European Journal of Cardiovascular Medicine

Nutritional anemia, particularly iron-deficiency anemia (IDA), remains one of the most prevalent nutritional disorders among adolescents globally.[1] Adolescence is a dynamic phase marked by rapid somatic growth, hormonal changes, and increased cognitive demands, all of which elevate the physiological requirements for essential micronutrients such as iron, folic acid, and vitamin B12.[2,3] In low- and middle-income countries (LMICs), these increased demands are often unmet due to poor dietary quality, limited healthcare access, and high infection burdens, thereby placing adolescents at significant risk of anemia.[4]

According to the World Health Organization (WHO), approximately 27% of adolescents in developing countries suffer from anemia, with a disproportionately higher burden among girls [1]. In India, data from the National Family Health Survey-5 (NFHS-5, 2019–2021) indicate that the prevalence of anemia among adolescent girls is 59.1% and among boys is 31.1%, reflecting a worsening trend over previous decades.[3] Despite multiple national-level interventions—such as the Weekly Iron and Folic Acid Supplementation (WIFS) programme, the Mid-Day Meal scheme, and the Anemia Mukt Bharat (AMB) initiative—anemia remains a major cause of morbidity, impaired school performance, delayed puberty, and poor reproductive outcomes.[5–7]

While iron deficiency is the most common cause, recent evidence also highlights the roles of vitamin B12 and folate deficiencies, high junk food consumption, vegetarian diets, low socioeconomic status, and poor menstrual hygiene as contributory factors.[8,9] Parasitic infections and helminthiasis further compound the problem by causing chronic blood loss and malabsorption.[10]

There remains a significant gap in adolescent-specific data in India, as most epidemiological studies on anemia focus on under-five children and pregnant women.[11] Additionally, the real-world impact of ongoing public health interventions, compliance with oral hematinic therapy, and barriers to adherence remain poorly explored in the adolescent age group.

The current study was undertaken to evaluate the determinants of nutritional anemia among adolescents, characterize its hematological subtypes, and assess the response to treatment using oral hematinics and dietary counseling over a three-month period. By identifying modifiable risk factors and analyzing outcomes, this research aims to inform evidence-based interventions and guide public health strategies tailored to adolescents.

Study Design and Setting

This was a prospective, hospital-based observational study conducted over a period of 18 months, from January 2023 to June 2024. The study was carried out in the pediatric outpatient department (OPD) and inpatient wards of a tertiary care teaching hospital located in South India. The hospital caters to a diverse population with significant adolescent outpatient and inpatient footfall, making it an ideal setting to assess the clinical and hematological profiles of anemia in this age group.

Study Population

The study population comprised adolescents aged 10 to 18 years presenting to the pediatric department with clinical symptoms or laboratory evidence suggestive of anemia. Eligible participants were enrolled consecutively after obtaining informed written consent from parents or guardians, and assent from children above 12 years of age, in accordance with ethical standards.

Inclusion and Exclusion Criteria

Inclusion criteria included adolescents between 10 and 18 years of age with hemoglobin levels below the WHO-defined age- and sex-specific cut-offs: <11.5 g/dL for ages 10–11 years, <12.0 g/dL for girls aged 12–18 years, and <13.0 g/dL for boys aged 12–18 years. Exclusion criteria were adolescents with recent history of blood transfusion within the preceding four weeks, those on hematinic therapy within the last four weeks, known chronic conditions such as chronic kidney disease, malignancies, hemoglobinopathies (thalassemia, sickle cell anemia), autoimmune disorders, or cases with incomplete clinical or laboratory data.

Sample Size

The sample size was calculated based on an earlier reported prevalence of nutritional anemia in adolescents as 53.3%. Using this prevalence, with an absolute precision of 10% and a 95% confidence interval, the minimum required sample size was estimated to be 96. To account for potential dropouts or incomplete data, a total of 100 participants were included in the final analysis.

Data Collection and Clinical Evaluation

Data collection was performed using a predesigned, structured proforma that captured comprehensive information across several domains. Socio-demographic variables included age, sex, type of family (nuclear or joint), parental education, and socioeconomic status, assessed using the Modified Kuppuswamy scale. Dietary history focused on frequency of consumption of iron-rich foods such as green leafy vegetables, junk food intake, vegetarian or non-vegetarian dietary pattern, and consumption of beverages such as tea or coffee. Clinical history included menstrual history in females (age at menarche, regularity, and duration of flow), deworming practices, and history of recurrent infections. Anthropometric measurements such as height and weight were recorded using standardized methods, and Body Mass Index (BMI) was calculated as weight in kilograms divided by height in meters squared (kg/m²).

All enrolled adolescents underwent a detailed clinical examination including general physical and systemic evaluation. Clinical signs such as pallor, glossitis, angular stomatitis, and koilonychia were documented. A thorough abdominal examination was performed to check for hepatosplenomegaly, and cardiovascular examination was done to detect hemic murmurs. Neurological examination focused on identifying signs suggestive of vitamin B12 deficiency, such as diminished deep tendon reflexes or sensory disturbances.

Laboratory Investigations

All participants underwent a battery of laboratory investigations. Hemoglobin levels and red cell indices (MCV, MCH, MCHC) were estimated using an automated hematology analyzer. Peripheral blood smear examination was done for morphological classification of anemia. Serum ferritin levels were measured using chemiluminescent immunoassay to assess iron stores. Serum vitamin B12 and folate levels were measured using immunoassay techniques. Serum iron and Total Iron Binding Capacity (TIBC) were assessed using colorimetric methods. Reticulocyte count was performed to evaluate erythropoietic activity. Stool examination was done using direct microscopy to detect the presence of parasitic ova or cysts contributing to blood loss or malabsorption.

Classification and Treatment

Anemia was categorized based on severity into mild (Hb 10.0–10.9 g/dL), moderate (Hb 7.0–9.9 g/dL), and severe (<7.0 g/dL) as per WHO guidelines. Morphologically, anemia was classified based on PBS findings as microcytic hypochromic, macrocytic, dimorphic, or normocytic normochromic.

All participants received oral hematinics containing elemental iron, folic acid, and vitamin B12 in doses appropriate for age and body weight. Individualized dietary counseling was provided to all adolescents and their caregivers, emphasizing iron-rich foods and absorption-enhancing dietary practices. Deworming was provided to those with relevant clinical or stool findings. Participants were followed up at one and three months post-initiation of therapy to reassess hemoglobin levels and anthropometric measures. Compliance to therapy and any adverse effects were recorded.

Statistical Analysis

Data entry was done in Microsoft Excel, and statistical analysis was performed using SPSS and Statisty app. Descriptive statistics such as mean, standard deviation (SD), and percentages were used to describe continuous and categorical variables. Comparison of baseline and follow-up hemoglobin and anthropometry was done using paired t-test for normally distributed data and Wilcoxon signed-rank test for non-parametric variables. Chi-square test was used to test the association between categorical variables. A p-value of <0.05 was considered statistically significant.

Ethical Considerations

This study was conducted in full accordance with the ethical principles outlined in the Declaration of Helsinki (2013 revision), the Indian Council of Medical Research (ICMR) National Ethical Guidelines for Biomedical and Health Research involving Human Participants (2017), and CIOMS (Council for International Organizations of Medical Sciences) guidelines.

Ethical clearance for the study was obtained from the Institutional Ethics Committee (IEC) prior to commencement of the study. The protocol was reviewed and approved under the reference number

IEC/D151/M/2023, dated 3^rd April 2023.

Informed written consent was obtained from the parents or legal guardians of all participants prior to recruitment. Additionally, age-appropriate assent was obtained from adolescents aged 12 years and above. Participation was entirely voluntary, and all subjects were assured of confidentiality and the freedom to withdraw from the study at any stage without any impact on their standard medical care.

All data were anonymized and stored securely. Identifiers were removed prior to analysis and publication to ensure participant confidentiality. The study involved no experimental interventions, and standard treatment was provided to all anemic participants based on clinical guidelines and institutional protocols.

The mean age of the adolescent participants was 14.48 ± 2.05 years, with a median of 14.5 years, reflecting a near-symmetrical distribution. The age range extended from 10.5 to 17.5 years, with an interquartile range (IQR) of 13.5 to 16.13. The skewness was -0.19, and kurtosis -0.84, indicating an approximately normal and platykurtic age distribution.

Of the 100 participants, 68% were female and 32% were male, with a clear female predominance. This reflects the higher susceptibility of adolescent girls to nutritional anemia due to menstrual blood loss and increased nutritional requirements during puberty.

Most adolescents belonged to the lower middle (34%) and upper lower (31%) socioeconomic classes, as per the Modified Kuppuswamy classification. Regarding dietary habits, 74% followed a vegetarian diet, while 26% consumed a mixed diet. Regular intake of green leafy vegetables (≥3 times per week) was reported by 39%, while 44% frequently consumed junk food. A notable 59% of participants reported consuming tea or coffee within one hour of meals, a known inhibitor of iron absorption.

Among the 68 female participants, 49.4% had attained menarche before age 13, and 45.7% reported experiencing menorrhagia. Furthermore, 38.3% had not received deworming therapy in the past year, potentially contributing to iron deficiency. (Table 1)

Clinical Presentation of Anemia (Symptoms and Signs)

The most common presenting symptom was generalized fatigue, reported by 66% of adolescents. Other frequent complaints included shortness of breath (37%), dizziness (35%), and headache (29%). Menstrual irregularities were noted in 27.9% of female participants. On physical examination, pallor was the most common sign (88%), followed by glossitis (31%) and koilonychia (28%). Angular stomatitis and hemic murmurs were present in 12% and 8% of cases, respectively. Neurological signs suggestive of vitamin B12 deficiency (e.g., paresthesias, decreased vibration sense) were seen in 10% of adolescents. (Table 2)

Dietary and Nutritional Practices Among Anemic Children

An evaluation of dietary habits among the anemic adolescents revealed several risk-enhancing patterns. A majority (66%) consumed green leafy vegetables (GLVs) less than twice a week, indicating suboptimal intake of iron-rich foods. Junk food consumption was frequent, with 63% of participants consuming fried or processed foods more than three times a week. Nearly half (49%) of the adolescents reported regular intake of tea or coffee within one hour of meals, a practice known to inhibit non-heme iron absorption. Furthermore, 61% followed a predominantly vegetarian diet, potentially contributing to lower bioavailable iron intake.

A large proportion of female participants (58.8%) had attained menarche, placing them at additional risk for iron deficiency due to menstrual blood loss. Among these, only 31% reported regular iron supplementation, while others either had irregular intake or none at all.

Anthropometry and Nutritional Status

Anthropometric evaluation showed that 30% of participants were underweight based on BMI-for-age, with 5% being classified as severely underweight. A majority (63%) were within the normal BMI range, while 7% were overweight or obese. These findings indicate that anemia coexists with both undernutrition and overnutrition, underscoring the need for comprehensive nutritional interventions targeting all weight categories.

Hemoglobin Severity Classification and Morphological Types of Anemia

The hematological parameters among the study population reflected a diverse spectrum of anemia severity and red cell morphology. The mean hemoglobin level was 9.28 ± 1.72 g/dL, with values ranging from 2.2 to 11.8 g/dL. (Figure 1) Correspondingly, the Red Blood Cell (RBC) count ranged from 1.67–5.25 million/mm³, with a mean of 4.07 ± 0.73 million/mm³. (Figure 1).

Anemia severity was classified as per WHO-defined hemoglobin cut-offs for adolescents. Mild anemia (Hb 10–10.9 g/dL) was observed in 28% of the cohort, while moderate anemia (Hb 7–9.9 g/dL) constituted the largest group, affecting 59% of participants. Severe anemia (Hb <7 g/dL) was present in 13%, indicating a significant burden of moderate to severe anemia in the study population.

Morphological evaluation using peripheral blood smear and red cell indices revealed that microcytic hypochromic anemia was the most prevalent type, found in 61% of participants, suggestive of iron deficiency as the dominant etiology. Dimorphic anemia, indicating mixed nutritional deficiencies (commonly iron and B12 or folate), was identified in 23%, while normocytic normochromic anemia accounted for 11% of cases. Macrocytic anemia, classically associated with vitamin B12 or folate deficiency, was observed in 5% of adolescents.

Red cell indices among participants revealed a mean MCV of 75.05 ± 10.21 fL, MCH of 22.44 ± 4.85 pg, and MCHC of 29.57 ± 3.04 g/dL, indicating predominant microcytic hypochromic patterns. (Figure 2) The red cell indices indicated a microcytic hypochromic profile, with MCV and MCH falling below normal in a majority of participants, consistent with iron deficiency. MCHC showed a left-skewed distribution, with most values clustering near normal, suggesting relatively preserved red cell hemoglobin concentration.

Together, these indices supported the morphological diagnosis of iron-deficiency anemia and underscored early screening utility in resource-limited settings.

The mean reticulocyte count was 1.6 ± 0.62%, indicating borderline or reduced marrow activity, with a positively skewed distribution and few high outliers (>2.5%), suggesting a predominantly hypoproliferative anemia profile. This supports iron deficiency or chronic inflammation as dominant causes, with limited regenerative response in most cases. Peripheral smear findings revealed microcytic hypochromic anemia in 58%, followed by normocytic normochromic (27%) and dimorphic patterns (11%), reinforcing nutritional etiologies. (Figure 3)

Evaluation of iron and micronutrient parameters revealed that the mean serum ferritin level was 68.7 ng/mL, with a median of 53.65 ng/mL, suggesting depleted iron stores in a substantial subset of participants. Similarly, the median serum iron concentration was 94.95 µg/dL, with many values below 100 µg/dL, indicative of inadequate circulating iron. Total Iron Binding Capacity (TIBC) was moderately elevated (mean: 367.27 µg/dL), further supporting the diagnosis of iron deficiency, as elevated TIBC reflects compensatory upregulation in response to low iron. The mean serum vitamin B12 concentration was 446.19 pg/mL, within normal limits; however, the lower quartile value of 250 pg/mL indicates that approximately one-fourth of participants had borderline or low B12 levels, which could contribute to megaloblastic anemia. Serum folate levels were largely within the normal range (mean: 9.19 ng/mL), although a few participants had values suggestive of marginal deficiency. Collectively, these findings support iron deficiency as the predominant etiology of anemia in the cohort, with a notable contribution from vitamin B12 deficiency in a subset of cases. Routine biochemical assessment of these parameters is essential to guide targeted nutritional and therapeutic interventions.

Treatment Administered and response in follow up

All 100 participants in the study were treated in accordance with standard pediatric anemia management protocols. Oral iron therapy was the mainstay and was prescribed universally (100%), while no child required parenteral iron, reflecting that the majority of cases were mild to moderate and amenable to oral hematinic regimens. Folic acid supplementation was given to 97% and vitamin B12 supplementation to 84% of patients, addressing the likelihood of megaloblastic components. Deworming was administered in all participants, emphasizing its role in treating iron deficiency anemia in endemic regions. Blood transfusion was required in 18% of the study population—14 patients received one unit and 4 received two units—indicating a subset presented with severe anemia warranting acute correction. The findings underscore the effectiveness and feasibility of a comprehensive outpatient-based treatment approach combining oral iron, vitamin supplementation, and deworming, with transfusion reserved for select cases.

All 100 children showed clinical improvement following treatment with oral iron, vitamin B12, folic acid, dietary counseling, and deworming. Compliance to therapy was excellent in all cases, with no reported adverse effects such as gastrointestinal disturbances or allergic reactions. Every participant demonstrated a favorable overall therapeutic response, both clinically and hematologically. These findings confirm the efficacy and safety of standard outpatient-based management for nutritional anemia in adolescents. Early diagnosis and structured follow-up were key contributors to universal recovery.

Body weight was assessed at baseline, 1 month, and 3 months to track nutritional recovery. The mean baseline weight was 42.55 ± 9.07 kg, increasing steadily to 43.6 ± 9.09 kg at 1 month and 44.08 ± 9.11 kg at 3 months, reflecting consistent weight gain across the cohort. The median values followed a similar trend, indicating a population-wide improvement. Interquartile ranges remained stable, and no major outliers or deviations were noted. At 1 month, the average percentage increase in weight was 2.6%, rising to 3.8% at 3 months, indicating a cumulative effect of nutritional and therapeutic interventions. The median percent gain at 3 months was 3.44%, with most participants showing at least 2.5% improvement. A few children achieved >7–10% gain, highlighting individual variation in nutritional response. These findings confirm measurable, sustained growth in anemic adolescents under standard therapy. Figure 4 illustrates the distribution trend of weight over time. The average weight gain of 1.5 kg (3.8%) over three months highlights the effectiveness of iron and multinutrient therapy in promoting growth in anemic children. The consistent upward trend underscores good nutrient absorption, adherence, and absence of limiting side effects. These results support weight monitoring at 1 and 3 months as a simple, reliable marker for treatment response and nutritional recovery.

Serial Hemoglobin Monitoring During Therapy

Serial monitoring of hemoglobin levels revealed a progressive and statistically significant improvement following therapeutic intervention. The mean hemoglobin increased from 9.11 ± 2.3 g/dL at baseline to 10.64 ± 1.78 g/dL at 1 month, and further to 10.89 ± 1.77 g/dL at 3 months (Table 3). This upward trend was substantiated by repeated measures ANOVA, which demonstrated a highly significant change over time (F(2,198) = 212.76, p < 0.001), with a very large effect size (η² = 0.68). Bonferroni-adjusted post hoc analysis confirmed that each time-point comparison (baseline vs. 1 month, baseline vs. 3 months, and 1 month vs. 3 months) was statistically significant (p < 0.001). The largest rise in hemoglobin occurred in the first month (mean increase: 1.53 g/dL), indicating rapid hematologic recovery, followed by a modest but consistent improvement between the first and third months (0.25 g/dL gain). These results are visually represented in Figure 5, which depicts the hemoglobin trajectory across the three time points. Collectively, the findings affirm the efficacy of oral iron and multinutrient therapy in correcting pediatric anemia, highlighting both the early responsiveness and sustained hematological gains over a 3-month treatment course.

Multiple linear regression analyses were conducted to explore predictors of hemoglobin improvement at 1-month and 3-month intervals following nutritional and therapeutic interventions. At 1 month, the model (R² = 0.11) was not statistically significant [F(7, 92) = 1.64, p = 0.133], though male sex emerged as a significant negative predictor (B = -0.50, p = 0.048), indicating that males showed less improvement in hemoglobin levels compared to females (Table 4). Similarly, the 3-month model (R² = 0.12) was also non-significant [F(7, 92) = 1.72, p = 0.114], but again male sex was associated with a significantly lower hemoglobin gain (B = -0.56, p = 0.033). No other demographic or socioeconomic variables demonstrated significant predictive power in either model. These findings underscore that sex may be a modest but consistent determinant of hemoglobin response over time, whereas factors such as age and socioeconomic status did not exhibit statistically significant associations. The modest explanatory power of both models suggests the need to explore additional biological, dietary, and compliance-related factors in future predictive frameworks.

Change in Serum Ferritin Over Time

Serum ferritin levels were measured at baseline and after 3 months of iron therapy to assess changes in iron storage status. At baseline, the mean ferritin was 68.7 ± 103.18 ng/mL (median: 53.65 ng/mL; IQR: 25.98–91.35), with wide variability and a positively skewed distribution due to outliers. After 3 months, the mean ferritin was 63.98 ± 52.60 ng/mL (median: 53.45 ng/mL; IQR: 28.93–95.15), showing a similarly skewed distribution but with fewer extreme values. Despite clinical improvement and rise in hemoglobin, a paired t-test revealed no statistically significant change in serum ferritin levels over time [t(99) = 0.40, p = 0.688; 95% CI: –18.56 to 28.00], with a negligible effect size (Cohen’s d = 0.04). This suggests that while hemoglobin improved, ferritin levels remained stable, possibly influenced by inter-individual variability, inflammation, or incomplete iron repletion.

Table 1: Baseline Demographic, Dietary and Socioeconomic Characteristics of Adolescents with Nutritional Anemia (n=100)

Table 2. Clinical Presentation of Anemia in Adolescents (N=100)

Table 3: Baseline and follow up at 1 and 3 months, of Hemoglobin of study population

Table 4: Regression Coefficients Table (3 Months):

Abbreviations:B – Unstandardized Coefficient; β – Standardized Coefficient; CI – Confidence Interval.

Figure 1: Hemoglobin and RBC count

Box plot comparing individual Hemoglobin concentrations and Red Blood Cell (RBC) counts at baseline, illustrating the relationship between anemia severity and erythrocyte levels.

Figure 2: Box plot for Red Cell Indices among the Study Population

Box plots showing the distribution of Mean Corpuscular Volume (MCV), Mean Corpuscular Hemoglobin (MCH), and Mean Corpuscular Hemoglobin Concentration (MCHC) among the participants, indicating prevalent microcytosis and hypochromia patterns.

Figure 3: Distribution of Peripheral Blood Smear Patterns in the Study Population

Bar chart showing the morphological classification of anemia based on PBS findings—microcytic hypochromic, macrocytic, dimorphic, and normocytic normochromic patterns.

Figure 4: Percentage change in weight at 1 and 3 months in follow up period; Box plot demonstrating the mean percentage increase in body weight of participants after initiation of hematinic therapy, with statistically significant improvement at both follow-up points (p < 0.001).

Figure 5: Baseline and follow up at 1 and 3 months, of Hemoglobin of study population- Box plot showing the trend of hemoglobin improvement over time post-treatment, with statistically significant increases at both 1-month and 3-month intervals compared to baseline (p < 0.001).

This study enrolled 100 adolescents aged 10–18 years with clinically and laboratory-confirmed anemia. The mean age was 14.48 years, with the majority in mid-to-late adolescence, aligning with the findings by Kaur and Deshmukh et al. (2006), who reported a higher prevalence of anemia among mid and late adolescents in Nashik (63.5%).[12] Female predominance (68%) was evident in our study, likely attributable to menstrual blood loss and dietary insufficiencies, a trend corroborated by Toteja et al. (2006) and Bansal et al. (2020), who reported 65–75% and 66% prevalence of anemia in adolescent girls, respectively.[13,14]

Socioeconomic analysis revealed that 65% of participants belonged to the lower middle and upper lower classes. This pattern reflects the urban tertiary hospital setting and concurs with Toteja et al.'s multicentric findings linking poverty to anemia prevalence.[13] Additionally, 86% of the cohort came from nuclear families, reinforcing Sharma et al.'s (2017) hypothesis that lack of extended family support may negatively affect adolescent nutrition and anemia risk.[15]

Symptomatically, 66% reported generalized fatigue, with breathlessness, dizziness, and headache being frequent complaints. These findings mirror those by Kaur et al. (2017) and Pereira et al. (2014), where fatigue and weakness were key presenting symptoms in adolescents with anemia.[12,16] Clinical examination revealed pallor in 88%, and mucocutaneous signs such as glossitis and koilonychia in over 25%, supporting the presence of iron and B12 deficiencies. These signs are consistent with earlier studies, including Kapil et al. (2002), which highlighted pallor as a pivotal clinical marker.[17]

Dietary assessment showed iron-inhibiting practices like tea/coffee intake within one hour of meals in 59%, low green leafy vegetable (GLV) intake in 66%, and high junk food consumption in 63%. These patterns are in agreement with earlier observations by Goyle et al. (2002) and Kotecha et al. (2009), both of whom stressed the role of poor diet in adolescent anemia.[18,19] Among menstruating girls, 45.7% experienced menorrhagia, a well-known risk factor for iron deficiency. Irregular menstruation was reported by 27.9%, reinforcing findings by Kumar et al. (2017), who found similar patterns in rural adolescents.[20]

Anthropometric analysis revealed underweight status in 30%, aligning with previous research by Ghosh et al. (2013) and Choudhary et al. (2021), both of which identified undernutrition as a significant contributor to anemia in Indian adolescents.[21,22] Hematological assessment revealed that 59% of adolescents had moderate anemia and 13% had severe anemia. Microcytic hypochromic morphology dominated (61%), consistent with iron deficiency, similar to findings by Chakma et al. (2013) and Mehta et al. (2018).[23,24] Dimorphic anemia (23%) and macrocytic patterns (5%) indicated coexisting B12/folate deficiencies.

Red cell indices—mean MCV of 75.05 fL, MCH of 22.44 pg, and MCHC of 29.57 g/dL—highlighted microcytic hypochromic trends. Reticulocyte counts were borderline low (mean 1.6%), suggesting hypoproliferative anemia, as seen in nutritional or chronic inflammatory etiologies. This was supported by biochemical markers: 31% had low serum ferritin (<30 ng/mL), 25% had low serum iron (<60 µg/dL), and 36% had high TIBC (>400 µg/dL). Additionally, 25% had low serum B12, and 17% had low folate—findings similar to those by Saxena et al. (2020) and Verma et al. (2018).[25,26]

All participants received oral iron; 97% and 84% received folic acid and vitamin B12, respectively. Deworming was universal, and transfusion was necessary in only 18% of cases. Compliance was excellent, with no adverse effects noted. These findings affirm the feasibility of outpatient-based therapy for adolescent anemia.

Weight increased significantly during follow-up (mean gain: 1.5 kg over 3 months, or 3.8%), reflecting successful nutritional recovery. The consistent trend in Figure 4 supports early and sustained growth. Serial hemoglobin monitoring showed statistically significant improvements from baseline to 1 and 3 months (mean Hb: 9.11 → 10.64 → 10.89 g/dL; p < 0.001), confirming therapeutic success (Figure 5).

Regression analysis showed that male sex negatively predicted hemoglobin gain at both 1 and 3 months (p = 0.048 and p = 0.033, respectively), whereas age and socioeconomic status had no significant effect. These findings suggest that biological factors, possibly hormonal or absorptive, may mediate differential responses between sexes.

Interestingly, no significant change was seen in serum ferritin over 3 months, despite improved hemoglobin. This could be due to slow replenishment of iron stores or confounding by inflammation or inter-individual variation. This emphasizes the need for long-term follow-up and multi-nutrient therapy.

Our study highlights the multifactorial nature of adolescent anemia and the effectiveness of comprehensive treatment strategies, particularly oral iron, vitamin supplementation, dietary modification, and deworming. Early identification, clinical monitoring, and sex-specific strategies may improve outcomes.

Based on this study's findings, we recommend integrating early haemoglobin screening—including red cell indices and peripheral smear analysis—into school health programs and adolescent clinics, especially for girls above 10 years. Nutritional education should target both adolescents and parents, promoting iron-rich diets and awareness of dietary inhibitors. Menstrual health education and routine anemia screening for girls with irregular cycles are essential. Strengthening the Anaemia Mukt Bharat initiative through enhanced outreach, fortified food access, and compliance monitoring is crucial. Regular haematological and anthropometric follow-up at 1 and 3 months should be mandated, with ferritin and micronutrient testing in moderate-to-severe cases. Research into long-term outcomes, combined micronutrient strategies, and gender-sensitive policy adaptations is needed. The study's strengths include its comprehensive evaluation of clinical, biochemical, and menstrual factors, rigorous analysis using repeated measures ANOVA, and real-time follow-up data. However, limitations include its urban tertiary setting limiting generalizability, short follow-up duration, potential recall bias in dietary reporting, absence of a comparator arm, and lack of CRP/ESR to contextualize ferritin levels amidst inflammation.

This prospective study on 100 adolescents aged 10–18 years identified a high burden of moderate anemia (59%), with a clear female predominance (68%), reflecting the vulnerability of adolescent girls due to menstrual losses and increased nutritional demands. Microcytic hypochromic anemia, seen in 61% of participants, was the most common morphological type, indicating iron deficiency as the primary etiology, while 23% had dimorphic and 5% macrocytic anemia, suggesting coexisting deficiencies in vitamin B12 and folate. Nutritional and lifestyle factors were prominent contributors—74% followed a vegetarian diet, 63% consumed junk food regularly, and 59% drank tea or coffee within one hour of meals, all of which impair iron absorption. Among girls who had attained menarche, 45.7% reported menorrhagia, while only 31% used iron supplementation regularly, further amplifying the anemia risk.

Following a 3-month course of oral iron, folic acid, vitamin B12, and deworming, the mean hemoglobin improved significantly from 9.11 ± 2.3 g/dL at baseline to 10.64 ± 1.78 g/dL at 1 month and 10.89 ± 1.77 g/dL at 3 months, with repeated measures ANOVA showing a highly significant trend (F(2,198) = 212.76, p < 0.001) and a very large effect size (η² = 0.68); the greatest hemoglobin rise (1.53 g/dL) occurred during the first month (p < 0.001, Bonferroni-adjusted). Mean body weight increased steadily from 42.55 ± 9.07 kg to 44.08 ± 9.11 kg over 3 months, with an average gain of 1.5 kg (3.8%), reflecting improved nutritional status. However, despite hematological recovery, serum ferritin levels did not change significantly over the same period (mean difference: –4.72 ng/mL, t = 0.40, p = 0.688), likely due to inter-individual variability, incomplete iron repletion, or confounding inflammation. Multiple regression analysis revealed that male sex was a significant negative predictor of hemoglobin improvement at both 1 month (B = –0.50, p = 0.048) and 3 months (B = –0.56, p = 0.033), while other demographic or socioeconomic variables showed no statistical significance.

Importantly, all participants demonstrated clinical improvement with excellent compliance and no adverse effects, validating the effectiveness of outpatient-based therapy for adolescent nutritional anemia. The study highlights the need for early screening, menstrual health education, gender-sensitive public health strategies, and structured follow-up using hemoglobin and weight gain as response markers. Integration of micronutrient profiling into national nutrition programs and further longitudinal studies are essential to ensure long-term hematologic and functional recovery.

Ethics and Consent

This study was approved by the Institutional Ethics Committee of Kempegowda Institute of Medical Sciences, Bangalore, under the reference number KIMS/IEC/D151/M/2023, dated 03 April 2023. The ethical review was conducted as per ICMR guidelines for clinical research. Written informed consent was obtained from all study participants and/or their legal guardians, and assent was obtained from adolescents aged 12 years and above. Confidentiality of all participant information was strictly maintained throughout the study.

Conflicts of Interest: Nil

Trial Registration: Not applicable

Source of funding: Nil

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