Describe iron deficiency anaemia as a public health problem.

Iron Deficiency Anaemia

• The WHO cut-offs — below 11 g/dL in children 6 to 59 months and in pregnant women; below 11.5 in children 5 to 11 years; below 12 in non-pregnant women; and below 13 in adult men
• The causes in India are multiple, and treating them all as iron deficiency is the reason programmes underperform:
• Nutritional — low dietary iron; and, more importantly, low bioavailability
• The bioavailability problem IS the heart OF the INDIAN situation — haem iron from animal foods is absorbed at 20 to 30%, whereas non-haem iron from plant foods is absorbed at only 1 to 5%
• Predominantly vegetarian Indian diets therefore supply iron that is present but poorly absorbed, so the total intake figure is misleading
• Inhibitors of absorption — phytates in cereals and pulses; tannins in tea and coffee; oxalates; calcium; and excess fibre
• Enhancers — vitamin C, which is the most important; animal protein; and fermentation, germination and soaking, which reduce phytate
• The practical counselling that follows is specific and easily given — avoid tea with or immediately after meals, and take a source of vitamin C (lemon, amla, guava, tomato) with the meal
• Increased demand — infancy, adolescence, pregnancy and lactation
• Blood loss — hookworm infestation, which remains an important cause in India; menorrhagia; repeated pregnancy; and peptic ulcer and malignancy in adults
• Other non-iron causes that programmes have historically ignored — vitamin B12 and folate deficiency; malaria; haemoglobinopathies — sickle cell disease and thalassaemia, which are common in specific Indian populations; chronic disease and inflammation; and fluorosis
• The recognition of these is a major reason for the design of anaemia MUKT BHARAT, which explicitly includes testing, treatment and attention to non-nutritional causes rather than iron alone
• The consequences — fatigue and reduced work capacity, with measurable economic loss; impaired cognitive development and school performance in children, which is partly irreversible; reduced immunity; and, in pregnancy, maternal mortality, preterm birth, low birth weight and perinatal death
• Anaemia in pregnancy is a leading contributor to maternal death in India, both directly and by reducing tolerance of haemorrhage
• Prevention and control — the 6 x 6 x 6 strategy of anaemia MUKT BHARAT:
• Prophylactic iron and folic acid, in age-appropriate doses and colours — syrup for infants, pink tablets for children, blue for adolescents and red for pregnant and lactating women and women of reproductive age
• Pregnant women receive iron and folic acid for at least 180 days during pregnancy and 180 days postpartum
• Deworming with albendazole biannually
• Intensified behaviour change communication, including the tea and vitamin C advice
• Testing and treatment, using digital haemoglobinometers at point of care
• Mandatory fortification, including double fortified salt and fortified rice
• Addressing non-nutritional causes — malaria, fluorosis and haemoglobinopathy in endemic areas
• The reasons supplementation has underperformed — poor compliance, driven by gastrointestinal side effects; irregular supply; low awareness of the need to continue when feeling well; and failure to address the non-iron causes
• Side effects are reduced by taking iron after food, starting at a lower dose, or giving it on alternate days, which recent evidence suggests may be as effective and better tolerated
• Bioavailability matters more than intake, since non-haem iron is absorbed at a fraction of the haem rate
• No tea with meals, and vitamin C with them, which are two specific pieces of counselling that actually work
• Treat anaemia as more than iron; B12, folate, malaria, hookworm and haemoglobinopathy all contribute
• Alternate-day iron may be as effective and better tolerated, which addresses the compliance problem directly
• Anaemia contributes to maternal death both directly and by reducing tolerance of haemorrhage
• Cognitive damage in children is partly irreversible, which is why prevention matters more than treatment
• Colour-coded tablets by age group simplify a complex regimen for frontline workers and families
• One hundred and eighty days in pregnancy and the same postpartum, which is the schedule to quote
• Fermentation and germination reduce phytate, which is a traditional practice with a sound nutritional basis