Dietary Management of IndianVegetarian DiabeticsM. Viswanathan and V. Mohan

It was widely believed that the most diet" with carbohydrate comprising 60important principle of the diabetic diet percent of the total energy (Table 1).was to restrict carbohydrate intake. This When our patients subsisted on thisprinciple was also followed in India diet for periods up to 10 years, we foundthrough the 1950s. The typical diabetic that, contrary to existing beliefs, the car­diet of India in 1955 was similar to the bohydrate tolerance did not worsen. Inconventional (carbohydrate-restricted) fact, control of diabetes was better. Indiabetic diet used in Western countries most patients, the requirement of oraland that recommended by the American antidiabetes drugs was low16.

Diabetes Association? This carbohy- However, the protein content of thisdrate-restricted diet provided about 33 diet was considered insufficient. In orderpercent of energy from carbohydrate, 50 to provide a more balanced diet, we in­percent from fat and 17 percent from creased the protein content of the dietprotein. by adding vegetable proteins

The diet of an average Indian is like bengal gram, green gram and blackcereal-based and consequently rich in gram17. In India, even though manycarbohydrate which constitutes approxi- people use non-vegetarian foods, themately 80 percent of the total calories8. average intake of the non-vegetarianAs early as 1958, Viswanathan noted items is restricted to one or two meals inthat a marked reduction in the carbohy- a week. The amount of protein deriveddrate content of Ute diet of diabetic pa- from animal sources is hence meagretients resulted in drastic changes in the and this was the reason why we addedusual diet pattern which could not be vegetable proteins in the form of pulsesadhered to by the patients for long and legumes. The amino-acid profiles ofperiods of time. In order to achieve bet- proteins of cereals and pulses are suchtel' compliance, diabetic patients were as to complement each other in a man­instructed to follow their usual food pat- ner expected to ensure desired proteintern with reduction in the total caloric in- qualityB. Thus the diet became a Hightake, but were prohibited the use of free Carbohydrate High Protein Diet?sugar and sweets. This resulted in a diet About this time there was growingwhich we termed the "high carbohydrate interest in the subject of dietary fibre. In

Table 1: High Carbohydrate Diet of Diabetes Research Centre, Madras

GramsCaloriesPercentage

Carbohydrate

265106060Protein

5020010Fat

6054030

Total Calories

1800

collaboration with Dr. J. Anderson of the

University of Lexington, Kentucky, wecomputed the dietary fibre content of ourdiet. It was found that our diet provided

52 gms of dietary fibre which was doublethat of the American Diabetic Associa­tion's diet". Hence we renamed our diet

the "High Carbohydrate, High Fibre(HCHF) diet". Table 2 shows the com­position of the HCHF diet.

Type of carbohydrate: Cereals inthe form of rice and wheat are the staplefoods of the people of south and northIndia, respectively. Hence the carbohyd­rate we recommend for our patients inthe south is in the form of whole cereals,

chiefly rice.

Fats: The fat content of the diet isrestricted to the oil used in cooking. Atleast 50 percent of the fat is in the formof polyunsaturated fatty acids. Thecholesterol intake is reduced to less

than 300 mg/day.

Vegetables and fruits: By pre­scribing non-starchy vegetables con­taining only three to four percent ofenergy as carbohydrate (eg. greens,cucumber, drumstick, bitter gourd,banana-flower, cabbage, cauliflowerand ladies finger), the bulk of the mealwas increased and patients' hunger

• Dietary Management of IndianVegetarian Diabetics - M. Vis-wanathan and V. Mohan 1

• Prevention and Control ofAnaemia in India: Theory andPractice - B.S. Narasinga Rao 4

• Reviews and Comments: Controlof Anaemia - C.Gopalan 8

• Nutrition News 8

• Foundation News 8

satisfied without an appreciable in­crease in the total calories1B. Table 2: High Carbohydrate, High Fibre (HCHF) Diet of Diabetes Research

Centre, Madras

Table 4: Short-term Effects of High Carbohydrate, High Fibre Diets and OralAgents on 250 NIDDM Patients Hospitalised for One Week

GramsCaloriesPercentage

Carbohydrate

301120467Protein

8634419Fat

2825214

Total Calories

1800

Table 3: Sample Menu Plan 1800 Kcal Diet of DRC, Madras

Time

ItemServingsIngredientsAmountCalories

6A.M.

Coffee*1 cupMilk 60ml408A.M.

Idlis 4Nos.Rice

50gmS}Blackgram dhal25gms260

ChutneyCoconut

5gmS}Roasted bengal10gms60

gramdhaloror

Sambar1 cupRed gram dhal

20gmS}60

Vegetables20gms

Coffee1 cupMilk 60ml40

11 A.M.Buttermilk240mlMilk100ml65

1 P.M.Rice200gmsRice70gms220

Sambar1 cupDhal20gms60

Curds1 cupMilk120 ml80

Vegetables1 cupVegetables100gms20

Pulses3/4 cupWhole bengal gram25gms90

4P.M.Coffee1 cupMilk 60ml40

Vadas2 Nos.Bengalgram dhal

25gmS}140

Oil5gms

6P.M.Tomato Juice200mlTomatoes100gms20

8P.M.Rice200 gmsRice70gms220

Sambar1 cupDhal20gms60

Curds1 cupMilk120ml80

Vegetables1 cupVegetables100gms20

Pulses3/4 cupWhole gram25gms90

BedTimeMilk1 cupMilk120 ml80

Oil15 gms135

Total Calories

1820

* 1cup = 120 ml

Fibre content: As already men­tioned, the use of whole cereals, pulsesand leafy vegetables helps to increasethe fibre content of the diet. Hence, we

do not add any artificial or purified fibreto the diet except in certain special situa­tions. A sample menu plan for a 1,800­calorie diet is given in Table 3.

Beneficial Effects OfHCHF Diets In Diabetes

Glycemic control: Short-termstudies at our centre showed that the

HCHF diet, when used in conjunctionwith small doses of oral hypoglycaemicagents, helps to achieve rapid control ofdiabetes19. On long term follow-up, theeffect on blood glucose level was sus­tained for several years21.

Lipid profile: Studies at our centreshowed that there was a consistent re­

duction in the plasma cholesterol andtriglyceride levels. These effects weresustained for long periods of time20,21.Tables 4 and 5 summarise the short­

term and long-term effects of HCHFdiets on plasma glucose and lipid pro­files.

Improvement in insulin sensitiv­ity: The mode of action of the high car­bohydrate, high fibre (HCHF) diet in

diabetes was studied by measuring theimmunoreactive insulin (IRI) levels inpatients at the beginning and after con­

trolof hyperglycaemia with diet therapy22.The data showed that the HCHF diet did

not cause hyperinsulinism, but on theother hand, the mean IRI concentrationcame down with a concommitant reduc­

tion in blood sugar. This suggests thatthe diet acts by increasing the peripheralsensitivity to insulin perhaps by improv­ing the insulin receptor number and/oraffinity at post-receptor levels.

Parameter

Body weight, kgFasting values, mg/dl

Blood glucoseSerum cholesterolSerum triglyceride

Initial

62.6 ± 0.7

207 ± 7268 ± 7153 ± 9

Final

61.9 ± 0.7

142 ± 7"238 ± 4b130 ± 5c

Studies on glycemic responsesof South Indian breakfast items: In a

recent study23, we investigated theglycemic and insulin responses to fourcommon breakfast items, namely, idli,pongal, uppuma and bread in South In- .dian non-insulin dependent diabeticsubjects. The breakfast provides 300 Kcals of which complex carbohydratecontributed 68-81 percent, proteins 12­14 percent, fat 8-19 percent of totalcalories and the dietary fibre content

ap VS. initial < 0.001,. bp <0.01,. cp <0.05

Values represent Mean ± SEM

varied from 3.8 g to 7.4 g. The results in­dicated that pongal, uppuma and idliwere suitable for diabetics as their

glycemic responses to the test foodswere low. Bread was considered unsuit­

able as its glycemic response was ashigh as that of glucose. A number ofparameters like the mode of cooking

2

and processing, the form of food and thedifferences in food constituents which

affect digestion, absorption andmetabolism seem to influence the

glycemic and insulin responses.Other workers in India9,10,11,14have

also noted the beneficial effects of highcarbohydrate diets for diabetic patients.

\,

Table 2: Dietary Iron Requirements (RDA) Expressed as mg/1000 Kcal*

• Hookworm infestation was present .•• Report of Working Group on Fortification of Salt (1982); Am. J. Glin. Nutr. 34: 1442.

• IGMR (1990) Recommended Dietary Allowance for Indians.Report of an Expert Group.•• Reference person with moderate activity.

Prevention And Control Of AnaemiaIn India: Theory And Practice

B.S. Narasinga RaoConsequences of anaemia:

Anaemia, characterised by decreasedlevels of circulating haemoglobin andtissue iron contents, is known to lead toseveral functional abnormalities withhealth consequences. The conse­quence of a mild form of anaemia is notyet clearly recognised. Although mildanaemia with haemoglobin levels above10 g/d is not known to result in any seri­ous impairment of function, moderate tosevere anaemia is known to have sev­eral functional consequences. They in­clude the following:

Impaired maximal work capacity4;decreased immunological competence2;behavioral abnormalities and reducedlearning ability among children18; poorpregnancy outcome24.

among the vulnerable groups who sufferfrom varying degrees of energy (food)deficiency.

Table 1: Prevalence of Anaemia in Rural India **

Percent Anaemia PrevalenceAge

SexHyderabadDelhiCalcutta'

(Years)

CentreCentreCentre

1-5

M+F65.9 59.095.4

6-14M55.0 72.4961

F65.3 69.497.0

15-22M38.7 65.190.1

F692 63.796.7

25-44M801 57.388.6

F71.4 71.396.4

",,45M+F47.6 59.392.4

RecommendedDietary Iron RequirementGroup

Energy Intakemg/dmg/1000 KcalKcal/dChildren

1-3 Yrs12401159.34-6 Yrs

169018.410.97-9Yrs

195026.013.3

Adolescent Boys

10-12Yrs219034.215.613-15 Yrs

245041.416.916-18 Yrs

264049.518.8

Adolescent Girls

10-12Yrs197018.99.613-15 Yrs

206028.013.616-18 Yrs

206029.914.5

Adults"

Men287528.09.7Women

222530.013.5

Pregnant Women252537.514.9

Lactating Women'277530.010.8

diets are highly correlated (r=O.769)presumably because a major proportionof both dietary iron and energy are de­rived from cereals 11. Apart from in­adequate content of iron, reduced intakeof energy (food) which is widely seenamong the poor in the country, furtherreduces daily iron intake. This is particu­larly so among young children, womenand pregnant women. This is evidentfrom Table 3 where dietary iron intakes(corrected for contaminant iron) arecompared with RDA. It is, therefore, notsurprising that there is widespread diet­ary iron deficiency in India, particularly

Anaemia is a major nutritional defi­ciency disorder in India and other de­veloping countries22. Large populationsurveys in rural India23indicate that theprevalence of anaemia in India accord­ing to WHO criteria21ranges from 38-72percent depending upon age and sex(Table 1). Hookworm disease, malariaand other infections, if present, furtheraggravate iron deficiency anaemia andincrease its prevalence. The most vul­nerable groups are pregnant womenand preschool children among whomprevalence of anaemia may exceed 70percent. The main cause of anaemia inIndia is iron deficiency although folatedeficiency contributes to anaemiaamong pregnant women and preschoolchildren16.

Etiology: The main cause of irondeficiency is inadequate food intake aswell as poor bioavailability of dietaryiron11in the habitual cereal-based diets.Bioavailability of iron from predomin­antly cereal-based habitual diets in Indiahas been shown, with radio isotopictechnique, to range between 1.5 and 6percent depending upon the type ofcereal in the diet15. Apart from phytate,tannins present in Indian diets suppressiron absorption to a significant extent13.The chemically determined iron contentof the diets eaten in India is apparentlyhigh, namely 14.8 mg per 1000 Kcal,but when corrected for the presence of asignificant amount (30 percent) of unab­sorbable "contaminant" iron, the truedietary iron content reduces to 10.4 mg/1000 KcaP7. Iron requirement of Indiansrecommended recently6, when expres­sed on the basis of recommendedenergy intakes, range from 9.8 to 18.8mg per 1000 Kcal (Table 2). Thus the"true" iron content of habitual diets ofabout 10 mg/1000 Kcal, can meet theiron requirements of adult men, childrenof one to six years and lactating women,provided their dietary intake meets theirenergy requirements. However, in orderto meet the iron requirements of othergroups, either the bioavailability of ironfrom their diets has to be improved orthe diets have to be supplemented withadditional 3-9 mg of iron per 1000 Kcal.

Energy and iron intakes on Indian4

Table 2: Dietary Iron Requirements (RDA) Expressed as mg/1000 Kcal*

• Hookworm infestation was present.•• Report of Working Group on Fortification of Salt (1982); Am. J. Clin. Nutr. 34: 1442.

• ICMR (1990) Recommended Dietary Allowance for Indians.Report of an Expert Group.

•• Reference person with moderate activity.

Prevention And Control Of AnaemiaIn India: Theory And Practice

B.S. Narasinga RaoConsequences of anaemia:

Anaemia, characterised by decreasedlevels of circulating haemoglobin andtissue iron contents, is known to lead toseveral functional abnormalities withhealth consequences. The conse­quence of a mild form of anaemia is notyet clearly recognised. Although mildanaemia with haemoglobin levels above10 g/d is not known to result in any seri­ous impairment of function, moderate tosevere anaemia is known to have sev­eral functional consequences. They in­clude the following:

Impaired maximal work capacity4;decreased immunological competence2;behavioral abnormalities and reducedlearning ability among children18; poorpregnancy outcome24.

among the vulnerable groups who sufferfrom varying degrees of energy (food)deficiency.

Table 1: Prevalence of Anaemia in Rural India **

PercentAnaemiaPrevalenceAge

SexHyderabadDelhiCalcutta*(Years)

CentreCentreCentre

1-5

M+F65.9 59.095.46-14

M55.0 72.496.1F

65.3 69.497.015-22

M38.7 65.190.1F

692 63.796.725-44

M80.1 57.388.6F

71.4 71.396.4~45

M+F47.6 59.392.4

RecommendedDietaryIron RequirementGroup

Energy Intakemg/dmg/1000KcalKcal/dChildren

1-3Yrs124011.5934-6Yrs

169018.410.97-9Yrs

195026013.3

AdolescentBoys

10-12Yrs219034.215.613-15Yrs

245041.416.916-18Yrs

264049.518.8AdolescentGirls

10-12Yrs197018.99613-15Yrs

206028.013.616-18Yrs

206029.914.5Adults··

Men28752809.7Women

222530.013.5PregnantWomen

252537.514.9LactatingWomen

"277530010.8

diets are highly correlated (r=0.769)presumably because a major proportionof both dietary iron and energy are de­rived from cereals11. Apart from in­adequate content of iron, reduced intakeof energy (food) which is widely seenamong the poor in the country, furtherreduces daily iron intake. This is particu­larly so among young children, womenand pregnant women. This is evidentfrom Table 3 where dietary iron intakes(corrected for contaminant iron) arecompared with RDA. It is, therefore, notsurprising that there is widespread diet­ary iron deficiency in India, particularly

Anaemia is a major nutritional defi­ciency disorder in India and other de­veloping countries22. Large populationsurveys in rural India23indicate that theprevalence of anaemia in India accord­ing to WHO criteria21ranges from 38-72percent depending upon age and sex(Table 1). Hookworm disease, malariaand other infections, if present, furtheraggravate iron deficiency anaemia andincrease its prevalence. The most vul­nerable groups are pregnant womenand preschool children among whomprevalence of anaemia may exceed 70percent. The main cause of anaemia inIndia is iron deficiency although folatedeficiency contributes to anaemiaamong pregnant women and preschoolchildren16.

Etiology: The main cause of irondeficiency is inadequate food intake aswell as poor bioavailability of dietaryiron11in the habitual cereal-based diets.Bioavailability of iron from predomin­antly cereal-based habitual diets in Indiahas been shown, with radio isotopictechnique, to range between 1.5 and 6percent depending upon the type ofcereal in the diet15. Apart from phytate,tannins present in Indian diets suppressiron absorption to a significant extent13.The chemically determined iron contentof the diets eaten in India is apparentlyhigh, namely 14.8 mg per 1000 Kcal,but when corrected for the presence of asignificant amount (30 percent) of unab­sorbable "contaminant" iron, the truedietary iron content reduces to 10.4 mgl1000 KcaP7. Iron requirement of Indiansrecommended recently6, when expres­sed on the basis of recommended

energy intakes, range from 9.8 to 18.8mg per 1000 Kcal (Table 2). Thus the"true" iron content of habitual diets ofabout 10 mg/1000 Kcal, can meet theiron requirements of adult men, childrenof one to six years and lactating women,provided their dietary intake meets theirenergy requirements. However, in orderto meet the iron requirements of othergroups, either the bioavailability of ironfrom their diets has to be improved orthe diets have to be supplemented withadditional 3-9 mg of iron per 1000 Kcal.

Energy and iron intakes on Indian4

• Corrected for contaminant iron (30%)

Iron absorption from diets. Men and Children 3%, Women 5%, Pregnant women 8%.

Table 3: Dietary Iron Intake by Indians and its Adequacy

Although a moderate degree ofanaemia may not seriously affect day­to-day work, most of which correspondsto sedentary to moderate level of activ­ity, impaired work capacity is seen onlyin those engaged in hard physical labourwith moderate to severe anaemia22. Irondeficiency anaemia with haemoglobinlevel below 10 g/dl is known to reducecell mediated immunity20. Anaemia ofpregnanCY is known to cause increasedmaternal morbidity and mortality; in­creased fetal morbidity and mortality; in­creased risk of low birth weight.

The Control OfAnaemia In India

Iron fortification programme: Thetwo obvious approaches to the control ofanaemia are:• Increasing the iron content of the dietby inclusion of iron rich foods like greenleafy vegetables and/or enhancing ironbioavailability in the existing diets by in­clusion of foods rich in absorption prom­oters like ascorbic acid and animal foods

like fish and meat22.This approach - im­portant as it is - is a long-range effortwhich may not yield results in the im­mediate future.

• The alternative approach is to in­crease iron intake through fortification ofa universally consumed food item withiron. Iron fortification has been attemp­ted in several countries?, and in India ahighly successful technology for the for­tification of common salt with iron hasbeen developed14•

Iron fortified salt has been exten­

sively tested in the community10.23andits effectiveness in improving iron statusand reducing the prevalence of anaemiahas been clearly demonstrated. Themerit of this technology is that the vehi­cle used for fortification, namely salt, isuniversally consumed by all segmentsincluding the poor among whomanaemia is much more prevalent.

65.5"

60.0'"70.080.090.0

100.0

Daily doseof iron

supplement(mg)**

Daily ironneeded for

a45 Kgwoman;absorbed

dose (mg)

5.06.07.08.09.0

10.0

salt could be introduced in areas of thecountry where both anaemia and goitreare prevalent and iron-fortified salt couldbe introduced in the rest of the countrywhere only anaemia is prevalent. Thesame formula developed for the doublefortified salt can be used for the man­

ufacture of iron fortified salt also byomit­ting the addition of iodine.

If the iron balance in the total popu­lation is improved through iron-fortifiedsalt, the anaemia prophylaxis prog­ramme among pregnant women throughdistribution of folifer tablets will have bet­ter success. Iron fortification of salt isbeing suggested as an adjunct and notas an alternative to the present anaemiaprophylaxis programme.

Anaemia prophylaxis throughsupplementation of medicinal iron(tablets): The most vulnerable groupswith regard to anaemia prevalence arewomen, pregnant women and preschoolchildren. In the background of wide­spread prevalence of anaemia amongwomen, the stress of pregnancy with itsincreased demand for iron further aggra­vates anaemia. Dietary iron requirementduring the second and third trimester ofpregnancy is 25 mg/1000 Kcal. A normaldiet with 10 mg/1000 Kcal can hardlymeet the iron requirement during pre­gnancy. Therefore additional iron sup­plementation is needed in the form ofmedicinal iron. This widely recognisedtherapeutic iron suplementation is re­commended during pregnancy even forwomen who start their pregnancy withnormal haemoglobin levels. If a womanstarts her pregnancy not with a normallevel of haemoglobin but with variousdegrees of anaemia as it happens with

Daily Iron Requirement For(iLg/Kg/d.)

Correcting Pregnancy Totalanaemia demand*

Percent Adequacy

646189

634579

Haemoglobinlevel (g/dl)

Final

Average* dietaryiron intake

7.711.022.519.717.123.7

Table 4: Daily Dose of Elemental Iron Required to Correct Anaemia and toProvide for Pregnancy Needs

12 120110110

11

122211013210

12441101549

12661101768

12881101987

12110110220

Initial

• Assuming 75% of total iron requirement to be provided during the last 100 days."Absorption 8% in non-anaemic""Absorption 10% in anaemic (Hb < 11 g/dl).

Although the technology for the for­tification of salt has been available for

the past one decade, it has not been in­troduced on a large scale to combat irondeficiency anaemia in India, despitebeing strongly recommended23. Iron for­tified salt is currently being produced ona small scale only by a few private man­ufacturers and by the Food and NutritionBoard of the Ministry of Food and Ag­riculture. Large-scale introduction ofiron-fortified salt is currently being or­ganised only in Tamil Nadu by the TamilNadu Government with support fromUNICEF, Food and Nutrition Board andTamil Nadu State Industrial Corporation.

A possible reason for the hesitationto introduce the fortification programmeon a countrywide scale may be the ap­prehension that it might impede andcomplicate the important ongoing salt io­dation programme to combat iodine defi­ciency.

In view of this, a new technology forthe double fortification of salt with ironand iodine has been recently de­veloped12;and this is currently undergo­ing field evaluation. The double-fortified

RDA for Iron

mg/d

121828

30

3830

Sex

M+FM+F

MF

1-34-7Adult

Pregnant WomenLactating Women

AGE

(Years)

Table 5: Haemoglobin Responses to Different Doses of Elemental Ironin Pregnant Women with Different Initial Hb Levels

Non-anaemic subjects: In a studyby Iyengar et a/9 pregnant women were

Duration of Final Hb level at different doses of Reference

supplementation iron and 500 /Lg of folate No.(weeks) (mg/d)

30 60 120 240

the majority of pregnant women in ourcountry, therapeutic supplementation tosuch women should cover both her re­

quirements of iron during pregnancyplus the amount needed to correct theexisting anaemia3,7.

,y~~-

anaemia and to maintain haemoglobinlevel at 11 g/dl or above, a daily supple­mentation of 120 mg iron with 500 fLg

folate for the last 100 days of pregnancywould be required. The haemoglobinlevel in this study did not increasebeyond 11 g/dl even with a dose of 240mg given for 10 weeks. The explanationfor this, however, is not clear. This as-pect requires further study.

The results of the two supplementa­tion studies in India indicate that alongwith iron, supplementation with folate(although not vitamin B12) is also essen­tial for maximal response. If the womenare non-anaemic with haemoglobinlevels above 11 g/dl a dose of 60 mgiron is adequate to maintain haemoglo­bin levels and apparently meets the ironneeds of pregnancy. However, amonganaemic pregnant women a dose of 120mg iron is needed to correct moderateand severe forms of anaemia and tomeet the iron requirement of pregnancy.

Although appropriate dosage of ironfor therapeutic intervention, to controlanaemia of pregnancy, has been deter­mined through pilot supplementationstudies, their adoption for the anaemiaprophylaxis programme through primaryhealth care is beset with many practicaldifficulties. One has to contend with sideeffects like epigastric discomfort,nausea, vomiting and constipation anddiarrhoea which oral administration ofiron causes. The frequency of such sideeffects is directly related to the dose ofiron. These side reactions do adverselyaffect compliance. There have beenstudies designed to minimise these sideeffects and maximise the acceptance ofthe tablets7,22. A balance must bestruck between the dose, time of con­sumption of tablets, compliance and thedesired biological response. Althoughthe ideal objective would be to eliminateanaemia completely by raising haemog­lobin level above 11 g/dl, a more modestand practical objective would be to elimi­nate severe and moderate anaemia byraising haemoglobin level above 10 g/dlwhich can prevent adverse conse­quences.

From the studies discussed above,it would appear that two-dose schedulemay have to be adopted in theprophylaxis programme. One for thenon-anaemics, that is 60 mg iron, and ahigher dose of 120 mg (60 x 2) foranaemics. The two-dose (60 x 2) regi­men for the anaemics may have lessside effects. The practical problemwould be to identify anaemic subjects by

supplemented with 30 mg of iron dailywith and without 500 fLg folate and 2 fLg

vitamin B12. The subjects of this studywere apparently non-anaemic with anaverage haemoglobin level of 12.8 g/dl.When these subjects were supple­mented for 12-16 weeks with a dose of

30 mg iron and 500 J.L9 folatedaily,the aver­age haemoglobin level decreased by 1gindicating that a daily dose of 30 mg ofiron is not sufficient to maintain the

haemoglobin level unaltered in non­anaemic pregnant Indian women. In asubsequent study, Iyenga~ studied theeffect of supplementation of 60 mg ironplus 500 fLg of folate daily to non­anaemic pregnant women with an aver­age haemoglobin level of 13.0 g/dl. Atthe end of six weeks of supplementationthe average haemoglobin remained un­altered at 13.6 g/dl. It can be concludedfrom these two studies that in non­

anaemic pregnant women a daily sup­plement of 60 mg elemental iron with500 fLg of folate is appropriate to meetthe iron needs of pregnancy. Both thesestudies confirm the need for folate sup­plementation to obtain optimal re­sponse.

Anaemic subjects: In another sup­plementation study1922 amongst Indianpregnant women with varying degreesof anaemia, the haematological re­sponse to different daily doses of ironfrom 30 mg to 240 mg with 500 fLg folateand vitamin B12 was investigated. Theresults of this study (Table 5) indicatedthat a maximal response after 10 weeksof supplementation was obtained with120 mg iron and 500 fLg folate. Increase­ing the daily dose to 240 mg did notfurther. improve haemoglobin level toany significant extent. the mean maxi­mal haemoglobin level reached in thisstudy ranged between 10.1 to 11.3 g/dldepending on the initial level of haemog­lobin. It would appear that to correct

12-16 11.9 9

6

13.6 8

10

8.79.1 10.110.110

10.010.110.710.719

10

11.311.211.211.3

6

Non-Anaemic12.813.0

Anaemic7.09.0

11.0

Initial Hb level(g/dl)

Dosage of iron supplementation:The dosage of elemental iron to be usedin the therapeutic supplementation dur­ing pregnancy has been a subject ofmuch discussion and controversy.

The amount of iron to be supple­mented during the later half of pre­gnancy during the last 100 days can becomputed from the initial haemoglobinlevel, final haemoglobin level to bereached, and the normal requirement ofiron during the later half of pregnancy.Such computations for a 45 kg Indianpregnant woman with initial haemoglo­bin level ranging from 7-12 g/dl aregiven in Table 4. The average iron ab­sorption from a therapeutic dose of irongiven on an empty stomach has beenassumed to be 8 percent in case of nor­mal and 10 percent in case of anaemicsubjects. Iron absorption in anaemicsubjects will be initially high and it de­clines as anaemia is corrected and the

average figure may correspond to about10 percent. It is seen from Table 4 thatthe theoretical dose of elemental iron(ferrous) is about 60 mg in non-anaemicand 100 mg in anaemic pregnantwomen.

The actual dose of iron requiredand the need for other haematenics like

folate and B12 in correcting or preventinganaemia of pregnancy has been deter­mined by controlled therapeutic supple­mentation trials22. Two such studieshave been reported from India9•19.Somesignificant results of these studies aregiven in Table 5.

a simple field test.Another important hurdle in the suc­

cessful operation of the iron-folate tabletdistribution programme is the lack ofmotivation on the part of the be­neficiaries to accept the tablets and con­sume them regularly particularly sinceanaemia, especially in its mild and mod­erate forms, is not perceived by thecommunity as ill health. A strong educa­tional programme to improve com­pliance is therefore essential for the suc­cess of the programme.

Table 6: Recommendations of the leMR Task Force on Evaluationof NAAP

1. All the pregnant women to be covered, since there are no simple methods of identifyinganaemics.

2. Education of the health functionaries involved in implementation of the programme at alllevels.

3. Periodic checking of the quality of tablets.4. Pilot study to find out the best strategy for delivery of the supplement.5. Ensuring adequate and regular supply of the supplement at the PHC level.6. Ensuring the quality of tablets with regard to its contents as well as the coating.7. A rationalised fixing of targets in different states based on population statistics.8. To consider alternate strategies as additional measures to control nutritional anaemics.

The Current AnaemiaProphylaxis Programme In India

A study group on nutritionalanaemia of the Nutrition Society of Indiarecommended in 1968 an anaemiaprophylaxis programme for the eradica­tion of anaemia of pregnancy and child­hood16. According to this Expert Group,the most practical and expeditious wayof doing this is to give supplements of ironand folate to anaemic pregnant womanduring the last 100 days of pregnancy.Based on the results of controlled sup­plementary trials then available andtheoretical computations, the Group re­commended 60 mg of elemental iron inthe form of ferrous compound and 500p.g of folic acid. They recommended atleast 50 percent of all pregnant womento be covered during the first five years.They suggested the use of PHC, thesubcentre and MCH Centres as outlets forthe distribution of tablets. They alsogave a plan for distribution of tablets andtheir quality control. They also em­phasised the educational component tomotivate the women and periodic evalu­ation of the impact of the programme.

In pursuance of the above recom­mendations, the Government of Indiahad set up the National AnaemiaProphylaxis Programme (NAPP) in1970 in all States of the country. Thetarget population under this programmecomprise pregnant women, lactatingwomen, family planning acceptorwomen (of terminal methods andI.U.D.s) and children of both sexes be­tween one and 11 years (both years in­clusive). The supplementation providedunder this programme consists of tab­lets of iron folate containing 60 mg ofelemental iron (ferrous sulphate) and500 p.gfolic acid for all adult woman be­neficiaries. For children smaller tabletscontaining 20 mg elemental iron(FeS04) and 100 p.gfolate are provided.For children who cannot swallow tablets,iron and folic acid in the same dose as in

single tablet is given in 2 ml of syrupy liq­uid.

Each beneficiary is given one tabletdaily for a period of 100 days once ayear for every year of his/her beneficiarystatus.

Although the programme has beenin operation for more than 15 years, noimprovement in anaemia prevalencewas discernible as several studies con­ducted during this period indicated.There were many speculations as to thecause for the lack of impact of the prog­ramme. One reason that was stronglyadvanced was that the dose of iron

given to pregnant women was insuffi­cient and there were proposals to in­crease the dose to 120 or 240 mg/daybased on a study in India19, A multi-cen­tric field study to test different doses ofiron, namely 60, 120, 180 and 240 mgwas organised by ICMR; though thestudy is reported to have been com­pleted the results of this study are notavailable. However, an evaluation of theprogramme in 11 states of the country,conducted by the ICMR during 1985-865yielded the following depressing conclu­sions

• The programme has not made anysignificant impact on the prevalence ofanaemia.

• The important drawback of the prog­ramme was that a large proportion of thewomen did not receive the tablets due to

poor supply of tablets to PHC.• The monitoring of supply of tabletsand their distribution as well as com­

pliance were far below the desired level.• There were also the problems of thepoor quality of the tablets.

Apparently the programme has re­mained all these years as a "low prior­ity" programme! Another aspect of theprogramme which has not been high­lighted is adequacy of production offolifer tablets and the availability ofchemicals.

Arising from the evaluation, certainrecommendations for the improvementof the programme have been made(Table 6). Another important point thathas not been mentioned in the recom­mendation is the question of dosage ofiron. Iron dosage to anaemic pregnantwomen should be 120 mg/day. It couldbe delivered as a single tablet or twotablets of 60 mg3 each,by which side ef­fects can be reduced. There is also aneed to improve the appearance of thetablet viz. the changeover from brown tored colour. Hopefully the implementationof these guidelines will improve theprogramme.

It is clear that present efforts to­wards prevention and control ofanaemia in the country are wholly in­adequate. To a considerable extent thiscould be a reflection of the general in­adequacies of our health system with re­spect to the delivery of health care. Withimproved outreach, and greater motiva­tion of health workers and of the com­

munity, it should be possible to promotebetter implementation. Better linkagesbetween the ICDS and the health sys­tem could facilitate wider coverage.

While medicinal iron supplementa­tion to selected groups at risk is impor­tant, the need to augment dietary intakeof iron·must be recognised as this is theobvious logical approach.

The studies of Agarwal and col­leagues1 indicate that supplementationof iron in pregnancy, after the formationof the placenta, may not result in signifi­cant benefit to the offspring. This obser­vation, considered in the light of the factthat anaemia is widespread in adoles­cent girls well before they enter pre­gnancy, should serve to underscore theimportance of dietary improvement inany programme for combating anaemia.

The author is former Director, National Institute of

Nutrition, Hyderabad.

FOUNDATIONNEWS

NUTRITIONNEWS

and anganwadi workers should be en­couraged to contact girls immediatelyaft,e,rmarriage fqr this purpose as part ofa revised plan of operation for control ofanaemia of pregnancy. It will be fareasier to ensure the acceptance and in­take of iron folate tablets in pregnancy, ifgirls have been properly educated andconditioned in this regard even beforethe onset of pregnancy.

With this strategy, even if the supplyof iron folate tablets to the girls is some­what irregular and cannot be rigidly en­sured on a daily basis (as is bound to bethe case given the weaknesses of ourhealth system), the chances of ourmitigating the anaemia problems wouldbe far brighter. The additional cost in­volved may not be great; among newlymarried girls of poor income group, thetime lag between the consummation ofmarriage and the onset of pregnancy isgenerally no more than a few months.

C. Gapalan

• The meeting of the National Commit­tee for IUNS was held on February 18,1991, at the INSA office under the chair­manship of Dr. C. Gopalan.• The sixth Asian Congress of Nutritionwill be held on October 16-19, 1991, atKuala Lumpur, Malaysia. The ScientificProgramme includes seven plenary lec­tures and 20 symposia. Full details ofthe programme can be obtained fromDr. Chong Yoon Hin, President of theOrganising Committee, at the followingaddress: Dr. Chong Yoon Hin, SpecialAdviser to DG, PO RIM, NO.60,PersiaranInstitusi, Bandar Baru Bangi, 43000Kajang, Selangor, Malaysia.

Control Of Anaemia

REVIEWS ANDCOMMENTS

References

Copies of Scientic Report 11,Growth Performance Of Affluent Indian

Children (Under-fives):Growth Standard For Indian Childrenare now available (Rs.50 in India and $5

overseas) and can be had from the office ofthe Nutrition Foundation of India, India

International Centre, Lodi Estate,New Delhi 110 003.

Anaemia is the most widespread,and yet the most neglected nutritionaldeficiency disorder in the country today.With minimal inputs, well within our na­tional resources, we should be able tocontrol this problem, if not to eradicate it.Our failure, thus far, to effectively con­tain this problem is perhaps traceable toa basic defect in our strategy. The facileassumption that anaemia of pregnancycan be combated. through the conven­tional approach of providing iron-folatetablets to pregnant women during thelast trimester of pregnancy needs to becritically re-examined in the prevailingcontext of widespread prevalence ofanaemia in our children.

The great majority of adolescentgirls of poor income groups in our coun­try today suffer from anaemia. Accord­ing to WHO criteria, 65 percent to 70percent of girls between 6 to 14 years ofage in Hyderabad and Delhi areas, anda much larger percentage in the Cal­cutta area (see Table 1 in the above arti­cle) were reported to be anaemic. In aconsiderable proportion the anaemia isof moderate and severe degree.

It is thus obvious that a high propor­tion of girls in the country are alreadyanaemic (some of them moderately andsome severely so) before starting ontheir pregnancy. Pregnancy only servesto aggravate the pre-existing anaemia.

Under the circumstances, it seemsdoubtful if the conventional approach ofproviding 100 or even 200 tablets of ironfolate during the last trimester of pre­gnancy will really meet the situation,even if through efficient management,our health services do succeed in deliv­ering the tablets to pregnant women. Weneed a radical departure in our strategyfor combating anaemia of pregnancy.

Iron folate tablets should be made

freely available to all girls in the country- • Task Force Meeting on the ongoingside immediately after the consumma- project on "Education for better living fortion of marriage. Iron folate supplemen- rural adolescent girls" was held on Feb­tation in the case of these anaemic girls ruary 5, 1991, at the India Internationalshould start at the time of marriage, not Centre, New Delhi.when they are more than half way • Task Force Meeting on the ongoingthrough their pregnancies. It may be project on "Effect of supplementary nut­wrong strategy to wait for the arrival of rition during the last trimester of pre­pregnancy. The intake of iron folate tab- gnancy on the birth weight and sub­lets by newly married girls should be ac- sequent growth of the infants" was heldtively promoted through an intensive on March 29, 1991, at the India Interna-education programme. Health workers tional Centre, New Delhi.

Editedby RavinderChadhafortheNutritionFoundationof India,B·37GulmoharPark,NewDelhi.Designedandproducedby MediaWorkshop.Typesetat Fototype.PrintedatVashimaPrinters.

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sequences of nutritional anaemia. Proc. Nutr.Society (in press).2. Dallman, P.A. (1987): Am. J. Clin. Nutr. 46,P.329.

3. DeMeyer, E.M. (1989); Prevention and con­trolling of iron deficiency anaemia through pri­mary health care, WHO, Geneva.4. Hallberg, L., and Scrimshaw, N.S. (Ed.)(1981): Iron deficiency and work performance,INACG, Washington D.C.5. ICMR (1989); Report of a Task ForceStudies on the evaluation of National Anaemia

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11. Narasinga Rao, B.S. (1983); Proc. Nutr.Soc. 28 : P.1.12. Narasinga Rao, B.S. (1990); Double fortifi­cation of salt. Proc. Nutr. Society (in press).13. Narasinga Rao, B.S. and Prabhavati, T.(1982); J.Sc. Food Agr. 33:89.14. Narasinga Rao, B.S., and Vijayasarathi, C.(1975); Am. J. Clin. Nutr. 28: 1395.15. Narasinga Rao, B.S., Vijayasarathi, C. andPrabhavati, T. (1983); Ind. J. Med. Res. 77: 648.16. Nutrition Society of India (1968); NutritionalAnaemia Report of an Expert Group.17. Prabhavati, T. and Narasinga Rao, B.S.(1981); Ind. J. Med. Res. 74: 37.18. Pollitt, E. and Liebel, A.L. (Ed.) (1982): IronDeficiency. Brain Biochemistry and Behaviour,Raven Press.

19. Sood, S.K. et al (1975); Quart. J. Med. 44:241.20. Srikantia, S.G., Prasad, J.S., Bhaskaram, C.

and Krishnamachari, KAV.A. (1976); LancetI: 1307.

21. WHO (1968); Nutritional Anaemia, Reportof a WHO Scientific Group Tech. Rep. Ser. No.405.

22. WHO (1975); Technical Report Series 580,Control of Nutritional Anaemia with speCial re- 'ference to iron deficiency.23. Working Group on Fortification of Salt(1982); A Report. Am. J. Clin. Nutr. 34,1442.24. Yusufji et al (1973): Bull. World Health Or­ganisation, 48, P. 15.