Nutritional Anemia in Bangladesh:
Problems and Solutions
Dr Tahmeed Ahmed
Director
Centre for Nutrition & Food Security
ICDDR,B
Professor, Public Health Nutrition
James P. Grant School of Public
Health, BRAC University
Anemia
A condition in which the Hb
concentration in the blood is below
a defined level, resulting in a
reduced oxygen-carrying capacity
of red blood cells
Definition of Anemia at Sea Level
Stoltzfus & Dreyfuss; INACG/UNICEF/WHO 1998
Consequences of Anemia
• Poor immune function and increased morbidity
from infection
• Fatigue and lower physical work capacity
• Poor physical growth
• Impaired learning and school achievement
Brabin BJ 2001
Grantham-McGregor S 2001
Consequences of Anemia in Pregnancy
• Increased risk of complications during
delivery, including prolonged labor, preterm
delivery, LBW and maternal and neonatal
deaths
• Infants of mothers with iron deficiency anemia
are more likely to have low iron stores and to
become anemic
Brabin BJ 2001
Grantham-McGregor S 2001
Anemia causes huge economic loss
• Results in productivity loss
• Economic cost of anemia in Bangladesh is
estimated to be 7.9% of GDP
Christian P 2005
UN/SCN 2004
What are the causes of anemia?
•
•
•
•
•
•
Iron deficiency – dietary deficiency, loss of iron
Hookworm
Vitamin deficiencies, eg vitamin B12, folic acid
Malaria
Hemoglobinopathies, eg thalassemia
Chronic infections, such as TB, HIV
Iron Deficiency Anemia
• Iron deficiency is the most important cause of
anemia
• 60% of all anemia is due to iron deficiency
Stoltzfus R 1998, Black RE 2008
Review of Anemia Control Program
• Review of literature, survey reports
• Meta analyses
• Communication with stake holders from
public, private and research sectors
• 22 interviews - NNP, DGFP, IPHN, IEDCR,
CMSD, NIPORT, EDCL, UNICEF, MI, BRAC,
ICDDR,B
• Informal round table discussion at ICDDR,B
Prevalence of Anemia in Bangladesh
Age
Infants
(6-11 mo)
Year
20041
20032
20032
20013
19994
Settings
Rural
Urban
CHT
Rural
Urban
Sample Size
1227 U-5
93
51
1148 U-5
183
%
92
83.9
90
74.1
92.3
NSP 20041 , Anemia prevalence survey
UNICEF/BBS 20032, NSP 20023 , NSP 20004
Prevalence of Anemia in Bangladesh
Age
Infants
(6-11 mo)
Year
20041
20032
20032
20013
19994
Settings
Rural
Urban
CHT
Rural
Urban
Sample Size
1227 U-5
93
51
1148 U-5
183
%
92
83.9
90
74.1
92.3
• Demand for iron is high
• Complementary feeding is inappropriate
• No program for anemia control in infants
NSP 20041 , Anemia prevalence survey
UNICEF/BBS 20032, NSP 20023 , NSP 20004
Complementary Foods Provide little
Micronutrients to Bangladeshi Infants







Breast milk contributes to 75% of total energy intake
Small amounts of CF offered
Vitamin B6 50% of RNI
Vitamin A 48% of RNI
Zinc 45% of RNI
Iron 9% of RNI
Increase in CF will not substantially increase MN
intake
Kimmons J, 2006
Pre-school Children and Adolescent Girls
Age
Year
Settings
Sample Size
%
Pre-school
(6-59 mo)
20041
20032
20013
Rural
Urban
Rural
1227
861
1148
68
55.7
48.3
Adolescent
(13-19 yr)
20041
20032
20013
Rural
Urban
Rural
661
1341
237
39.7
23.4
30
NSP 20041 , Anemia prevalence survey
UNICEF/BBS 20032, NSP 20023
Percent
Anemia Prevalence Trends in Bangladesh
100
90
80
70
60
50
40
30
20
10
0
Infant
Adolescent
Pregnant Women
Pre school
NPNL women
Lactating Women
92
74.1
67.9
48.3
46
46
39.7
46.7
35
33
38.8
30
2001
2003
2004
NSP 2004, Anemia prevalence survey UNICEF/BBS
2003, NSP 2002, WHO global database on anemia
Strategies for Anemia Prevention
and Control
• Micronutrient supplementation
• Dietary improvement
• Parasitic disease control
• Food fortification
• Family planning and safe motherhood
National Strategy for Anemia Prevention and Control
in Bangladesh, MOHFW 2007
Existing Programs on Iron Supplementation
Age group
Department
Infants, children
No national program
Adolescents
DGFP
PLW
DGFP, DGHS, NGOs
NPW
DGFP
Dose of Iron-folic Acid Tablets
Target group
Doses
Adolescent girls
2 tablets/week
Newly wed women
2 tablets/week
Pregnant women
2 tablets daily up to delivery
(NGOs 1 tab daily)
Lactating mother
1 tablet daily for 90-120 d
Iron-folic Acid Tablets
Dispensing IFA Tablets
DGFP
Given in a polythene bag
Spoilage ?
DGHS
Wrapped in paper
Spoilage ?
BRAC
Now giving tablets in
blister pack
Tk 14 for 100 tab vs
Tk 12 for 100 open tabs
Iron Coverage among Pregnant Women
HFSNA 2009
IFA Tablet Coverage during Pregnancy in
BINP Areas
Indicator
Survey Area
BINP (%)
Comparison (%) All (%)
IFA intake
Regular
Irregular
None
25.4
9.9
64.7
16
9.5
74.5
19.5
9.6
70.9
Total (n)
2193
3785
5979
NNP Baseline Survey 2004
Reasons for Not Taking IFA Tablets
Regularly
Reasons
Side effects (diarrhea, etc)
Forget to take
Did not consider necessary
Lack of supply
Do not receive enough tablets
Economic constrains
Objection of family members
Lost tablets
Others
N=1741 pregnant
women, %
25.5
19.5
16.3
12.0
6.1
4.5
1.9
0.2
7.8
NNP Baseline Survey 2004
Multiple Micronutrient Powder
1 RDA of
• Iron
• Folic acid
• Vitamin A
• Vitamin C
• Zinc
No color
No taste of its own
No odor
Children with the following conditions are excluded:
• Any acute illness
• Severe cough
• Breathlessness
• Severe visible wasting
What can we do to control anemia?
Comprehensive Nutrition Actions Required
• Increase exclusive breastfeeding rates
• Improve complementary feeding practices by
using various foods rich in iron
• Consider home-based fortification of CF using
multiple micronutrient powder
• Coordination of efforts of different agencies and
the private sector in control of anemia
• Promote factors that will increase coverage of
IFA supplementation among adolescent girls,
pregnant & lactating women
–
–
–
–
–
Effective counseling
Sustained supply
Appropriate packaging
Mass media coverage
Trained workforce