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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Title: ISSUES IN PREVENTION OF IRON DEFICIENCY ANEMIA IN INDIA

Name of the authors:

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

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

Dr. Pragya Sharma, MBBS, MD (Community Medicine), Assistant Professor1

Short title: Issues in prevention of iron deficiency

Source of support: Nil

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

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Institution: 1Department of Community Medicine, Maulana Azad Medical College &

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

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

E mail Address: drtanu.anand@gmail.com

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Telephone no: 9811028964

Guarantor of paper: Dr. Tanu Anand

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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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ISSUES IN PREVENTION OF IRON DEFICIENCY ANEMIA IN INDIA

Abstract

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

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

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

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

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

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

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

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

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

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

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

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

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

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some innovative approaches to deal this with major health problem.

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Key words: Iron Deficiency Anemia, India, maternal deaths

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Introduction

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

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

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

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

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

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

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

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

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mortality and national development.4

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

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

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

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

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

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

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

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oxygen in myoglobin in muscles.7

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

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

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

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

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anemia are profound.

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

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

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

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capita, 4.05% of GDP. Evidently, economic implications of IDA are also massive.10

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

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

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

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

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

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

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Burden of Anemia in India

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

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

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

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

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

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

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

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

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

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anemic.13

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

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

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

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

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

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

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development and economic productivity at the national level.15

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

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

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

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

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

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

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

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widespread in India.

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

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of anemia is not well established in our population.16 Hence, there is need to understand the

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

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Causes of Iron Deficiency Anemia (IDA) in India

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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examination of factors determining its availability and absorption.

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

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

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

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

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

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

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prevalence.16

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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missed and not reached for iron supplementation.

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

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

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

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

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

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

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

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umbilical cord.17

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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frank anaemia.16 Exploration of data on molecular mechanisms in iron absorption, highlight the

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

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iron into plasma by regulating the activity of the sole known iron exporter ferroportin-1.

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

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

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

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

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variety of iron related disorders including IDA.

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

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

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

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

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

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

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also been found to contribute to iron deficiency states.37

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

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

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

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

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

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

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measures for IDA in India.

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Current Prevention and Control Strategies against IDA in India

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

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

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

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planning are given one tablet of iron and folic acid containing 100 mg elementary iron and 500

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

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

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per day for 100 days in a year. Children 610 years of age receive iron in the dosage of 30 mg

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elemental iron and 250 mcg folic acid for 100 days in a year and adolescents 1118 years shall

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receive supplements at the same dosage as adults.38

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National Nutrition Policy, 1993: A National Nutrition Policy was adopted in 1993, with the

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

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

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

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

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

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

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

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

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surveillance.39

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Integrated Child Development Services (ICDS): Launched on 2nd October 1975, ICDS Scheme

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represents one of the worlds largest and most unique programmes for early childhood

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

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

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that exists in disadvantaged communities and control of nutritional anemia.40

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

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Programme): The programme was launched as a Centrally-Sponsored Scheme in August 1995

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

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

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

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

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

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folic acid, vitamin-A etc.41

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12 x 12 Initiative: A multi-pronged 12 12 initiative has been launched in the country for

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

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

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

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

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

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

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

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professional bodies.42

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Rajiv Gandhi Scheme for Girls Empowerment of Adolescent (RGSEAG), SABLA: It aims at

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

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

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

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

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SABLA, each AG has to be given at least 600 kcal and 1820 grams of protein and the

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

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Initiatives under National Rural Health Mission (NRHM): A mix of prevention, treatment,

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

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

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

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

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

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

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

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

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

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

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

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

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and Young Child Feeding Practices (IYCF).44

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Other initiatives:

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Anemia Chale Jao-Nishchay-2007 was started by Federation of Obstetrics & Gynecological

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Societys of India (FOGSI). It aimed to eliminate anemia by 2007 by ensuring that every single

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

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

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

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from anaemia, were given iron tablets for 1 month however no follow up was being done.42

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

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

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pregnant and lactating women and; children in the age group of 660 months) and introduce new

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

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

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anemia across levels of care.38

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

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

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

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

286

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

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

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

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

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

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

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accessible foods to fortify.42

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Critical Review: The NNACP is operational for more than 40 years but has not been successful

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

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

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

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(Table 1). Some of these are:

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a) Inadequate supplies due to large number of beneficiaries, only 10% of the actual need is

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provided.45

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b) Poor outreach and inadequate coverage.45,46

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

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time is left to take corrective measures.47,48

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

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required no. of tablets.49

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

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

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g) Absence of monitoring and supervision.51

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

309

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

311

AC
C

310

EP

305

treatment.49, 52

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

14

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

313

supplementation without taking into account other factors.

314

Key Interventions required to combat Iron Deficiency Anemia

315

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

316

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

318

2. Improving access to diversified diets

319

3. Improving health services and sanitation

320

4. Promotion of better care and feeding practices

M
AN
U

317

SC

RI
PT

312

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

322

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

323

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

324

includes strategies53:

326

deficiencies and at the same time

-

328
329

products, vitamin C, fruit and vegetables;

-

330
331

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

EP

327

increasing the overall quantity of foods consumed by those most vulnerable to

TE

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

AC
C

325

321

vitamin C);
-

processing, preservation, and preparation practices that retain micronutrient availability

332

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

333

reduce losses as well as the seasonal variation in availability;

334

nutrition education;
15

ACCEPTED MANUSCRIPT

335

food quality and safety issues with implications for public health and disease control
measures to reduce nutrient losses by the body and to maximize the potential of fruit and

337

vegetables as high value commodities for income generation;

338

fortification including bio-fortification; and

339

supplementation with follow ups.

RI
PT

336

Expanding coverage of beneficiaries under Reproductive Child Health (RCH) programme:

341

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

342

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

343

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

344

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

345

Parasitic Disease Control Programmes: The better implementation of these programmes, in

346

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

347

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

348

Integration with other micro-nutrient control programmes: Preventive supplementation is

349

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

350

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

351

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

352

monitoring mechanism to ensure consumption of the preparations to achieve the desired result.5

353

Strengthening the surveillance system42: There should be a better surveillance system for

354

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

355

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

356

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

357

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

AC
C

EP

TE

M
AN
U

SC

340

16

ACCEPTED MANUSCRIPT

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

359

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

360

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

361

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

362

action.

363

Intersectoral Coordination: This component should include, in particular, agricultural extension

364

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

365

garden and lunch programmes; community development programmes; and community

366

involvement.5 Further, integration of anemia control strategy with the activities of primary health

367

care and maternal and child health should also be strategized.

368

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

369

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

370

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

371

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

372

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

373

the consumer level.5

374

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

375

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

376

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

377

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

378

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

379

Indian context.

380

Conclusion

AC
C

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TE

M
AN
U

SC

RI
PT

358

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

382

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

383

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

384

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

385

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

386

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

387

Life Cycle Approach needs to be adopted more assertively, starting intervention for adolescent

388

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

389

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

390

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

391

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

392

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

393

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

394

taking into account the population groups affected.

TE

M
AN
U

SC

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PT

381

395

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396

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49. IIPS. National Family Health Survey (NFHS-3), 2005-06. Volume 1. Mumbai:
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522

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

5.
6.

7.

8.

524

RI
PT

National Nutritional
Anemia Prophylaxis
Programme,
Reproductive &
Child health,
SABLA scheme

Strategy to
overcome the
drawback
Weak interFood based
sectoral
approaches
coordination,
including food
Poor knowledge
fortification,
about anaemia
strengthening
intersectoral
coordination
Inadequate
Integration
supplies of iron
with other
pills, inadequate
micro-nutrient
coverage, poor
deficiency
antenatal
control
coverage, poor
programmes,
compliance and
expansion of
lack of motivation RCH quality
of women, lack of services
monitoring and
strengthening
supervision, lack
of surveillance
of orientation of
systems,
health workers,
Advocacy and
weak
social
implementation of mobilization,
parasitic infection research,
control
training of
programmes
health workers

SC

4.

Repeated
pregnancy &
lactation
Excessive blood
loss during
pregnancy
Poor iron reserves
at birth
Timing of
umbilical cord
clamping
Timing and type
of complementary
food introduction
Infections

De-merits

M
AN
U

3.

Infant & Young

Feeding Practices

De-worming under
RCH, SABLA, 12
by 12 initiative

EP

2.

Efforts made for

prevention & control
of IDA
National Nutrition
Policy, ICDS, Midday Meal Scheme,
Nutrition Education
under NRHM

AC
C

1.

Factors
responsible for
IDA
Inadequate dietary
intake of iron
Defective iron
absorption

TE

S. No.

523

23