Elsevier

Nutrition

Volume 30, Issues 7–8, July–August 2014, Pages 764-770
Nutrition

Review
Issues in prevention of iron deficiency anemia in India

https://doi.org/10.1016/j.nut.2013.11.022Get rights and content

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, is why, despite being the first country to launch the National Nutritional Anemia Prophylaxis Programme in 1970, the problem of IDA remains so widespread. As is to be expected, the economic implications of IDA are also massive. The issues of control of IDA in India are multiple. Inadequate dietary intake of iron, defective iron absorption, increased iron requirements due to repeated pregnancies and lactation, poor iron reserves at birth, timing of umbilical cord clamping, timing and type of complementary food introduction, frequency of infections in children, and excessive physiological blood loss during adolescence and pregnancy are some of the causes responsible for the high prevalence of anemia in India. In addition, there are other multiple programmatic and organizational issues. This review, therefore, is an attempt to examine the current burden of anemia in India, its epidemiology, and the various issues regarding its prevention and control, as well as to offer some innovative approaches to deal with this major health problem.

Introduction

Anemia is a global public health problem, affecting 1.62 billion people worldwide [1]. Although the highest prevalence is found preschool-age children (47.4%), the greatest number of individuals affected are non-pregnant women (468.4 million). Iron deficiency anemia (IDA) is by far the most common cause of anemia [2]. Although as few as 50% of cases of anemia in sub-Saharan Africa may be attributable to iron deficiency, the proportion of anemia caused by iron deficiency increases to >70% among premenopausal women in India [3]. Although prevalence of anemia is on the decline in industrialized countries, developing countries are not yet experiencing such a trend. An estimated 90% of cases occur in developing countries, significantly effecting morbidity, mortality, and national development [4].

IDA is when individual hemoglobin levels are 2 SDs below the distribution mean or >5% of a given population has hemoglobin levels that are 2 SD below the distribution mean in an otherwise normal population of individuals from same sex and age groups, living at the same altitude [5]. Significant public health implications are more commonly associated with moderate to severe anemia defined as hemoglobin levels <11 mg/dL [6]. Iron is a vital nutrient. It is the functional group in hemoglobin for oxygen transport in red blood cells and helps in storage of oxygen in myoglobin in muscles [7].

Anemia is the most common clinical problem associated with its deficiency and chronic IDA results in cognitive and behavioral impairments in infants and children [8], fatigue and decreased work capability in older children and adults [8], prematurity, and perinatal mortality among pregnant women [9]. Thus, functional consequences of IDA are profound.

Illustrative calculations for 10 developing countries suggest that the median value of annual physical productivity losses due to iron deficiency is around $2.32 per capita, or 0.57% of gross domestic product. Median total losses (physical and cognitive combined) are $16.78 per capita, or 4.05% of gross domestic product. Economic implications of IDA are also massive [10].

Despite continuous intensive efforts at national and international levels, prevalence of anemia has continued to remain high in India and has shown increasing trends over the years. Policymakers often have failed to recognize the significant health consequences, and societies too often are ignorant of anemia's capability to cause permanent disability or death.[11] In this review we discuss the current burden of anemia in India, its epidemiology, and various issues regarding its prevention and control.

Section snippets

Burden of anemia in India

IDA is the most widespread yet neglected micronutrient deficiency disorder among young children, adolescents, and pregnant women. It is estimated that about 20% of maternal deaths are directly related to anemia and another 50% of maternal deaths are associated with it [12]. A nationally representative survey i.e., National Family Health Survey (NFHS) has been carried out in three rounds (1991–1992, 1998–1999 and 2005–2006) and is a country-wide survey creating a vast databank on several

Causes of IDA in India

The circumstances under which IDA arises in India are numerous. In our opinion, the most important ones are inadequate dietary intake of iron, defective iron absorption, increased iron requirement due to repeated pregnancies and lactation, poor iron reserves at birth, timing of umbilical cord clamping, timing and type of complementary food introduction, frequency of infections in children, and excessive physiological blood loss during adolescence and pregnancy [17], [18]. Recent evidence also

National Nutritional Anemia Prophylaxis Programme

NNAPP was launched in 1970 with the objective of preventing anemia in pregnant and lactating mothers and children. Under NNAPP, expectant and nursing mothers as well as acceptors of family planning are given one tablet of iron and folic acid containing 100 mg elementary iron and 500 μg of folic acid. Children, from the age of 6 mo to 5 y, receive iron supplements in a liquid form in doses of 20 mg/d elemental iron and 100 μg/d folic acid for 100 d/y. Children ages 6 to 10 y receive iron in the

Key interventions required to combat IDA

There are certain fundamental elements that are needed to be addressed in any program aimed at improving general well-being, and the improvement of iron status in particular. These include [5]:

  • 1.

    The reduction of poverty.

  • 2.

    Improvement of access to diversified diets.

  • 3.

    Improvement of health services and sanitation.

  • 4.

    Promotion of better care and feeding practices.

Conclusion

IDA continues to a major public health concern in the Indian subcontinent, affecting nearly half the population. There are certain factors that are particularly making the Indian population susceptible to IDA, such as multiple infections, multiple pregnancies, poor access to health services, and so on. Although the Indian government has undertaken many initiatives, the outcome has not been as hoped. There remains a pressing need to strengthen the existing programs by overcoming the shortcomings

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