META ANALYSIS OF MICRONUTRIENT DEFICIENCY DISORDERS AND THEIR MAPPING IN RAJASTHAN.

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1 META ANALYSIS OF MICRONUTRIENT DEFICIENCY DISORDERS AND THEIR MAPPING IN RAJASTHAN J. Lakshminarayana 1, Madhu B.Singh 2, Ritu D 3, and Shelly Soni 4 1,2,3 &4 Desert Medicine Research Centre, ICMR, Jodhpur , Rajasthan, India lakshmi_nj@dmrcjodhpur.org Abstract The meta analysis has been carried out from the collection of published papers and reports from different medical colleges and through on line searching through internet bibliographic searches from Medlars PubMed, EMBASE, and Cochrane databases The data consists of 15 publications to study the effect of Vitamin - A among school children. The duration was considered to be for a period of 10 years. We have used a binomial model to estimate the results. The data analysis revealed that the educational intervention and combined intervention and the cohorts were non-homogeneous (P < and P < 0.01, respectively); however, the behavioral intervention cohort was homogeneous (Q = 52.48, d.f. = 35, P=0.36). The overall ES for behavioral interventions was 0.06 (95% confidence interval [CI] = ); there were no significant differences among the behavioral & educational interventions which had an overall ES of 0.10 (95% CI = ). The overall ES of the combined interventions was 0.08 (95% CI = ). While stratifying the combined interventions the behavioral had the largest impact (ES = 0.38). The mapping for three micronutrient deficiency disorders for the Rajasthan with ecological variations among the districts has been mapped out. This will be useful to many researchers and health administrators for identifying the incidences among the MND s at district level and can implement the state level nutritional programmes INTRODUCTION Meta Analysis is collection of data systematically and synthesizing the results from individual studies to estimate overall size. Studies with positive results are more likely to get published than those studies with negative results. By using only the results of more positive studies leads to publication bias. We have used different methods to detect this publication bias. The present study was started in the year 2008 which is aimed with the objectives: Meta Analysis of available published or unpublished information of three important Micronutrient Deficiency Disorders namely Vitamin A, Iron Deficiency Anemia(IDA) and Iodine Deficiency Disorders. To study regional/ecological variations of these three micronutrient Deficiency Disorders in Rajasthan by systematic reviews and To map out the districts for three micronutrient deficiencies in the western region. Co-Published By: Human Resource Management Academic Research Society 179

2 MATERIALS AND METHOD The data of meta analysis was collected through literature search for the Vitamin A Deficiency (VAD) Iron Deficiency Anemia (IDA) and Iodine Deficiency Disorder (IDD). The systematic review of these meta analysis were carried out. The data consists of 15 publications to study the effect of Vitamin - A among school children. The duration was considered to be for a period of 10 years. We have used a binomial model to estimate the results and rank correlation method proposed by Begg and linear regression method proposed by Egger & Trim and Fill method to evaluate bias. The publication bias was adjusted by using Trim & Fill method. The analysis was done using EPI META package 3. The effect size and the standard errors were calculated for all the studies and were depicted in the figures The data for meta analysis was collected through literature Gene Glass, (1976) search for the Vitamin A Deficiency (VAD). A total of 124 studies were collected by Systematic review of these 15 studies only met the criteria for meta analysis and the re-analysis has been carried out. For 15 publications on the effect of Vitamin A among school children. The duration was considered to be for a period of 10 years. Binomial model Has been used to estimate the results and rank correlation proposed by Begg and linear regression method proposed by Egger & Trim and Fill method to evaluate publication bias, Jick et al. (1973), Eager, M and smith GD, Phillips AN (1997), Greenhalgh T,(1997). The publication bias was adjusted by using Trim & Fill method. The analysis was done using REVMAN package Mehta CR, Patel NR, Gray R, (1985). The mapping of districts has been done from the data collected by using GIS and reported in the maps. All the micronutrients VAD, IDA and IDD VCD are far below the recommended levels of RDA as per ICMR, RDA Reference values ICMR value shown with different colors in the maps and the cut offs were also shown, Thompson SG, Pocock SJ, (1991), Lakshminarayana, J. Singh B. Madhu (2009). RESULTS AND DISCUSSION The re-analysis of the data revealed that the educational intervention and combined intervention and the cohorts were non-homogeneous (P < and P < 0.01, respectively); however, the behavioral intervention cohort was homogeneous (Q = 52.48, d.f. = 35, P=0.36). The overall ES for behavioral interventions was 0.06 (95% confidence interval [CI] = ); there were no significant differences among the behavioral & educational interventions which had an overall ES of 0.10 (95% CI = ). The overall ES of the combined interventions was 0.08 (95% CI = ). While stratifying the combined interventions the behavioral had the largest impact (ES = 0.38). Meta Analysis of studies of interventions improved the heterogeneity among the studies and gave valid Conclusions. The mapping of districts has been done from the data collected by using GIS and reported in the maps. All the micronutrients VAD, IDA and IDD VCD are far below the recommended levels of RDA as per ICMR values which were shown with different colors in the maps and the cut offs were also shown. In regards to VAD the districts with green color are having >200 gm are better in comparison to others which is showing significant results (P<0.05). Similarly the IDA the districts with <30 are Co-Published By: Human Resource Management Academic Research Society 180

3 deficient in anemia which were colored with yellow. In case of iodine non of the districts were meeting the requirements and there are no studies to report so VCD is shown which is also deficient and the cut off values taken were <30 are very much deficient and shown significant different (P<0.05) when compared with other states data. The color with light blue are deficient districts FINDINGS The study has provided information of three micronutrient deficiency disorders through Meta Analysis for the entire state of Rajasthan with variations in different ecological/geographic regions The mapping for three micronutrient deficiency disorders for the Rajasthan with ecological variations among the districts. This will be useful to many researchers and health administrators for identifying the incidences among the MDD s at district level and can implement the state nutritional programmes on micronutrients. With this approach this can become nodal centre and member of Cochrane data bases for western desert region. This will be an innovative work and well documented scientific study on MDDs and the strategies can be developed and informed to state govt. for intervention programmes to be launched and for implementing the control programmes in the districts. CONCLUSION There are very few studies from desert part of Rajasthan, Intervention studies are to be planned in the desert. Strategies can be developed to improve the micronutrient deficiencies in desert part of rajasthan. The MND like VAD, IDA and IDD VCD are far below the recommended levels of RDA as per ICMR values which were shown with different colours in the maps and the cut offs were also shown. The deficiency is existing in all the districts very few districts are some what better compared to the rest of the districts. This study will be useful to many researchers and health administrators for identifying the incidences among the MND s at district level and can implement the state level nutritional programmes. Co-Published By: Human Resource Management Academic Research Society 181

4 Table-1: Calculations of Estimates of Intervention Studies and Odds Ratios of Different Studies on Micronutrients Study Ref. a b c d n Var. Weight OR Wt x OR Q Co-Published By: Human Resource Management Academic Research Society 182

5 Table-2: Calculation of Publication Bias among the Studies by Different Methods Methods Educational intervention Behavioral intervention Begg s Z=2.04 P=0.04 Egger s T=2.14 P=0.05 Trim & Fill O.R=1.16 ( ) O.R=0.98 ( ) Effect Size ( ) ( ) Over All 0.38 Fig-1: Map Showing Iron Deficiency Anemia (IDA) in Different Districts of Rajasthan Co-Published By: Human Resource Management Academic Research Society 183

6 Proceedings of the 1st International Technology, Education and Environment Conference Fig 2: Map Showing Vitamin - A Deficiency (VAD) in Different Districts of Rajasthan Fig 3: Map Showing Vitamin-C Deficiency (VCD) in Different Districts of Rajasthan Co-Published By: Human Resource Management Academic Research Society 184

7 Proceedings of the 1st International Technology, Education and Environment Conference REFERENCES Gene Glass. (1976). Coined the term Meta analysis, Edu. Res.; 5:3-8. Jick et al, Meta analytic approach (1973). New England Journal of Medicine; 289: Eager, M and smith GD, Phillips A. N( 1997). Meta Analysis : beyond the grand means. British Medical Journal.; 315: Greenhalgh T,(1997). Papers that summaries other papers (systematic reviews and Meta Analysis) British Meduical Journal,; 315: Mehta CR, Patel NR, Gray R, (1985). Computing an exact confidence Interval for the common Odds Ratio in several 2x2 contingency table. Journal of American Stat. Assoc.; 80: ICMR publication, (1999). Recommended dietary Allowances for Indians, Thompson SG, Pocock S. J ( 1991). Can meta analysis be trusted? Lancet ; 338: Lakshminarayana, J. Singh B. Madhu (2009). Meta Analysis of micro nutrient deficiency disorders and their mapping in Western Rajasthan. DMRC, Jodhpur, Annual Report, Co-Published By: Human Resource Management Academic Research Society 185