.3%) 16 (37.2%)
Protein
Low level 28 15 (26.3%) 13 (30.2%) 0.666
Adequate 72 42 (73.7%) 30 (69.8%)
Vitamin C
Low level 24 13 (22.8%) 11 (25.6%) 0.750
Adequate 76 44 (77.2%) 32 (74.4%)
Folate
Low level 70 39 (68.4%) 31 (72.1%) 0.690
Adequate 30 18 (31.6%) 12 (27.9%)
Vitamin B6
Low level 43 24 (42.1%) 19 (44.2%) 0.840
Adequate 57 33 (57.9%) 24 (55.8%)
Vitamin B12
Low level 69 41 (71.9%) 28 (65.1%) 0.470
Adequate 31 16 (28.1%) 15 (34.9%)
Vitamin E
Low level 84 48 (84.2%) 36 (83.7%) 0.040
Adequate 14 8 (14.0%) 6 (14.0%) Table III.
Notes: Results were compared with age-specific recommended daily allowances (American dietary Dietary intakes
guidelines) and interpreted as adequate and inadequate with their corresponding percentage in brackets. among children with
Proportions were compared using chi-square test SCD
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NFS between nutritional intakes and haemoglobin. Chi-square test and Fisher’s exact test were
49,2 used to compare proportions between genders where appropriate. The analysis was
presented at 95 per cent significant level, p-value< 0.05.
Results and discussion
In this study, a total number of 100 children with SCD participated, with a mean age of 7.06
236 2.7 years. Majority of the participants (57 per cent) were male, a finding that is consistent
with a study done by Al-Saqladi et al. (2010), whose male participants constituted 54.9
per cent. The most occurring type of SCD found among the study participants was the SS
genotype (65 per cent), followed by the SC genotype (25 per cent). Thus, SCD-SS is the most
prevalent type of SCD, and this finding is consistent with studies done by Jacob (2011) and
Osei-Yeboah and Rodrigues (2011), who reported that haemoglobin-SS is the most prevalent
among children with SCD.
In the study, dietary intakes of the SCD children were compared with age-specific
recommended daily allowance for normal children (DeSalvo et al., 2016). With the exception
of vitamin E and iron, which showed significant difference (p < 0.05), all other nutrients
showed no significant difference by gender. Contrary to these findings, Cox et al. (2011)
reported worse nutritional intakes and status in boys compared to girls. Generally, the study
found poor dietary intake among the study participants, and this finding is consistent
with studies done by Hyacinth et al. (2013), who reported that undernutrition in children
with SCD in most developing countries is mostly associated with inadequate diet.
Variables B 95% confidence interval p-value
RBC 1.722 1.505-1.939 0.001
Protein 0.007 From0.014 to 0.028 0.515
Table IV. Folic acid 0.002 0.000-0.005 0.082
Multivariable model Vitamin B12 0.282 From0.335 to 0.229 0.001Zinc 0.320 0.15-0.49 0.001
of factors Age 0.030 From0.074 to 0.063 0.876
associated with
haemoglobin levels Notes:Multiple variate regression model showing dependent variable: haemoglobin, R2 = 0.763 and p< 0.001
Parameter Total mean Boys Girls p-value
Albumin (g/L) 39.06 3.4 38.66 4.1 396 4.5 0.9
Serum ferritin (ng/ml) 167.06 173.8 117.96 181.3 154.06 164.6 0.5
WBC (103/mL) 10.46 5.2 10.86 4.9 9.86 5.5 0.4
RBC (106/mL) 3.46 1.2 3.36 0.9 3.56 1.4 0.3
Hb (g/dL) 8.66 1.7 8.46 1.8 8.76 1.7 0.6
HCT (%) 27.26 5.9 26.96 5.8 27.46 5.9 0.7
MCV (fL) 80.66 11.3 81.56 12.4 79.26 9.6 0.3
Table V. MCH (pg) 25.86 3.3 25.96 3.5 25.56 3.0 0.6
Mean values of PLT (10
3/mL) 388.26 155.5 370.16 143.0 4126 169.3 0.2
biochemical Notes: Data represent Mean 6 SD biochemical measures. Mean levels of boys and girls were compared
variables among using independent t-test. Hb: haemoglobin; WBC: white blood cell; HCT: haematocrit; MCV: mean
children with SCD corpuscular; MCH: mean cell haemoglobin; PLT: platelet
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Children with SCD have higher metabolic rate and resting energy expenditure, and this may Nutritional
increase metabolic and nutrient demands; thus inadequate nutrient intake makes children status of
with SCD susceptible to undernutrition, which increases disease severity (Mandese et al.,
2015). children
Anthropometric measures reflect the nutritional and growth status of children with SCD.
From the study, 37 per cent of the participants had low weight-for-age. Similar observations
were made by Lukusa Kazadi et al. (2017), who reported that 47.7 per cent of children with
SCD were underweight. Again in a longitudinal study, Fung et al. (2008) reported lower 237
weight-for-age for male subjects compared to female subjects with SCD. Differences in
growth may be attributable to environmental factors, nutritional status and disease severity
(Lukusa Kazadi et al., 2017). Prevalence of underweight (37 per cent) in this study was also
higher compared to prevalence found among normal children (26.5 per cent) in the Kumasi
metropolitan area (Ronald et al., 2006). Underweight and stunting determined by BMI-for-
age and height-for-age recorded 40 per cent and 22 per cent, respectively; however, there was
no significant difference when gender was compared.
Low anthropometric index has shown significant impact on disease severity in SCD such
that underweight increases the number of hospital admissions per year (Cox et al., 2011).
Typically, homozygous SS and heterozygous S/b 0 patients have low red blood cell
(RBC), haemoglobin, haematocrit and reticulocyte count due to chronic haemolytic
anaemia (Alapan et al., 2016).Total mean haemoglobin levels of the children in the
study was 8.6 g/dl, which is a good indicator that the participants were at steady state.
Similar studies done by Ballas et al.(2012) reported that SCD patients with haemoglobin
levels 7.8-8 g/dl may not require blood transfusion. However, mean haemoglobin
indicated anaemia when compared with normal reference standard for children (Behera
and Bulliyya, 2016). There was no significant difference between haematological
markers by gender.
Using multiple variate regression, dietary zinc intake (r2=0.763, p < 0.001) was
significantly related to haemoglobin levels. Zinc plays a major role in the absorption of iron,
which is needed in the synthesis of haemoglobin, and thus may positively influence
haematological parameters such as haemoglobin (Rahfiludin and Ginandjar, 2013). Similar
observation wasmade by Khan et al. (2016), who reported that zinc supplementation reduces
vaso-occlusion crisis and improves haemoglobin. Direct association between RBC and
haemoglobin observed in the study was expected because increase in haemoglobin levels
positively influence RBC (Akinbami et al., 2012).
Conclusion
It was observed from the study that SCD is associated with a high prevalence of
malnutrition and growth retardation. Also, dietary nutrient intakes among the study
participants were inadequate, with significant differences in gender for iron and vitamin E.
Nutritional status using anthropometric measures revealed that underweight and stunting
were prevalent in the study participants. The study also established a direct association
between zinc intake and haemoglobin levels.
It is recommended that macro- and micronutrient supplementation and nutritional
education be added as part of the treatment protocol for children with SCD in developing
countries.
Note
1. n= N/1þ N (e) 2.
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Corresponding author
Tracy Bonsu Osei can be contacted at: tracob@yahoo.com
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