nutrition volume 30 issue 7-8 2014 india

8/19/2019 Nutrition Volume 30 Issue 7-8 2014 India

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Accepted Manuscript

Issues In Prevention Of Iron Deficiency Anemia In India

Tanu Anand, MBBS, MD (Community Medicine) Manju Rahi, MBBS, MD (Community

Medicine) Pragya Sharma, MBBS, MD (Community Medicine) G.K. Ingle, MBBS, MD

(Community Medicine)

PII: S0899-9007(13)00550-9

DOI: 10.1016/j.nut.2013.11.022

Reference: NUT 9175

To appear in: Nutrition

Received Date: 8 August 2013

Revised Date: 18 October 2013

Accepted Date: 10 November 2013

Please cite this article as: Anand T, Rahi M, Sharma P, Ingle GK, Issues In Prevention Of Iron

Deficiency Anemia In India,Nutrition (2014), doi: 10.1016/j.nut.2013.11.022.

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http://dx.doi.org/10.1016/j.nut.2013.11.022


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Title: ISSUES IN PREVENTION OF IRON DEFICIENCY ANEMIA IN INDIA

Name of the authors:

Dr. Tanu Anand, MBBS, MD (Community Medicine), Senior Resident1

Dr. Manju Rahi, MBBS, MD (Community Medicine), Scientist D2

Dr. Pragya Sharma, MBBS, MD (Community Medicine), Assistant Professor 1

Dr. G.K. Ingle, MBBS, MD (Community Medicine), Director Professor & Head1

Short title: Issues in prevention of iron deficiency

Source of support: Nil

Institution:

1

Department of Community Medicine, Maulana Azad Medical College &Associated L.N, G.N.E.C & G.B. Pant Hospitals, New Delhi-110002.

2Division of Epidemiology and Communicable Diseases, Indian Council of Medical Research

Address for Correspondence:

Dr. Tanu Anand, Senior Resident, Department of Community Medicine, Maulana Azad Medical

College & Associated L.N, G.N.E.C & G.B. Pant Hospitals, New Delhi-110002.

Postal Address: H-1/7 Malviya Nagar, New Delhi-110017

E mail Address: [email protected]

Telephone no: 9811028964

Guarantor of paper: Dr. Tanu Anand

Word Count of Abstract: 192 words

Word Count of Main text: 4722 words

No. of references: 54

No. of tables: 1

Conflict of Interest: None


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1

ISSUES IN PREVENTION OF IRON DEFICIENCY ANEMIA IN INDIA1

Abstract2

Iron deficiency anemia (IDA) continues to be major public health problem in India. It is3

estimated that about 20% of maternal deaths are directly related to anemia and another 50% of4

maternal deaths are associated with it. The question therefore, remains that despite being the first5

country to launch National Nutritional Anemia Prophylaxis Programme in 1970, the problem of6

IDA remains widespread in India. Evidently economic implications of IDA are also massive.7

The issues in control of IDA in India are multiple. Inadequate dietary intake of iron, defective8

iron absorption, increased iron requirement due to repeated pregnancy and lactation, poor iron9

reserves at birth, timing of umbilical cord clamping, timing and type of complementary food10

introduction, frequency of infections in children and excessive physiological blood loss during11

adolescence and pregnancy are some of the causes responsible for high prevalence of anemia in12

India. Besides, there are other multiple programmatic and organizational issues. The current13

paper, therefore, is an attempt to discuss the current burden of anemia in the country, its14

epidemiology and various issues regarding prevention and control of anemia and is offering15

some innovative approaches to deal this with major health problem.16

Key words: Iron Deficiency Anemia, India, maternal deaths17

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http://ees.elsevier.com/nut/viewRCResults.aspx?pdf=1&docID=5837&rev=1&fileID=111046&msid={2606EB93-307A-460D-83C8-FF84A8241F87}


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Introduction24

Anemia is a global public health problem, affecting 1.62 billion population worldwide.1 Though25

the highest prevalence is in pre-school age children (47.4%), the greatest number of individuals26

affected are non-pregnant women (468.4 million). Iron deficiency anemia is by far the27

commonest cause of anemia.2 While as low as 50% of anemia in sub-Saharan Africa may be28

attributable to iron-deficiency, the proportion of anemia caused by iron-deficiency increases to29

over 70% among premenopausal women in India.3 Though prevalence of anemia is on decline in30

industrialized countries, developing countries have not yet experienced such a trend. An31

estimated 90% of cases occur in developing countries, impacting significantly on morbidity,32

mortality and national development.4 33

Iron deficiency anemia (IDA) is defined as a condition whereby either individual hemoglobin34

levels are two standard deviations below the distribution mean or more than 5% of a given35

population has hemoglobin levels that are two standard deviations below the distribution mean in36

an otherwise normal population of individuals from same gender and age, living at same37

altitude.5 Significant public health implications are more commonly associated with moderate to38

severe anemia defined as hemoglobin levels below 11 mg/dl.6 Iron is a vital nutrient. It is the39

functional group in hemoglobin for oxygen transport in red blood cells and helps in storage of40

oxygen in myoglobin in muscles.7 41

Anemia is the most common clinical problem associated with its deficiency and chronic iron42

deficiency anemia results in cognitive and behavioral impairments in infants and children8,43

fatigue and decreased work capability in older children and adults8, prematurity and perinatal44


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mortality among pregnant women.9 Thus, evidently functional consequences of iron deficiency45

anemia are profound.46

Illustrative calculations for 10 developing countries suggest that the median value of annual47

physical productivity losses due to iron deficiency is around $2.32 per capita, or 0.57% of gross48

domestic product (GDP). Median total losses (physical and cognitive combined) are $16.78 per49

capita, 4.05% of GDP. Evidently, economic implications of IDA are also massive.1050

Despite continuous intensive efforts at national and international levels, prevalence of anemia51

has continued to remain high in India and rather has shown increasing trends over the years.52

Policy makers have often failed to recognize the significant health consequences, and societies53

are too often ignorant of anemia's capability to cause permanent disability or death.11 With this54

preview, the current paper aims at discussing the current burden of anemia in the country, its55

epidemiology and various issues regarding prevention and control of anemia in India.56

Burden of Anemia in India57

IDA is the most widespread yet neglected micronutrient deficiency disorder among children,58

adolescents and pregnant women. It is estimated that about 20% of maternal deaths are directly59

related to anemia and another 50% of maternal deaths are associated with it.12 Nationally60

representative survey i.e., National Family Health Survey (NFHS) has till now been carried out61

in three rounds (1991-92, 1998-99 and 2005-06) and is a country-wide survey creating a vast62

databank on several parameters including iron deficiency anemia among children, women and63

men, using hemacue method. The latest round (2005-06) reveals alarmingly high prevalence of64

69.5% among children aged 6-59 months and 55.3% among ever married women. Anemia in65


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breastfeeding mothers was 63.2% while 58.7% of the pregnant women were found to be66

anemic.13 67

According to National Nutrition Monitoring Bureau (NNMB) Report 200314, the mean68

hemoglobin levels among different physiological groups were much below the cutoff points69

suggested by World Health Organization (WHO) to diagnose anemia. The overall prevalence of70

anemia was found to highest among lactating mothers (78%) followed by pregnant women71

(75%), adolescent girls (about 70%) and pre-school children (67%). Thus, it is evident that our72

population continues to live with anemia throughout entire life cycle, endangering child growth,73

development and economic productivity at the national level.15 74

Data obtained from NFHS-2, NFHS-3 and NNMB show neither a time trend nor an appreciable75

decrease in anemia prevalence in the Indian population. An increase has been noted from 74% in76

NFHS-2 to 79% in NFHS-3 among children 6-35 months, primarily in rural areas. The anemia77

situation has worsened for women also from NFHS-2 (52%) to NFHS-3 (56%). Review of78

various community based studies from 1950-2002 also points towards increase in prevalence of79

anemia in India. The question therefore remains that despite being the first country to launch80

National Nutritional Anemia Prophylaxis Programme in 1970, the problem of IDA remains81

widespread in India.82

The causality between poor dietary iron density, bioavailability, infections and high prevalence83

of anemia is not well established in our population.

16

Hence, there is need to understand the84

epidemiology of anemia in Indian settings considering its multi-factorial etiology.85

Causes of Iron Deficiency Anemia (IDA) in India86


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The circumstances under which IDA arises in India are numerous. The more important ones are87

inadequate dietary intake of iron, defective iron absorption, increased iron requirement due to88

repeated pregnancy and lactation, poor iron reserves at birth, timing of umbilical cord clamping,89

timing and type of complementary food introduction, frequency of infections in children and90

excessive physiological blood loss during adolescence and pregnancy.17,18 Recent evidences also91

state infections as a much more important cause of anaemia than previously thought.16 92

Iron in food exists either in haem or non-haem form. Haem iron which is found in meat, poultry93

and fish, is better absorbed than non-haem iron available in all plant foods. Non haem iron94

contributes about 90-95% of the total daily iron in Indian diets.16 Nutritionists recommend that95

vegetarians need to increase dietary iron by 80% to compensate for lower iron bioavailability of96

10% in vegetarian diet as compared with 18% from omnivorous diet and this constitutes a major97

challenge in India.3 The results of large number of diet surveys have shown that despite the fact98

that the iron content of cereal based diet is 30.5 mg/day, iron deficiency has remain99

widespread.17 Further, it was surprising to note that the extent of anemia prevalence among rural100

females aged 15-49 years, is not correlated with the current intake of iron with Indian states 101

Gujarat showing 55% anemia prevalence upon 23 mg/day iron intake and Kerala showing 33%102

anemia prevalence with 11 mg/d iron intake.16 Thus, this paradoxical observation requires closer103

examination of factors determining its availability and absorption.104

Iron absorption is enhanced by gastric acidity so, hypochlorhydria or achlorhydria due to any105

cause affects iron absorption from food.19 Comparison of gastric acidity measured by different106

groups in Delhi, Vellore and Mumbai with that reported from western countries have shown that107

the basal acid output in normal Indians is significantly lower (~ pH 3.4) than that in western108


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subjects (pH 2.5).20 This difference may account for compromised non-haem iron solubility and109

accessibility in Indians and can therefore, be considered in the aetiology of high anemia110

prevalence.16 111

Iron must be in ferrous state before it could be absorbed by the mucosa of intestinal tract and112

dietary supplements of vitamin C have shown to facilitate this process. Further, vitamin C has113

been found to be strong enhancer of plant iron and can overcome inhibitors of iron absorption.21 114

In a study Seshadri et al, vegetarian children with IDA and low vitamin C intakes in India were115

given 100 mg of vitamin C at both lunch and dinner for 60 days. They saw a drastic116

improvement in their anemia, with most making a full recovery.22 However, the intake of117

ascorbic acid in Indian dietaries is very low.16,23 A study by Chiplonkar et al in 200724 revealed118

sub-normal status of ascorbic acid among 214 men (0.35mg/dl) and 108 women (0.30mg/dl) in119

Pune as against recommended intake of 0.4 mg/dl.25 Another study conducted among married120

adolescent girls from Indian urban slums showed low intake of vitamin C by the study group121

(25mg/d).26 On the other hand, Indian diets based on cereals and pulses have shown to contain122

more than 40% of the total phosphorus as phytins, an inhibitor of iron absorption. An analysis of123

in vitro non-haem iron solubility in composite Indian diets showed that the solubility of iron124

decreased from 7.9 to 1.52% as the phytate content increased from 0.3-1.3mg/d.27 Polyphenols,125

which include tannic acid, can also inhibit iron absorption, and are found in coffee, cocoa, and126

black, green and many herbal teas. Studies have revealed that most of the Indians have the habit127

of taking beverages like tea or coffee (which are high in tannins) with meals thereby resulting in128

decreased bio-availability of iron.3,21 Epidemiologic data suggests that calcium interferes with129

iron absorption.15,21,28 It is possible that absorption of iron and calcium may depend upon the130

relative amounts of calcium, iron and phosphorus in the intestinal lumen.17 131


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Iron loss from the body is another important factor that should be taken into consideration while132

assessing IDA in a given population. Iron is not actively excreted from the body in urine or in the133

intestines but only lost with cells from the skin and the interior surfaces of the body - intestines,134

urinary tract, and airways. The total amount lost is estimated at 14 µg/kg body weight/day. 29 135

While the basal losses of iron from skin and sweat may be negligible and may not contribute to136

widespread IDA, heavy blood loss during menstruation, repeated pregnancies and prolonged137

nursing of baby may act as important causes for iron losses in women.138

In Indian girls, the highest prevalence of anemia is reported between the ages of 12-13 years139

which coincides with the average age of menarche.30 The mean menstrual iron loss, averaged140

over the entire menstrual cycle of 28 days, is about 0.56 mg/day.7 Thus, the mean daily total iron141

requirement during female adolescence becomes 1.36 mg. In 10 percent of menstruating142

teenagers, the corresponding daily total iron requirement exceeds 2.65 mg, and in 5 percent of143

the girls it exceeds 3.2 mg/day due to marked variation in menstrual blood loss amongst girls. 31 144

Evidence from various researches indicate that nearly 40-50% of the adolescent girls suffer from145

menstrual abnormalities while only one-third of them are seeking appropriate health care146

regarding them.7 This means that a large proportion of girls with heavy blood loss are being147

missed and not reached for iron supplementation.148

According to NFHS-3, currently 27% of the 15-19 years old women are married. 13 Early149

marriage in girls leads to early initiation of sexual activity and consequently repeated child150

bearing, which in turn results in recurring loss of iron with each pregnancy. Evidence suggests151

that on an average 297 mg iron is lost per pregnancy amongst Indian women while 150 mg iron152

is conserved per pregnancy due to suppression of menstruation during that period.17 Thus there is153


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net loss of 150 mg of iron with each pregnancy. Iron loss during parturition is made up of blood154

loss during delivery, the iron transferred to the new born and iron content of placenta and155

umbilical cord.17156

Lactating women also have much greater iron requirements. They need to restore their iron157

losses from pregnancy and delivery, as well as meet the demands of infant requirement for iron158

through breast milk. In lactating women, the daily iron loss in milk is about 0.3 mg.7 Together159

with the basal iron losses of 0.8 mg, the total iron requirements during the lactation period160

amount to 1.1 mg/day.7 The average iron content of mature breast milk in the Indian nursing161

women has been found to be 0.12 mg/100 g.17 On this basis, the Indian women may be expected162

to lose, through breast milk, 0.5-0.7 mg of iron per day for several months.17 163

The high prevalence of IDA amongst children is attributed to numerous factors such as limited164

iron stores at birth, timing of umbilical cord clamping, timing and type of complementary food165

introduction, and frequency of infections.18 The amount of iron stored depends on the length of166

the gestational period and the weight of the baby at birth. Since in India, some 7.4 million infants167

are born either prematurely or with a birth weight of less than 2.5 kg, these factors play a large168

role in increasing the predisposition to anemia.32 The timing of the clamping of the umbilical169

cord at delivery is also a factor in the development of anemia.33 The amount of blood transferred170

to the infant depends on whether the cord is clamped early (less than a minute), intermediately171

(one to three minutes), or late (after pulsations cease).33 Beside this, human milk is poor source172

of iron as mentioned previously. Thus, iron stores in the exclusively breastfed infant will quickly173

be depleted so that by six months of age most storage iron is used up. If human milk remains the174

only food source, iron deficiency anemia, will ultimately develop.18 Therefore, there is a need to175


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introduce iron containing complementary foods with greater bio-availability. However, in India,176

the complementary foods are cereal based which have very low bio-available iron. In addition,177

during early childhood, children are pre-disposed to parasitic infections, bites by blood sucking178

insects that abound in warm tropical climate,17 malaria, upper respiratory tract infections16 etc.179

Further, in children with meager body iron stores, infections tend to aggravate anemia by180

blocking iron utilization. It is hypothesised that upon infection, iron is sequestered in the181

macrophages and hepatocytes and iron absorption decreases. This also results in decreased182

plasma iron levels, which if maintained, leads to iron restricted erythropoiesis and ultimately183

frank anaemia.

16

Exploration of data on molecular mechanisms in iron absorption, highlight the184

role of hepcidin, a 25 amino acid hepatocyte-derived peptide. Hepcidin controls movement of185

iron into plasma by regulating the activity of the sole known iron exporter ferroportin-1.186

Downregulation of the ferroportin-1 exporter results in sequestration of iron within intestinal187

enterocytes, hepatocytes, and iron-storing macrophages reducing iron bioavailability. Hepcidin188

expression is increased by higher body iron levels and inflammation and decreased by anemia189

and hypoxia.16,34,35 Thus, synergy between inflammatory processes and infection may result in190

variety of iron related disorders including IDA. 191

Hookworm infestation is also an important cause of IDA particularly in rural population engaged192

in agricultural pursuits. Infection is particularly disastrous to iron status during pregnancy as193

demand is already very high during pregnancy.36 Hookworm infection of moderate intensity194

leads to loss of 1.1-2.30 mg of iron through blood loss per day. This substantial amount of blood195

loss cannot be made up with iron poor diet of the Indians. High prevalence of infections such as196

schistosomiasis, trichuris, shigellosis, H. pylori and HIV in developing countries like India has197

also been found to contribute to iron deficiency states.37 198


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Thus, evidently etiology for high prevalence of IDA in India is multi-factorial. The deficient199

state seems to exist in the large majority at time of commencement of life and continues all along200

the childhood years, adolescent period, and adult life though with great variations in its severity201

from individual to individual, one stage in life to another, and between the sexes which further202

deteriorates at any point of time due to one or the other physiological or pathological resaons.17 203

Knowledge gained so far should lay the foundation for designing prevention and control204

measures for IDA in India.205

Current Prevention and Control Strategies against IDA in India206

National Nutritional Anemia Prophylaxis Programme (NNAPP): The programme was207

launched in 1970 with the objective of preventing anemia in pregnant and lactating mothers and208

children. Under this programme, expectant and nursing mothers as well as acceptors of family209

planning are given one tablet of iron and folic acid containing 100 mg elementary iron and 500210

mcg of folic acid. Infants from the age of 6 months onwards up to the age of five years receive211

iron supplements in liquid formulation in doses of 20 mg elemental iron and 100 mcg folic acid212

per day for 100 days in a year. Children 6 – 10 years of age receive iron in the dosage of 30 mg213

elemental iron and 250 mcg folic acid for 100 days in a year and adolescents 11 – 18 years shall214

receive supplements at the same dosage as adults.38215

National Nutr iti on Policy, 1993: A National Nutrition Policy was adopted in 1993, with the216

objective of operationalising multi-sectoral strategies to overall address the problem of under-217

nutrition/malnutrition. With regards to tackling IDA in India, the policy envisaged to undertake218

direct interventions such as expanding safety net to vulnerable groups such as children,219

adolescent girls and women, fortification of essential foods with iron, popularization of low cost220

nutritious foods and strengthening of NNAPP with introduction of iron supplementation for221


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adolescent girls. Indirect policy instrument included ensuring food security, improvement in222

dietary pattern through production and demonstration, improvement in purchasing power, land223

reforms, basic health and nutrition education, coordination with health and nutrition224

surveillance.39 225

I ntegrated Chi ld Development Services (ICDS): Launched on 2nd October 1975, ICDS Scheme226

represents one of the world’s largest and most unique programmes for early childhood227

development. Supplementary feeding support is provided for 300 days in a year to children228

below the age of six and pregnant & nursing mothers with the objective to bridge the caloric gap229

that exists in disadvantaged communities and control of nutritional anemia.

40230

National Programme for Nutritional Support to Primary Education (Mid-day Meal231

Programme): The programme was launched as a Centrally-Sponsored Scheme in August 1995232

and was revised in 2006. The scheme was intended to boost universalisation of primary233

education and simultaneous impacting on nutritional status of students in primary class,234

countrywide. According to revised norms, the nutritional value of the cooked mid day meal has235

been increased from 300 to 450 kcal and the protein content therein from 8-12 grams to 12236

grams. The scheme of 2006 also provided for adequate quantities of micronutrients like iron,237

folic acid, vitamin-A etc.41 238

12 x 12 I niti ative: A multi-pronged 12 × 12 initiative has been launched in the country for239

addressing the problem of anemia. The target group is the adolescent across the country. The aim240

was to achieve hemoglobin level of 12 gm% by the age of 12 years by 2012 for all in target241

group. The initiative comprises of health and nutrition education, weekly supplementation with242

iron folic acid tablet, parasite control through periodic de-worming, and appropriate243

immunization along with measures for capacity building. This initiative has been launched with244


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the support of Government of India, Indian Council of Medical Research, World Health245

Organization, UNICEF, Federation of Obstetrics and Gynecological Societies of India and other246

professional bodies.42 247

Rajiv Gandhi Scheme for Gir ls Empowerment of Adolescent (RGSEAG), SABLA: It aims at248

empowering Adolescent Girls of 11-18 years by improving their nutritional and health status, up249

gradation of home skills, life skills and vocational skills. It is being implemented in 200 districts,250

replacing Kishori Shakti Yojana and Nutrition Programme for Adolescent Girls (AG) where in251

kg of free food grains per beneficiary per month are given to underweight adolescent girls. Under252

SABLA, each AG has to be given at least 600 kcal and 18 – 20 grams of protein and the253

recommended daily intake of micronutrients, for 300 days in a year.43 254

I ni tiatives under National Rural Health Mission (NRHM): A mix of prevention, treatment,255

food diversification, awareness and education is a strategy adopted for reducing the prevalence256

of anemia in the country. Besides supplementation with iron folic acid as mentioned above for257

children and pregnant and lactating mothers, identification and tracking of severely anemic258

pregnant women at all the sub centres and PHCs for their timely management, de-worming of259

under 5 children, Introduction of Safe Motherhood booklet and Mother and Child Protection260

(MCP) card which are tools to enhance awareness and improve access to quality antenatal,261

intranatal and postnatal care services and distribution of Long Lasting Insecticide Nets (LLINs)262

and Insecticide Treated Bed Nets (ITBNs) in endemic areas to tackle the problem of anemia due263

to malaria particularly in pregnant women and children are being undertaken. Health and264

nutrition education is one of the activities during Village Health and Nutrition days (VHNDs) to265

promote dietary diversification, inclusion of iron folate rich food and increase the awareness to266


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bring about desired changes in the dietary practices including the promotion of optimal Infant267

and Young Child Feeding Practices (IYCF).44 268

Other ini tiatives: 269

“Anemia Chale Jao-Nishchay-2007” was started by Federation of Obstetrics & Gynecological270

Society’s of India (FOGSI). It aimed to eliminate anemia by 2007 by ensuring that every single271

Indian female must know her weight, height, blood group and hemoglobin level. The basis for272

this initiative was that 80% of females were not aware of their basic health parameters i.e. height,273

weight, Hb% and blood group. Under this, women, once they had been diagnosed with suffering274

from anaemia, were given iron tablets for 1 month however no follow up was being done.

42

275

National Anemia + Initiative has been envisaged recently to look at IDA comprehensively276

across all life stages. It will bring together existing programmes (IFA supplementation for:277

pregnant and lactating women and; children in the age group of 6 – 60 months) and introduce new278

age groups like school children (5-10 years), women in reproductive age group etc. the National279

Iron+ Initiative also defines a minimums service of packages for treatment and management of280

anemia across levels of care.38 281

Saloni Swasthya Kishori Yojna: It is a part of USAID funded pilot project (2004-2010)282

running in Uttar Pradesh, Uttarakhand and Jharkhand. It aims at identification of school drop-out283

adolescent girls, promotion of use of IFA and development of adolescent groups.284

Food Fortification: In 2004, Micronutrient Initiative (MI) supported the installation of a double285

fortified salt (DFS) manufacturing facility at the Tamil Nadu Salt Corporation (TNSC) plant.286

Vita-Shakti (a premix with iron-7 mg; vit A- 500 µg; folic acid- 50 µg) and Anuka (contents per287

0.5 g of this food supplement include: iron-3 mg; vit A-300 IU; vit C-30 mg) are the products288

developed by the MI in India to improve the intake of vitamins and minerals of young children.289


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MI developed lozenges fortified with vitamin A, iron, and other nutrients, often called nutri-290

candies or nutri-lozenges, to protect children who have no access to centrally processed and291

accessible foods to fortify.42 292

Cri tical Review: The NNACP is operational for more than 40 years but has not been successful293

in controlling/reducing anemia in any age group. The obstacles in achieving success and reasons294

of ineffectiveness of the National Programmes have been explored into and several constraints295

and limitations have been identified in successful implementation itself of these programmes.296

(Table 1). Some of these are:297

a)

Inadequate supplies – due to large number of beneficiaries, only 10% of the actual need is298

provided.45 299

b)

Poor outreach and inadequate coverage.45,46 300

c) Majority of women present late in pregnancy with moderate-severe anemia, when little301

time is left to take corrective measures.47,48 302

d) Irregular distribution- majority of beneficiaries (particularly children) do not receive the303

required no. of tablets.49 304

e) Lack of orientation/interest in health workers.45 305

f) Absence of nutrition education and lack of knowledge about anemia.50 306

g) Absence of monitoring and supervision.51 307

h) Enormous burden of undiagnosed infections contributing to anemia.37 308

i) Lack of follow up/motivation of women put on iron prophylaxis and therapeutic309

treatment.49, 52 310

j) Side effects of iron pills and poor compliance.52 311


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Further, most anemia control efforts have focused only on reducing anemia by iron and folic acid312

supplementation without taking into account other factors.313

Key Interventions required to combat Iron Deficiency Anemia314

There are certain fundamental elements which are needed to be addressed in any programme315

aimed at improving general well being, improvement of iron status in particular. These are5:316

1. Reducing poverty317

2. Improving access to diversified diets318

3. Improving health services and sanitation319

4.

Promotion of better care and feeding practices320

Food Based Approach: Food-based approaches represent the most desirable and sustainable321

method of preventing micronutrient malnutrition. Food-based strategies focus on improving the322

availability of, access to, and consumption of vitamin and mineral rich foods. This approach323

includes strategies53:324

- increasing the overall quantity of foods consumed by those most vulnerable to325

deficiencies and at the same time326

- diversifying their diets with focus on micronutrient rich sources of food including animal327

products, vitamin C, fruit and vegetables;328

- better managing and controlling dietary inhibitors (e.g., phytates) and enhancers (e.g.,329

vitamin C);330

- processing, preservation, and preparation practices that retain micronutrient availability331

including for example the use of iron cooking pots and improved drying techniques to332

reduce losses as well as the seasonal variation in availability;333

- nutrition education;334


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- food quality and safety issues with implications for public health and disease control335

measures to reduce nutrient losses by the body and to maximize the potential of fruit and336

vegetables as high value commodities for income generation;337

- fortification including bio-fortification; and338

- supplementation with follow ups.339

Expanding coverage of benef iciaries under Reproductive Chi ld Health (RCH) programme:340

Even though considerable success have been achieved in expanding package of health services to341

the beneficiaries under NRHM, yet, quality of care (including training and orientation of health342

personnel) being provided needs immediate attention. Nutrition Rehabilitation Centres require343

support for operationalization. There is a need to strengthen the outreach RCH services.54 344

Parasit ic Di sease Contr ol Programmes: The better implementation of these programmes, in345

particular those directed to hookworm, schistosomiasis and malaria control can reduce the load346

of iron deficiency anaemia in population with moderate to severe levels of infection;347

I ntegration with other micro-nutr ient control programmes: Preventive supplementation is348

particularly well-suited to strategies that combine multiple micronutrient interventions.349

Programmes that involve preparations containing iron, folic acid, and vitamins A and C, directed350

to infants, children, and pregnant and lactating women, are highly desirable with a very strong351

monitoring mechanism to ensure consumption of the preparations to achieve the desired result.5352

Strengthening the surveillance system 42 : There should be a better surveillance system for353

vitamin and micronutrient deficiencies with the aim to retrieve and summarize data on vitamin354

and mineral status of the population and track the progress made to timely intervene in the355

existing policies. The data provided from national level periodic surveys like National Family356

Health Survey may not be sufficient to comment upon the impact of the strategies and357


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programme in question. Instead, there should be strengthening of Vitamin and Mineral Nutrition358

Information System (VMNIS) which was originally established in 1991 by the Nutrition Unit of359

the World Health Organization in collaboration with the Department of International Health of360

the University of Michigan, United States of America for time to time review, analysis and361

action.362

I ntersectoral Coordination: This component should include, in particular, agricultural extension363

to promote the production and consumption of iron- and other micronutrient-rich foods; school364

garden and lunch programmes; community development programmes; and community365

involvement.

5

Further, integration of anemia control strategy with the activities of primary health366

care and maternal and child health should also be strategized.367

Advocacy and social communication: At all levels, from the community to that of national368

policy-makers, it is necessary to identify the target and communication objectives. A strong369

political will at the highest level is mandatory to ensure adequate budgeting, intersectoral370

collaboration and national coverage. A strong advocacy effort is therefore essential, starting from371

the highest levels down to local political leaders and communities to ensure a behavior change at372

the consumer level.5373

Research: Besides these interventions, there is a need for operational research to increase374

compliance among beneficiaries and System Research to find out solutions to administrative375

passivity and to explore Public-Private-Partnership. Research is also needed to find out the376

optimum dose and frequency of supplementation (daily-vs-weekly) for cost-effectiveness,377

compliance and absorption/bio-availability in clinical and community set-up particularly in378

Indian context.379

Conclusion380


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IDA continues to a major public health concern in Indian subcontinent, affecting nearly half the381

population. There are certain factors which are particularly making Indian population susceptible382

to IDA such as multiple infections, multiple pregnancies, poor access to health services etc. A lot383

of initiatives have been taken by the government, yet the outcome has not been desirable. There384

is a pressing need to strengthen the existing programmes by overcoming the shortcomings as385

discussed. The current problem requires tackling by multi-sectoral and multi-factorial approach.386

“Life Cycle Approach” needs to be adopted more assertively, starting intervention for adolescent387

girls, following them through motherhood and first birth. Nutrition education of the community388

should be a integral part of the Programme. Further, considering the enormous burden of389

infections and their contribution in causing anemic states, their early diagnosis and prompt390

treatment is mandatory. It also re-instates the importance of strengthening national control391

programmes for HIV, malaria and helminthic infections in the prevention and treatment of these392

diseases.37 However, the intervention for IDA control should be tailored to local conditions393

taking into account the population groups affected.394

395

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Table 1: Factors responsible for IDA and its Prevention and Control Strategies in India.523

S. No. Factorsresponsible forIDA

Efforts made for prevention & controlof IDA

De-merits Strategy toovercome thedrawback

1. Inadequate dietaryintake of iron

National NutritionPolicy, ICDS, Mid-day Meal Scheme, Nutrition Educationunder NRHM

Weak inter-sectoralcoordination,Poor knowledgeabout anaemia

Food basedapproachesincluding foodfortification,strengtheningintersectoralcoordination

2. Defective ironabsorption

3. Repeated pregnancy &lactation

National NutritionalAnemia ProphylaxisProgramme,Reproductive &

Child health,SABLA scheme

Inadequatesupplies of iron pills, inadequatecoverage, poor

antenatalcoverage, poorcompliance andlack of motivationof women, lack ofmonitoring andsupervision, lackof orientation ofhealth workers,weakimplementation of

parasitic infectioncontrol programmes

Integrationwith othermicro-nutrientdeficiency

control programmes,expansion ofRCH qualityservicesstrengtheningof surveillancesystems,Advocacy andsocialmobilization,

research,training ofhealth workers

4. Excessive blood

loss during pregnancy

5. Poor iron reservesat birth

6. Timing ofumbilical cordclamping

7. Timing and typeof complementaryfood introduction

Infant & YoungFeeding Practices

8. Infections De-worming under

RCH, SABLA, 12 by 12 initiative

524

nutrition volume 30 issue 7-8 2014 india

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