Nutritional Anemia and Its Control
D e e k s h a Kapur, Kailash N a t h Agarwal and D e v K u m a r i Agarwal
School of Continuing Education, Indira Gandhi National Open University, New Delhi,
University College of Medical Sciences & Guru Teg Bahadur Hospital, Delhi and
Institute Medical Sciences, Varanasi, India.
Abstract. Available studies on prevalence of nutritional anemia in India show that 65% infant and toddlers, 60% 1-6 years
of age, 88% adolescent girls (3.3% had hemoglobin < 7.0 g/dl; severe anemia) and 85% pregnant women (9.9% having
severe anemia) were anemic. The prevalence of anemia was marginally higher in lactating women as compared to pregnancy.
The commonest is iron deficiency anemia. National programmes to control and prevent anemia have not been successful.
Experiences from other countries in controlling moderately-severe anemia guide to adopt long-term measures i.e. fortification
of food items like milk, cereal, sugar, salt with iron. Use of iron utensils in boiling milk, cooking vegetables etc may contribute
significant amount of dietary iron. Nutrition education to improve dietary intakes in family for receiving needed macro/micro
nutrients as protein, iron and vitamins like folic acid, B12,A and C etc. for hemoglobin synthesis is important. As an immediate
measure medicinal iron is necessary to control anemia. Addition of folate with iron controls anemia and is neuroprotective.
Evidence in early childhood suggests vitamin B12 deficiency anemia; thus it may also be given alongwith iron and folate.
[Indian J Pediatr 2002; 69 (7) : 607-616]
Key words : Nutritional anemia; Pregnancy; Adolescence; Early childhood; Iron fortification.
Inadequate erythropoiesis and reduced hemoglobin
concentration characterize nutritional anemia. This is
due to inadequate supply of nutrients like iron, folic acid
and vitamin B~2. During intra-uterine life, the source of
these nutrients is entirely maternal in origin, whereas
postnatally they are obtained through the breast milk and
diet. Many other nutrients and cofactors are involved in
the maintenance of hemoglobin level. However, iron
deficiency is the main etiological factor responsible for
nutritional anemia in the community.
Protein, amino acids and calorie malnutrition states
have been associated with several other micronutrient
deficiencies resulting in altered erythropoeises.
Depending upon the deficiencies normocytic, microcytic,
megaloblastic or dimorphic anemias are observed in
marasmus, kwashiorkor etc. Protein deficiency in animals
impairs erythropoeitin response in hypoxia. Thus in
protein deprivation, decreased amino acids substrate
affects erythropoeitin synthesis. Amino acid methionine
deficiency is associated with megaloblastic anemia in
kwashiorkor. In anorexia nervosa, a situation of
starvation, patients may develop moderate anemia,
leucopenia and thrombocytopenia; bone marrow is
usually hypoplastic2
Vitamins
Deficiency of Vitamin B12 results in neuropsychiatry
features with or without megaloblastic anemia. This
Reprint requests : Dr. Kailash Nath Agarwal, D-115/Sector 36,
Noida-201301, India. Fax : 011-5741 782,
E-mail : kna_ped@yahoo.com
Indian Journal of Pediatrics, Volume 69---July, 2002
vitamin is essential for DNA synthesis, which is a
prerequisite for erythropoeisis. Deficiency of folate also
results in megaloblastic anemia. Vitamin B6 deficiency
can be associated with m a c r o / m i c r o - h y p o c h r o m i c
anemia. Riboflavin deficiency results in normocyticnormochromic anemia with bone-marrow hypoplasia,
reduced reticulocyte count and vacuolization of
normoblasts. 1
Vitamin C and A deficiency impair mobilization of iron
from stores. In addition, Vitamin C plays an important
role of converting Fe §247247
to Fe§ states, to enhance iron
absorption. Other Vitamin B complex group e.g. niacin
and pantothenic acid result in normocytic anemia. 1.
Of all the nutritional deficiencies; iron deficiency
anemia (IDA) is a major public health problem in India. It
is pervasive and affects all age-sex groups but the most
severely affected are women in the reproductive age
group and young children. It induces generalized as well
as systemic health consequences; the important one being
irreversible brain dysfunction.2
Prevalence of Anemia Among Young Children in India
In India, about 150 million children, 17.5 per cent of the
population is below the age of six. Nearly 70 million i.e.,
60 - 70 per cent of all children below 6 years suffer from
varying degree of anemia, Based on the earlier data
available from the different states, the prevalence varies
from 38.9 - 86.2 per cent, and interestingly it places all
states of India under the high magnitude category (Table
1). The prevalence has remained essentially the same
since the 1960's as is evident from the Table 1. In a study
607
Deeksha Kapur et al
TABLE1. Prevalence of Iron Deficiency Anemia among Infants and Toddlers in India
Study Region/Reference
North India Delhi Dhar et al, 19693
ICMR, 19774
Gomber et al, 1998)12
Kapur et al, 200211Ludhiana
Uberoi et al, 1972s
Varanasi Singla et al, 1982s
Agarwal et al, 19866
Age
Prevalence (%)
Criteria for Assessment
6m -3y
1-3y
3m-3y
9-36m
<3y
6m-5y
60
83
76
64
70
urban 56
1-3y
1-3y
1-2m
3-4m
5-6m
7-9m
10-12 m
13-15 m
16-18 m
19-24 m
24-36 m
54.3
605
52.8
85.2
63.3
77.5
86.2
75.0
75.0
76.9
47-57
I-lb. estimation
Hb. estimation (<10.8g/dl)
1-3y
1-3y
1-3 y
70.6
79
61
Hb. estimation (<10.8 g/dl)
Hb. estimation (<10.8 g/dl)
Hematocrit (PCV (<33%)
1-3 y
38.9
Hb. estimation (<33%)
0-3y
1-3y
65
62.8
Hb. estimation (<11.0 g/dl)
Hb. estimation (<10.8 g/dl)
Fib. estimation (<12g/dl)
Hb. estimation (<10.8 g/dl)
Based on response to supplementation
Hb. estimation (<11g/dl)
Fib. estimation
Based on response to supplementation
Fib. estimation (<11.0g/dl)
South India
Vellore
ICMR, 19774
Hyderabad ICMR, 1977
Raman et al, 1990 & 19927,s
I-lb. estimation
(<11g/dl)
West India
Bombay
ICMR, 1977 Pune
ICMR, 1977
Malin et al, 19829
East India
Kokkatta
ICMR, 1977
India
Combined Data4
ICMR, 1977
in 1969, involving 200 children below the age of 14 years,
highest prevalence rate of 60 per cent was found in the
age group of 6 months to 3 years. 3 A large multicentric
study reported 62.8 per cent of children, between the ages
of 1- 3 y e a r s , s u f f e r i n g f r o m a n e m i a since t h e y h a d
h e m o g l o b i n levels b e l o w 10.8 g p e r cent? The highest
incidence of anemia was found in Delhi (83%), followed
b y Pune (79%), B o m b a y (70.6%), H y d e r a b a d (60.5%),
Vellore (54.3%) and Calcutta (38.9%). Prevalence of severe
a n e m i a i.e., H b < 7 g / d l w a s 36% in D e l h i a n d
approximately 14% in two states H y d e r a b a d and Pune. 4
In a study a m o n g rural Punjabi children in Ludhiana, 70
per cent prevalence in children less than three years of age
was observed. 5 In another s t u d y f r o m Varanasi, 55 per
cent children b e t w e e n 3 months to 3 years of age were
f o u n d to be anemic; children of a n e m i c m o t h e r s h a d
significantly higher prevalence of anemia. 6
Studies f r o m H y d e r a b a d c o v e r i n g 250 infants a n d
preschool children <2 years and 150 preschool children
b e t w e e n the a g e s of 1-6 y e a r s e s t i m a t e d p e r c e n t
p r e v a l e n c e of 52.8-86.2%, a n d 47 - 57% respectively.
P r e v a l e n c e w a s m u c h l o w e r o v e r 4 y e a r s of age. z,a
Another s t u d y carried out in a large slum settlement in
Pune a m o n g children a g e d 6-60 m o n t h s r e p o r t e d an
608
overall 43 percent prevalence of anemia, w i t h highest
prevalence between 12 and 36 months, accounting for 61
per cent of all cases. 9 More recently, NFHS-2 (1998-99)
data reveal that 74% children, 6-35 m o n t h s of age, are
anemic. 1~Kaput et al in 523 children, aged 9-36 months, of
an ICDS u r b a n s l u m b l o c k in Delhi, o b s e r v e d 64%
children as anemic (Hb<11.0g/dl); 7.8% severly anemic,
with 88% children estimated to be iron deficient (on the
basis of ferritin level). The red cell m o r p h o l o g y showed
33.9% as m i c r o c y t i c - h y p o c h r o m i c a n d 37.1% as
dimorphic. 11The vitamin B12 deficiency in this age group
anemia was around 40%. 12
Based on the data from these studies, the prevalence of
anemia a m o n g infants, toddlers can be estimated to be
around 65% in India. Table 2 presents the prevalence of
iron deficiency anemia in preschool children (1-6 years).
A multicentric s t u d y sponsored b y Food and Nutrition
Board and UNICEF in 1981, r e p o r t e d a p r e v a l e n c e of
approximately 60% a m o n g r u r a l / u r b a n children aged 15 years, the highest being in villages near Calcutta (96.3%)
followed b y those near H y d e r a b a d (66.3%) a n d Delhi
(59%). Prevalence of anemia in the urban centre of Madras
was only 19.1%. Severe anemia (Hb < 7.0g/dl) in children
w a s also h i g h e s t in C a l c u t t a (18%). 13 S t u d i e s f r o m
Indian Journal of Pediatrics, Volume 69--July, 2002
Status of Nutritional Anemia : Measures to Control
TABLE2. Prevalence of Iron Deficiency Anemia in Pre-school Children (based on combined data for children 1-6 years of age)
Study
Region/Reference
Age
N
Prevalence
Criteria for
1-5y
90
59
Hb<11g/dl
6-8y
rural 1336
50.0
Hb<12.0g/dl
1-5y
1-5y
1-6y
1026
436
668
52
66.3
71
Hb<11g/dl
Hb<11g/dl
Hb<llg/dl
1-5 y
222
6
Hb<7g/dl
1-5 y
4838
66
Hb<11g/dl
1-5 y
410
96.3
18
Hb<llg/dl
Hb<7g/dl
North India
Delhi
Food & Nutr Board & UNICEF, 198113
Varanasi
Agarwal et al. 198716
South India
Hyderabad
Visweswara Rao et al, 19801~
Food & Nutr Board &
UNICEF, 1981
Madras
Food & Nutr Board &
UNICEF, 1981
West India
Gujarat
ACC/SCN, 199117
East India
Kolkatta
Food & Nutr Board &
UNICEF, 1981
TABLE3. Prevalence of Anemia Among Pregnant Women
Sr.No
N
Trimester
% Prevalence of anemia
4775
> 20w~c
87
1968
11 States
16
5654
II
4.
ICMR (1989)
11 States (All India) 19
ICMR (1992)
6 States (All India)2~
ICMR (District Nutrition
Survey) 1999-200021
NFHS 2000 (All India) 1~
5.
Seshadri et al 1994~2
160
II
62
84.6 (Hb < 11.0 g/dl)
9.9 (Hb < 7.0g/dl)
52
Used Hemocue method
which gives 10% higher
Hb values
74
230
304
I+H+III
87
88
559
304
I+II+III
87
88
3461
Term
49
>100
II
80
1000
III
57
1
2
3.
6.
7.
8.
9.
10.
Baroda
Christian et a/~
Chandrapur (M.P.)
Panchmahal (M.P.)
Agarwal et a/19872'
Bihar
Panchamahal (M.P.)
Prema et al 19812s
Hyderabad
Sood et al 1975~
Delhi
Yusul~iet a1197327
Vellore
H y d e r a b a d i n 1978, 1980 a n d 1983 i n d i c a t e d 50-70%
p r e v a l e n c e a m o n g c h i l d r e n 1-6 y e a r s of age. ~4 S t u d i e s
f r o m V a r a n a s i r e p o r t e d p r e v a l e n c e rates a m o n g u r b a n
and rural preschool children between the ages of 6
m o n t h s a n d 5 y e a r s of 56.2% a n d 75.6%, r e s p e c t i v e l y . ~s
S i m i l a r f i g u r e of 50% ( H b < 12.0 g / d l ) w a s o b s e r v e d in
r u r a l c h i l d r e n of 6-8 y e a r s of age. ~6
F r o m the w e s t e r n region, studies f r o m G u j a r a t ( A C C /
S C N 1991) r e p o r t a p r e v a l e n c e of 66% a m o n g c h i l d r e n
Indian Joumal of Pediatdcs, Volume 69--July, 2002
1-5 y e a r s of a g e (Hb < 11.0g/dl). 17 S t u d i e s c a r r i e d o u t in
u r b a n B a r o d a b e t w e e n 1980 a n d 1996 h a v e i n d i c a t e d a
p r e v a l e n c e r a t e of 67% in p r e s c h o o l c h i l d r e n , w i t h 6%
p r e v a l e n c e of severe a n e m i a in c h i l d r e n 2-6 y e a r s of age. 18
Prevalence of anemia among pregnant women in India
N a t i o n a l r e p r e s e n t a t i v e a v a i l a b l e d a t a o n p r e v a l e n c e of
a n e m i a a m o n g p r e g n a n t w o m e n i n I n d i a is s h o w n in
Table 3. ICMR in 1989 t h r o u g h a c o u n t r y w i d e e v a l u a t i o n
609
Deeksha Kapur et al
of the anemia control programme examined 4775
pregnant women (from 11 states) at or beyond 20 wk of
gestational age for hemoglobin. The prevalence of anemia
defined as Hb <11.0g/dl was found to be 87% with 32%
women having Hb less than 8g/dlJ 9 Another study by
ICMR in 1992 carried out in six states among pregnant
women in second trimester reported a prevalence rate of
62% (with lowest prevalence of 33% reported from
Andhra Pradesh to highest of 98% in Rajasthan). 2~A
recent District Nutrition Survey conducted by ICMR, in
national sample (1998-2000) found 85% pregnant women
anemic with 9.9% having severe anemia. 21According to
the NFHS-2 data the prevalence of anemia in pregnant
women was essentially similar to that seen in
nonpregnant women (52%). However, they used
Hemocue method instead of cyanmethemoglobin
technique. The former estimates 10% higher haemoglobin
level, thus gives lower prevalence of anemia.1~
Other studies on anemia prevalence among pregnant
women are also available in literature (Table 3). 10"19-27
Anemia is a major public health problem among pregnant
women in all states, with data suggesting a lower
prevalence among women in the southern region as
compared to the western, eastern and northern region.
Prevalence of anemia a m o n g lactating w o m e n in India
With reference to IDA prevalence among lactating
women, few studies are available, that too providing
variable data. The NFI, 1988 study indicated the highest
prevalence of IDA among lactating women in Calcutta
(95%), followed by Bombay (90%) and Chennai (81%).28
The recently published NFHS-2 data give a prevalence of
56.4% among breastfeeding mothers. Interestingly,
marginally higher prevalence of anemia was recorded for
breast-feeding women as compared to pregnant women
in the NFHS-2 data. As mentioned above these estimates
are lower as these were by Hemocue method, m
Prevalence of anemia a m o n g Adolescent girls in India
There is paucity of data regarding prevalence of anemia
among adolescent in India. The few published available
data, however, suggest a high prevalence. The ICMRDistrict Nutrition Survey (1998-2000) reported anemia
prevalence of 88% among adolescent girls, with 3.3%
prevalence of severe anemia. 2~ Findings from a
multicentric study (UNICEF 1998) in 3 regions (Delhi,
Bombay, Baroda) to assess the effectiveness of weekly
supplementation revealed that over 50% adolescent girls
were anemic. The study in Delhi recorded a prevalence of
48-50% among adolescent girls in the age 11-18 yr, the
period, which coincides with accelerated growth and the
onset of menstruation. 57-65% per cent rural adolescent
girls (n=1513) in Gujarat and 57 - 65% girls in Mumbai
were anemic with Hb levels less than 12.0g/dl. 29Other
studies from Delhi, 3~Hyderabad 13and Varanasi 31have
given essentially similar figures for prevalence of anemia
in adolescent girls 11-18yr, 10-19 yr and 6-15yr,
610
respectively. The anemia prevalence data from the
metropolitan centers of Delhi, Mumbai, Coimbatore (NFI
1989) has indicated the Hb levels of affluent Delhi girls to
be marginally lower (11.6g/dl) as compared to levels of
girls from Mumbai and Coimbatore. 32"33NFHS-2 data
indicate IDA prevalence of 56% among subjects 15-19
years of age. 1~This leaves us with no doubt that iron
deficiency anemia is a major public health problem
among adolescent girls in India.
The consequences of iron deficiency anemia are wide
ranging. Iron deficiency anemia in infants, children is
associated with impaired growth and development, lower
development scores, poor mental performance and
cognitive functions; among adolescent it is associated
with poor performance in academic tests, reduced
physical activity and implications for the long term health
of their offspring.2
In the light of the debilitating effects of iron deficiency
anemia, a comprehensive strategy/policy needs to be
developed and implemented to achieve the goal of
reducing the incidence of nutritional anemia.
C O M B A T I N G IRON DEFICIENCY :
PRIORITIES FOR I N D I A
Taking cognisance of the ravages caused by nutritional
anemia, the Government of India has ongoing
programmes for the last 2-3 decades. The Ministry of
Health and Family Welfare initiated the National
Nutritional Anemia Prophylaxis Programme (NNAP) in
1970 in all the States in the country. The programme
targeted the vulnerable sections of the society including
pregnant/lactating women and pre-school children (1-5
years of age). The programme focused on provision of iron
and folate supplements in the form of iron-folic acid (IFA)
tablets to "high risk groups", for prevention as well as
treatment of severe anemia.
The evaluation of the programme, undertaken by the
Indian Council of Medical Research in 1989 clearly
showed that the programme failed to make any
noticeable impact on reducing the incidence of anemia
despite being in operation for 15 years. 19Following the
ICMR evaluation, the Government of India redefined the
policy on Control of Nutritional Anemia and in 1990, the
National Nutritional Anemia Prophylaxis Programme
was renamed the "National Nutritional Anemia Control
Programme". In this programme, the beneficiary groups
were redefined to include both anemic and non-anemic
pregnant/lactating women, and children 1-5 years of age
for iron-folate supplementation. The programme also
included nutrition education as a major objective to promote
the consumption offoods rich in iron. In 1992, the policy on
Nutritional Anemia Control was made an integral part of
the Government of India's guidelines on Child Survival &
Safe Motherhood (CSSM) programme. Subsequently, the
National Nutritional Anemia Control Programme was
reviewed by members of the Task Force on
Indian Journal of Pediatrics, Volume 60---July, 2002
Status of Nutritional Anemia : Measures to Control
Micronutrients (Report of the Task Force on
Micronutrients, 1996). The Task Force recognized certain
limitations of the programme, which included poor
compliance, irregular supplies, low e d u c a t i o n /
counselling. It was recommended that the National
Nutritional Anemia Control Programme needs further
strengthening with reference to its policy as well as its
implementation.
In 1993, the GOI adopted the National Nutrition
Policy, which advocated a "comprehensive, integrated
and inter-sectoral strategy for alleviating the multifaceted
problem of malnutrition and achieving the optimal state
of nutrition for the people". The National Plan of Action
on Nutrition (NPAN) was released in 1995 to implement
the National Nutrition Policy, which included strategies
specifically to address the prevention and control of
micronutrient deficiencies. ~ The National Nutrition Goals
(NPAN 1995) defined included:
9 Reduction in 'Iron Deficiency Anemia' among
pregnant women by 25 per cent by 2000 AD, and
9 Reducing the incidence of severe and moderate
malnutrition by half by the year 2000 AD.
A national consultative group on Control of
Nutritional Anemia (National Consultation on Control of
Nutritional Anemia in India 1998) further prioritises
children in the 6 - 24 month age group for intervention
(IFA supplementation).
Protein-energy alongwith micronutrients i. e. vitamins
and minerals are essential for formation of hemoglobin.
Thus strategies must try to provide basic nutritional needs
to sustain hemopoiesis. WHITE REVOLUTION (milk
products) has made landmark contribution by providing
safe, pasturized milk protein to prevent deficiency of this
vital nutrient (for hemoglobin synthesis).
P R E V E N T I N G I R O N DEFICIENCY A N E M I A - A
FOOD BASED STRATEGY
Iron deficiency and anemia are an outgrowth of poverty
and it is also linked to ignorance, faulty feeding practices,
inadequate access to food, consumption of foods of low
nutrient density, low bioavailability of iron, infections/
infestations and to the lack of knowledge about safe food
handling. Studies suggest that anemia found in
population groups is primarily due to dietary deficit of
iron. n,35 Since the problem (iron deficiency anemia) is
mainly of dietary origin, it would perhaps be logical to
presume that policies/strategies need to be developed
and implemented which ensure better year round access
and consumption of an adequate variety and quantity of
good quality, safe food. It is in this context that foodbased approaches as preventive strategies for iron
deficiency anemia are gaining momentum.
Few important food based approaches for bringing a
qualitative improvement in iron status include :
9
Dietary diversification/modification to promote
year round availability, access to and utilization of
Indian Journal of Pediatrics, Volume 69~July, 2002
9
9
9
foods which promote the increased intake and
absorption of dietary iron; cooking in cast iron
utensils is an important method for dietary iron
enrichment.
Horticulture intervention including home gardening
addressing issues of food production, preservation,
processing, marketing and preparation
Food fortification to improve dietary intake of iron
and its bioavailability. Currently this approach is a
priority, in view of high prevalence of moderate to
-severe anemia in India.
Nutrition and Health Education to promote food
based approaches.
A discussion on these approaches with emphasis on
nutrition~health education follows :
Dietary Diversification/Modification - A Food Based
Preventive Strategy
Lal et aP6 demonstrated that cooking in cast iron utensils,
which were traditionally used in Indian families until four
decades back for boiling milk, cooking vegetables etc.
provided extra dietary iron. This available dietary iron is
well absorbed. WHO 1992 report on prevalence of
anemia among pregnant women, records that lowest rates
of anemia of all the subregions of the developing world
were observed in Southern Africa, due to wide spread use
of iron cooking pots by indigenous people. 37
The important indicators of programme
implementation specific to dietary improvement among
vulnerable groups should therefore, take into account: 1)
the average dietary iron consumption by the vulnerable
group ii) analysis of effects of iron absorption promoters
(vitamin C) and inhibitors (tannins, phytates etc.), and iii)
policy and plan of action for promoting consumption of
iron-rich and other foods and adopting healthy dietary
practices. The approach to have enough dietary iron
should incorporate availability of recommended dietary
macro/micro nutrients for daily needs in regard to
physiological status i.e. growing infant, pregnancy,
lactation and adolescence.
H o r t i c u l t u r e I n t e r v e n t i o n s - A F o o d Based P r e v e n t i v e
Strategy
These inputs including home gardening addressing issues
of food production, preservation, processing, marketing
and preparation are innovative measures targeted to meet
the national nutrition goal of reducing the incidence of
deficiency anemia. Home gardening as a traditional
family food production system is widely practiced in
many developing countries. Fortunately India has done
well in this area as seasonal vegetables and fruits are
becoming affordable.
Fortification of Food With Iron - A Food Based
P r e v e n t i v e Strategy
With respect to infants and young children, who are
611
Deeksha Kapur et al
u n d o u b t e d l y vulnerable, for a number of reasons,
fortification of complementary foods (milk, cereals) is
positively one important preventive strategy for iron
deficiency.38 Clinical research in C h i n a , Chile and
Canada have also shown that the iron is bioavailable and
the iron-fortified cereals are effective in the prevention
and treatment of iron deficiency in infants.3~1 Fortification
of condiments with iron has proven to be efficacious
intervention to prevent iron deficiency and nutritional
anemia. Iron EDTA has been highly effective in
fortification trials with Egyptian flat breads, curry powder
in South Africa, fish sauce in Thailand, and sugar in
Guatemala, to name a few examples. Indian researchers
have field tested with success, iron fortified salt. A new
approach in fortification is the use of 'sprinkles', a small
sachet containing iron and other nutrients, which can be
sprinkled onto the complementing food prior to
consumption. Preliminary results with this strategy are
encouraging. In randomized controlled trials in Ghana
and a pilot study in India demonstrated that the iron
'sprinkles' are as efficacious as the gold standard, iron
drop, for the treatment of anemia.
N u t r i t i o n and H e a l t h E d u c a t i o n - A n A p p r o a c h to
Promote Food Based Strategies to Prevent Nutritional
Anemia
The Government of India's policy for control of
nutritional anemia includes Nutrition/Health Education
as one of the major long-term measures to prevent iron
deficiency. The National Consultation on Control of
Nutritional Anemia (GOI 1998) recommended that the
existing Nutritional Anemia Control Programme should
be comprehensive and incorporate Nutrition Education
through school health and ICDS infrastructure to
promote:
9
regular intake of iron/folic acid-rich foods by all age
groups
9
consumption of foods that increase absorption of
iron and vitamin C and avoid foods which inhibit
iron absorption (tea/coffee), and
9
adequate availability of iron-rich foods by:
- increasing their production through development of
kitchen gardens in homes, schools and the villages
- development of iron fortified foods and promoting
their consumption.
Food habits/practices are generally based on deeply
ingrained food preferences, attitudes, eating patterns that
are not easy to change. Such a change requires a carefully
planned communication intervention. Nutrition
education can convey information, persuade individuals
to consume food rich in iron/vitamin C, choose fortified
foods, prepare food in new ways to protect their nutrient
content and change patterns of feeding children. Further,
nutrition communication can help people develop
necessary skills and motivate people to make lifestyle
612
changes.
A s t u d y in Delhi by Kapur et al (unpublished)
developed specific communication strategies to improve
feeding practices and iron status of children less than 3
years of age. A well-conceived set of educational
messages as indicated herewith (Box 1) was formulated to
promote iron status. Anganwadi workers and caretakers
produced an extensive set of communication material
including a leaflet, a special child feeding flip chart,
calendar, and video programme for use. The evaluation
revealed that mother's knowledge of appropriate feeding
practices and iron nutrition was significantly greater in
intervention area and was associated with changes in
specific feeding practices. Further, there was a small, but
significant increase in the energy and iron intake of
children of 9 - 36 months of age. The study documents
provide information on the ability of different media to
communicate messages successfully. The use of multiple
channels of information and direct interpersonal
communication were noted to be important features
contributing to the success of the intervention
programme. 42
Key Nutrition Messages
9 Breast-feed the child exclusively for 4 months. Even
the anemic mother secretes more iron in milk43
9 Introduce complementary food at 4-6 months of age
9 Include regular and adequate amount of iron-rich
food or foods fortified with iron in the household diet
9 Provide lots of green leafy vegetables such as
mustard, fenugreek, spinach, corriander etc (these
provide protein, iron, B-carotene etc).
9 Ensure consumption of vitamin C-rich foods along
with meals as they help in iron absorption and
utilization. Add a few drops of lemon juice in dal/
vegetable preparations.
9 Avoid serving tea/coffee along with meals (atleast 23 hours before or after a meal).
9 Cook food in iron pots/kadhai. This will provide the
much-needed iron to keep the body healthy.
9 Include flesh foods (meat, poultry, liver, fish) in the
diet, whenever possible.
9 Use fermented and sprouted foods such as sprouted
pulses.
9 Wash raw foods thoroughly before eating or serving
to children.
9 Mixing cereal with pulse dietary item improves
quality of protein and amino acid composition.
9 Fermented milk or other food products have
probiotic properties, change intestinal flora, inhibit
harmful enzymes and modulate immune processes
and suited in lactose intolerance.
S u p p l e m e n t a t i o n w i t h Medicinal Iron - A Short Term
Preventive Strategy
Supplementation as a short term strategy to prevent iron
Indian Journal of Pediatrics, Volume 69--July, 2002
Status of Nutritional Anemia : Measures to Control
deficiency is most common in many countries. Efficacy
trials indicate the following benefit of iron supplementation for iron-deficient anemic population groups: in
pregnancy, improved maternal and infant iron status;44
for children, improved cognition and behaviour, although
more randomized, controlled trials are needed; and in
individuals of all ages with severe or moderate anemia,
increased work capacity and activity.
While more research is needed on the comparative
efficacy, effectiveness and other biological effects of the
frequency of iron supplementation (such as daily/weekly
supplements), it has become clearer that the expected
degree of improvement in iron status depends mostly on
the total a m o u n t of iron consumed during the
intervention period. It is strongly being proposed that in
controlled situations, intermittent iron supplementation
can effectively reduce the prevalence of iron deficiency in
several groups. ~47 A recent rneta-analysis to study the
efficacy of intermittent iron supplementation in the
control of iron deficiency anemia presents the following
conclusions. 29 The analysis was based on existing
experience (from 22 completed iron trials) in developing
countries :
9 Both daily and weekly iron supplementation are
efficacious. Weekly iron supplementation is likely to
be less effective than daily administration except in
situations where supervision is feasible with weekly
regimens and not with daffy supplementation.
9 Weekly s u p p l e m e n t a t i o n may be particularly
disadvantageous during pregnancy and in situations
where the baseline prevalence of anemia is very high.
9 Unless ways are found to greatly improve
"compliance" in comparison to that seen in existing
programs, neither daily nor weekly iron supplementation is likely to be an effective approach to
preventing and controlling iron deficiency anemia in
developing countries.
9 Regardless of the degree of supervision that can be
arranged, weekly, instead of daily, iron
administration is not recommended for pregnancy.
In India, the existing Nutritional Anemia Control
Program covers all children under 5 years of age for
supplementation. The daily dosage of iron/folate tablet
recommended is 20rag elemental iron + 100 mcg folic
acid. Studies do suggest deficiency of vitamin B12below
three years of age. n,~2,46Thus the desired/required syrup/
tablet to prevent anemia in early childhood should have
elemental iron 20 mg+ vitamins folic acid 50 ug + B12 1
ug, for average 10kg child. It is suggested that an effective
system for reaching infants and children could be through
immunization contacts. Iron folic acid (IFA) syrup
containing 100 doses each is given to the mothers - one
bottle at 5-6 months after 3rd dose of DPT and polio and
the second when the child is brought for the measles
vaccine. In fact, the breast .milk iron falls short by six
months for growth needs, the complimentary diet has low
Indian Journal of Pediatrics, Volume 69---July, 2002
iron in infant diet unless supplementary iron is provided
or infant m i l k / f o o d is cooked in cast iron vessels.
Therefore, the supplementation should be offered at the
3rd DPT plus Polio dose, measles immunization and at
third time at booster DPT plus Polio dose. For low birth
weight and preterm babies, a daily dosage 10 mg
elemental iron + 25 mcg folic acid+ 0.5 mcg of vitamin B~2
is recommended from the age of 2 months onwards (the
time when bone-marrow goes in active hemopoiesis).
Available Iron Syrups and Desired Composition for Our
Children
Fesovit elixir(SKB) ; Hemsi (Serum Inst); Iberol (Abbott);
Phosphomin-iron (Sarabhai); Sederplex drops (Raptakos);
Tonoferon (East India); Vitcofol (FDC). Of these only two
later preparations (Tonoferon and Vitcofol) have iron +
folic acid + vitamin B12.Tonoferon in each 5 ml has 80 ragcolloidal iron + 200 ug folic acid and 2 ug of vitamin B~2in
drops per ml has 25 mg elemental iron + folic acid 200 ug
+ vitamin B125ug with 1 lysine mono-hcl. Vitcofol has
ferrous fumarate 100 m g + folic acid 500 ug + vitamin B12
5 ug. All other mentioned preparations have additional
vitamins.
The supplementary doses of iron r e c o m m e n d e d
(internationally) for supplementation for different age
groups/conditions, either on a daffy or weekly basis, have
been presented in Table 4.48,49
The other recommended daily allowances for other
hematopoeitic micronutrients are presented in Table 5.~
Parasite Control and Public Health and Disease Control
M e a s u r e s - as Strategies to Prevent Iron D e f i c i e n c y
Anemia
The public health measures that can be used in the control
of micronutrient malnutrition problems (namely anemia,
vitamin A deficiency and iodine deficiency) are by and
large the same. Table 6 summarises the different public
health Lnterventions that are effective and appropriate.
Among parasitic infestations, hookworm disease and
Schistosomiasis play an important role in the etiology of
anemia by causing chronic blood loss. Evidence also
indicates that a number of other intestinal parasites such
as giardia, interferes with the absorption of iron,
particularly if the worm load is high. s~Removing these
parasites, therefore, should be an important component of
any programme dealing with anemia control and
prevention. Anti-helminthic treatment, irrespective of
infection status, is recommended at least annually.
However, high-risk groups such as children should be
treated more intensively i.e. 2 - 3 times per year. Evidence
indicates that deworming can help improve iron status
among children, particularly in areas where infestation is
heavy)s~l Along with deworming, simultaneous efforts to
eradicate the reservoir of infection through preventive
public health measures such as provision of safe water
and improvement in environmental sanitation/personal
and food hygiene should be an essential component of the
613
Deeksha Kapur et al
TABLE4. Supplementary Doses of Iron Recommended for Preventive/Therapeutic Administration, Either on a Daily or Weekly Basis
Target group
Prevalence
of anemia
Category
Schedule of supplementation
Therapeutic
Preventive
Infants < 2years
Normal
<40%
LBW
>40%
Nomral
LBW
Daily dosage
Duration
Weekly dosage
Daffy dosage
Duration
2 mg/kg body weight 12.5
rng iron + 50 ~tg folic acid
6-12 months of age
3mg/kg body
weight from 6
months
3mg/kg body weight
i.e. 25 rag iron + 100400 ~tg folic acid
(3 months)
3mg/kg - body
weight
3 mg/kg body weight
60 mg iron + 400 I~g
folic acid for 3 mths
2 mg/kg body weight i.e,
12.5 mg iron + 50 ~tg folic
acid
2-24 months of age
2mg/kg body weight i.e.
12.5 mg iron + 50 ~tg folic
acid
6-24 months of age
2 mg/kg body weight i.e.
12.5 mg iron + 50 p-g folic
acid
2-24 months of age
Children 2-5 years
2 mg/kg body wight
20-30 mg iron for a 2-3 week
course several times a year
Children 6-11 years
30-60 mg iron
To treat severe anaemia
60 mg iron + 400 ~g
fohc acid for 3 months
Adolescent
Pregnancy
<40%
>_40%
60 mg iron + 400 ~tg folic acid
120 mg iron + 400 ~g
folic acid for 3 months
60 mg iron + 400 ~tg folic acid daily for 6 months
60 mg iron + 400 ~tg folic acid (6 months in
pregnancy & continuing to 3 months
postpartum)
120 mg iron + 400 ~tg
folic acid daffy for 3
months
To treat severe anaemia
Source : Adapted from W H O (1996) 48 and I N A C G / W H O / U N I C E F (1998) 49 *LBW = Low Birth Weight
TABLE5. Recommended Daily Allowances for Other Hematopoeitic Micronutrients 1
Vitamins
B12 ~g/d
Folic acid ~tg/d
Vitamin Cmg/d
Riboflavin mg/d
VitaminA (I.U)
[~Caroteen
B6
Infancy
0.2
25
25
0.6
400
1200
0.1-0.4
1~3 yr
4-6yr
1.0
30
40
1.0
400
1600
0.9
1.0
40
40
1.0
400
2400
1.6
programme.
Besides intestinal parasites, m a l a r i a seriously w o r s e n s
iron status and satisfactory improvement cannot be
a c h i e v e d b y i r o n s u p p l e m e n t a t i o n u n l e s s m a l a r i a is
t r e a t e d . M a l a r i a p r e v e n t i o n m e a s u r e s a r e i m p o r t a n t in
c o n t r o l of a n e m i a . W h e n m a l a r i a is e n d e m i c , m a l a r i a
p r o p h y l a x s i s can b e c o n s i d e r e d . A m o n g o t h e r m e a s u r e s ,
the use of insecticide-impregnated
bednets in
c o m m u n i t i e s ( w h e r e m a l a r i a is e n d e m i c ) h a s s h o w n to
d e c r e a s e the p r e v a l e n c e of severe anemia.
614
7-gyr
1.0
70
40
1.2
600
2400
2.0
Adolescence
1.0
100
40
1.5
60 0
2400
2.0
Finally, d i a r r h e a l d i s e a s e s a n d o t h e r s e r i o u s illnesses
c o m m o n a m o n g c h i l d r e n in t h e d e v e l o p i n g w o r l d c a n
interfere w i t h n u t r i e n t a b s o r p t i o n / u t i l i z a t i o n . R e d u c t i o n
of the incidence of infections mainly diarrhea and
r e s p i r a t o r y diseases, c a u s i n g m o r b i d i t y in general, can b e
m o s t effective p r e v e n t i v e strategy.
To s u m m a r i z e , the effective c o m b i n a t i o n of p e d i a t r i c
s y r u p s h o u l d contain elemental i r o n 20 m g + folic acid 50
u g a n d l u g of v i t a m i n B12 p e r t e a s p o o n (5 ml) for 10 k g
w e i g h t child. These r e q u i r e m e n t s a r e b a s e d o n t h e R D A
Indian Journal of Pediatrics, Volume 69--July, 2002
Status of Nutritional Anemia : Measures to Control
TABLE6. Public Health Measures for Micronutrient Malnutrition
Control
Public health measures
Iron
Immunization
Deworming
Hookworm/schistosomiasis
Malaria prophylaxis
Diarrheal disease control
Respiratory disease control
Food hygiene and general
sanitation
Iodine
++
++
++
++
++
+
+++
Vitamin A
13.
+++(measles)
++
+
++
+
++
14.
15.
+++
Number of + indicates level of importance as a public health
measure in relation to each micronutrient
Source : Adapted from WHO (1996)~s
16.
17.
f o r h e m o p o i e s i s . T h i s d o s e is l i k e l y to be e f f e c t i v e in
t r e a t m e n t of a n e m i a ; for p r o p h y l a x i s the s a m e c o u l d be
g i v e n t w i c e a w e e k . T h e a d d i t i o n of v i t a m i n B12 is
n e c e s s a r y for c h i l d r e n b e l o w 3 y e a r s of a g e in v i e w of
p r e v a l e n c e of this n u t r i e n t deficiency a n d v e g e t a r i a n food
habits in o u r c o u n t r y . 11,12,46
T h e r e a r i s e s n e e d to c o n t r o l w o r m i n f e s t a t i o n s a n d
o t h e r g a s t r o i n t e s t i n a l infections to c o n t r o l n u t r i e n t loss.
T he n e e d for e d u c a t i o n a b o u t d i e t a r y n e e d s w i t h i n t h e
f a m i l y r e s o u r c e s r e m a i n s an i m p o r t a n t subject.
18.
19.
20.
REFERENCES
21.
1. Lee GR, Herbert V. Nutritional factors in the production and
function of erythrocytes. In Lukens J, Paraskevas F, Greer J, P,
Rodgers GM, eds. Wintrobe's Clinical Hematology. Lee GR,
Foerster Chap 11. Williams & Wilkins Baltimore, Maryland
USA. 1998; 228-266.
2. Agarwal K N. Iron and brain: neurotransmitter receptors and
magnetic response spectroscopy. Brit J Nutr 2001; 85 Suppl 2
$147-150.
3. Dhar N, Agarwal KN, Taneja PN, Gupta S. Iron deficiency
anemia in children. Indian J Pediatr 1969; 36: 436-441.
4. ICMR .Studies on preschool children. ICMR Tech Rep Ser No
26. National Institute of Nutrition. 1977; Hyderabad.
5. Uberoi IS, DeSweemer C, Taylor CE. A story of anemia among
rural punjabi children. Indian ] Med Res 1972; 60 : 793-799.
6. Agarwal DK, Bhardwaj B, Singla PN, Tripathi AM, Agarwal
KN. Etiology of maternal and early childhood deficiency
anemia. Indian J Pediatr 1986; 53 : 389-396.
7. Raman L Pawashe AB, Vasanthi G, Parvathi CH, Vasumathi
N, Rawal A. Plasma ferritin in the assessment of iron status
on Indian infants. Indian Pediatr 1990; 27 : 705-713.
8. Raman L, Pawashe AB, Ramalakshmi BA. Iro.n nutritional
status of pre-school children. Indian J Pediatr 1992; 59 : 209-212.
9. Malin AS, Stones RW. Nutritional anemia in the urban poor:
a community-based study of under fives in an Indian slum. J
Trop Pediatr 1988; 34 : 257-259.
10. NFHS (2000) India 1998-99 - National Family Health Survey2 (NFHS-2) - Key findings: Anemia among women and
children. International Institute for Population Sciences,
Murnbai, 2000 : 19.
11. Kapur D, Agarwal KN, Sharma S, Kela K, Kaur I. Iron status
of children aged 9 - 36 months in an urban slum Integrated
Child Development Services (ICDS) project in Delhi. Indian
Pediatr 2002; 39 : 136-144.
12. Gomber S, Kumar S, Rusia U, Gupta P, Agarwal KN, Sharma
Indian Journal of Pediatrics, Volume 69---July, 2002
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
S. Prevalence and etiology of nutritional anemias in early
childhood in an urban slum. Indian J Med Res 1998; 107 : 269273.
Food and Nutrition Board, Government of India, UNICEF.
The use of common salt fortified with iron. The Report on
Collaborative Studies. 1981, Government of India, New-Delhi.
Visweswara Rao K, Radhaiah G, Raju SVS. Association of
growth status and the prevalence of anemia in preschool
children. Indian ] Med Res 1980; 71 : 2337-2346.
Singla PN, Gupta HP, Ahuja C, Agarwal KN. Deficiency
anemias in preschool children - Estimation of prevalence
based on response to hematinic supplementation. J Trop
Pediatrics 1982; 28 : 77-80.
Agarwal DK, Upadhyay SK, Tripathi AM, Agarwal KN.
Nutritional status, physical work capacity and mental
function in school children. N F t Sci Rep 6 (1987) 30-32; 40-41
& 60-62.
ACC/SCN Controlling iron deficiency. ACC/SCIVState-of-theArt Series. Nutrition Policy Discussion Paper No 9. (1991)
Geneva.
Seshadri S, Mittal N. An experimental study to determine the
effect of mass deworming on the response of anemic
preschool children to nutritional supplements of iron-folic
acid, Vitamin A and Vitamin C. Arogya J Hlth Sci 1985; 11 : 4247.
ICMR Evaluation of National Anemia Prophylaxis
Programme. ICMR Task Force Study. Indian Council of
Medical Research, New Delhi, 1989.
ICMR Field supplementation trial in pregnant women with 60
rag, 120 mg and 180 mg of iron with 500 mcg of folic acid.
ICMR Task Force Study. Indian Council of Medical Research,
New Delhi, 1992.
Padam Singh, S Toteja. ICMR (1996-2000) District Nutrition
Survey - Personal Communications. ICMR, New Delhi.
Seshadri S, Sharma K, Raj AE, Thakore B, Saiyed F. Iron
supplementation to control pregnancy anemia. Proceedings of
the Nutrition Society of India 1994; 41 : 131-140.
Christian P, Abbi R, Gujaral S, Gopaldas T. At risk status of
pregnant women of Panchmahals (Gujarat) and Chandrapur
(Maharashtra). Arogya J Health Sci. 1989; 15 : 85-91.
Agarwal DK, Agarwal KN, Tripathi AM. Nutritional status in
rural pregnant women of Bihar and Uttar Pradesh. Ind Ped
1987; 24 : 119-125.
Prema K, Ramalakshmi BA, Madhavapeddi R, Samyukta S.
Changes in haemoglobin levels during different periods of
gestation. Nutr Reports International 1981; 23 : 634-636.
Sood SK, Ramachandaran K, Mathur M, Gupta K,
Ramalingaswami V, Swaaranbai TC, Poonaiah J, Mathur VI,
Baker SJ. WHO sponsored collaborative studies on nutritional
anemia in India. 1. The effects of supplemental oral iron
administration to pregnant women. Quart J Med 1973; 44 :
241-254.
Yusu~i D, Mathan VI, Baker SJ. Iron, Folate and Vitamin B12
nutrition in pregnancy: Study of 1000 women from Southern
India. Bull WHO 1973; 48 : 15-22.
NFI .Maternal Nutrition, lactation and infant growth in urban
slums. Scientific Report 1988; No. 9, Nutrition Foundation of
India, New Delhi.
Beaton GH, McCabe GP. Efficacy of intermittent iron
supplementation in the control of iron deficiency anemia in
developing countries. An analysis of experience. Canadian
International DevelopmentAgency workingwith the Micronutrient
Initiative'April, 1999.
Kapoor G, Aneja S. Nutritional disorders in adolescent girls.
Indian Pediatr 1992; 29 : 969-973.
Singla PN, Agarwal KN, Singh RM, Reddy ECG, Tripathi
AM, Agarwal DK. Deficiency anemia in pre-school children -
615
Deeksha Kapur et al
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
616
Estimation of prevalence based on response to hematinic
supplementation.] Trop Pediatr 1982; 26 : 239-242.
NFI Growth of affluent Indian girls during adolescent.
Scientific Report 10. Nutrition Foundation of India, 1989.
Sharma A, Kanti P, Visheshwara Rao K. Identification of an
appropiate strategy to contro anemia in adolescent girls of
poor communities. Indian Pediatr 2000; 37 : 261-67.
National Plan of Action on Nutrition. Food and Nutrition
Board, Department of Women & Child Development,
Ministry of Human Resource Development, Government of
India, New Delhi 1995.
MacPhail AP, Bothwell TH. The prevalence and causes of
nutritionaliron deficiency anemia In Fomon SJ, Zlotkin S, eds.
Nutritional Anemias. Nestle Nutrition Workshop Series, 1992;
Vo130, Raven Press, New York, pp 1-9.
Lal H, Agarwal KN, Gupta M, Agarwal DI( .Protein and iron
supplementationby altering cooking practices in community.
Indian J Med Res 1983; 61 : 918-925.
WHO. The Prevalence of Anemia in Woman: A Tabulation of
Available In~rmation. 2rid edn. 1992, Geneva.
FAO. Food fortification: technology and quality control_.
Report of an FAO Technical Meeting held in Rome, 20-23
November 1995. FAO Food and Nutrition Paper. Rome, FAO
1996.
Li T, Wang WM, Yeung DL. Efficacy of iron fortified infant
cereal in the prevention of iron deficiency in infants in China.
Nutr Rep Int 1988; 37 : 695-701.
Walter T, Dallman PR, Pizzaro F, Velozo L, Pena G,
Bartholmey SJ, Hertrampf E. Effectiveness of iron-fortified
infant cereal in prevention of iron deficiency anemia.
Pediatrics 1993; 91 : 976-1982.
Greene-Finestone L, Feldman W, Heick H, Luke B. Infant
feeding practices and socio-demographic factors in OttawaCarlton. Can [ Pub Health 1989; 80 : 173-176.
Kapur D, Sharma S, Agarwal KN. Impact of nutrition
43.
44.
45.
46.
47.
48.
49.
50.
51.
education on iron status in children (9-36months of age) and
maternal nutrition knowledge (submitted).
Franson GB, Agarwal KN, Mehdin GM, Hambraeus L.
Increased breast milk iron in severe maternal anemia:
physiological trapping or leakage. Acta PaediatrScand 1985;74
: 290-291.
Agarwal KN, Agarwal DK, Mishra KP. Impact of anemia
prophylaxis in pregnancy on maternal haemoglobin, serum
ferritin and birth weight. Indian J Mecl Res 1991; 94 : 277-280.
Beard JL. Weekly iron intervention: the case for intermittent
iron supplementation. Am ] Clin Nutr 1998; 68 : 209-212.
Das BK, Bal MS, Tripathi AM, Singla PN, Agarwal DK,
Agarwal KN. Evaluation of frequency and dose of iron and
other hematinics-an alternative strategy for anemia prophylaxis in rural preschoolers. Indian Pediatr 1984; 21 : 933-938.
Palupi L, Schultink W, Achadi E, Gross R. Effective
community intervention to improve haemoglobin status in
preschoolers using once-weekly iron supplementation. Am J
Clin Nutr 1997; 65 : 1057-1061.
WHO. Guidelinesfor the control of iron deficiency anaemia in
countries of the Eastern Mediterranean, Middle East and
North Africa. Based on a joint WHO/UNICEF consultation
on strategies for the control of iron deficiency anemia. 1996;
ed: Anna Verster.
INACG/WHO/UNICEF (InternationalNutritional Anemia
Consultation Group/World Health Organization/United
Nations Children's Fund) (1998). In Stoltzfus R, Dreyfuss M,
eds. Guidelines for the Use of Iron Supplements to Prevent and
Treat iron Deficiency Anemia.
De Vizia B. Iron malabsorption in giardiasis. J Pediatr 1985;
107 : 75.
Gopaldas T, Raghavan R, Kanani S. Nutritional impact of
antiparasitic drugs, prophylactic Vitamin A and iron folic acid
in under privileged school girls in India. Nut Res 1983;3 : 831844.
Indian Joumal of Pediatrics, Volume 69--July, 2002