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Year : 2023  |  Volume : 2  |  Issue : 1  |  Page : 4-6

Moving anemia needle: Imperatives of integrative approaches

The INCLEN Trust International, New Delhi, Delhi, India

Date of Submission05-Jun-2023
Date of Acceptance06-Jun-2023
Date of Web Publication21-Aug-2023

Correspondence Address:
Dr. Narendra Kumar Arora
The INCLEN Trust International, New Delhi, Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JIMPH.JIMPH_10_23

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How to cite this article:
Arora NK, Goteti HN. Moving anemia needle: Imperatives of integrative approaches. J Integr Med Public Health 2023;2:4-6

How to cite this URL:
Arora NK, Goteti HN. Moving anemia needle: Imperatives of integrative approaches. J Integr Med Public Health [serial online] 2023 [cited 2023 Sep 21];2:4-6. Available from: http://www.jimph.org/text.asp?2023/2/1/4/384117

Worldwide anemia continues to be one of the biggest challenges of public health across the life spectrum—women and children continue to be at the highest risk. The global prevalence of anemia in 2019 was 22% with 36% pregnant women, and 40% children aged 6–59 months being anemic.[1],[2] According to recent data from India, the prevalence of anemia was 57% in nonpregnant, 52.2% in pregnant women, and 67.1% in children aged 6–59 months (NFHS-5; 2019–21) and worryingly the burden appeared to have marginally increased in last 5 years (NFHS-4; 2015–16).[3],[4] Since the launch of national nutritional anemia prophylaxis program in 1970, the situation of anemia has not improved despite major strides in our economic situations, living standards, and increase in household incomes.[5]

Oral iron salts commonly used in program settings are low priced and have high bioavailability, e.g., ferrous sulfate (20% elemental iron), ferrous gluconate (12% elemental iron), and ferrous fumarate (33% elemental iron) but have significant gastrointestinal side effects adversely affecting the compliance.[6] Clearly there is a need for finding alternate formulations which are acceptable. Several studies are underway for improving iron formulations for tolerance and palatability besides the safety, efficacy, and bioavailability. Iron pyrophosphate in a phospholipid bilayer membrane is one such example; the salt is gastroresistant formulation with good absorption and reported to have reduced gastric side effects, increased tolerability, and consequent adherence.[7],[8] Another promising development is nano-iron particle-based salts (iron hydroxide adipate tartrate) which can be also linked to other micronutrients (zinc, selenium, vitamin B12, folic acid, and others, e.g., lactobacilli) are in different phases of human trials and are shown to be safe, tolerable, with less adverse gastrointestinal effects.[9] The program should be open to change the oral products after due health technology assessment exercises because doing the same for last half a century is not taking us anywhere. It is encouraging to observe that for severe anemia and occasional moderate anemia when oral iron is not tolerated, intravenous iron sucrose or iron carboxymaltose are recommended—these require supervised administration to monitor anaphylaxis.

Anemia is an ecological problem. Households with poor WaSH indicators, limited access to piped water, surrounded by unhygienic ecosystems, low household incomes, food insecurity, nutrition illiteracy compounded with low dietary diversity promote anemia, and other nutritional challenges among several members particularly the women and children in the household. The recognition of an anemic individual particularly with severe or moderate anemia is almost like a “canary in the coal mine”—several other members are likely to be anemic and therefore it is imperative that all members in households are screened and household as a unit is managed rather than an index patient.[10],[11]

Evidence suggests that consuming varieties of foods and that from multiple food groups reduces malnutrition and risk of anemia by restoring balance of micronutrients in the body. As an exemplar to impact of dietary diversity on anemia is a study in the Chakhesang tribe of Nagaland where the prevalence of undernutrition, anemia, and vitamin A deficiency (VAD) among young children is less than the country average and this was attributed to huge diversity in food items regularly consumed in their traditional diets.[12] However, there is no silver bullet to solve the low diversity of food among our populations. Studies on homestead cultivations, kitchen gardens, nutritional counseling, school gardening, and crop diversification have repeatedly shown to reduce micronutrient deficiencies in various countries including India.[13] However, scaling up these efforts to achieve food diversity among larger populations comes with challenges—investment of money, time, and chances of failure due to delay in perceived impact, sustained behavioral change, seasonality of crops, soil characteristics, etc.[14] Recent food and nutrition security report from FAO has also warned that food diversification has implication for additional expenditures for the families.[15] Having said that, the key to food diversification is normative behavioral change aligned with local cultural and culinary practices. This will require investments to generate evidence about the nature and content of the social mobilization and communication strategies that are effective in modifying food behavior, lead to food diversification and become an integral part of any program to reduce anemia in the communities.[16]

A look into successful fortification stories across the globe provides an insight into the barriers and challenges to achieving nutritional adequacy through fortification.[17] Indian journey into fortifying food began in 1950 with iodization of oils and salts but did not pick pace till 2000 when vitamin A, zinc, and vitamin B fortification of some staples started. Double-fortified salt was introduced in 2009. The FSSAI standards for fortification have further accelerated these efforts since 2016.[18],[19] Government of India introduced iron-fortified rice in August 2021.[20] Though the recent step to fortify rice kernels with iron folate and vitamin B12 is a welcome step for India in its battle against anemia, distribution is restricted to PDS, mid-day meals, and ICDS systems, and there is lack of wider engagement of private players.[19] Another significant barrier in iron fortification is the organoleptic properties and bioavailability of the salts that decide acceptability and effectiveness of the intervention. Ferrous pyrophosphate, encapsulated iron, micronized and nanoparticle-based iron ligated with other micronutrients have to be explored as potential better options for fortification.[21] This requires that health sector works closely with agriculture and food processing scientists as well as industry and develop locally acceptable products.

Anemia is not just due to iron folic acid deficiency—according to data from different parts of the country nutritional deficiencies due to vitamin B12 and other micronutrient deficiencies are also important.[22] A significant proportion of anemia also occurs due to other non-nutritional factors such as hemoglobinopathies, other genetic factors, inflammation, and infection. Sickle cell anemia a chronic single-gene disorder is one such disorder predominantly seen in tribal area. In the health budget of Yr2023–24, resources have been allocated to eliminate sickle cell anemia by 2047. This shall certainly bring focus on non-nutritional anemia but several more steps are necessary in this direction.[23],[24]

The multifactorial nature of anemia also requires a multisectoral comprehensive approach to engage different ministries if the needle on anemia is to be moved. This requires a whole-of-governance and whole-of-society approach where ministries of health, agriculture, tribal welfare, rural development, human resource development, women and child development to take ownership in their efforts on controlling the determinants of anemia. Collaboration, communication, and cohesive work between sectors and departments are necessary to achieve effective and sustainable solutions for anemia prevention.

Anemia Mukt Bharat (AMB), the flagship program of the Government of India, has ambitiously targeted a 3% per year point reduction of anemia in all beneficiaries using 6 × 6 × 6 strategies. However, huge gaps exist in translation of policy into action on the ground. The country needs evidence-based scientific approaches to move forward but the system need not be shy to take bold steps revisit the existing policy and program strategies and adopt new approaches to minimize this public health menace causing huge health, cognitive, and economic losses on a sustained basis.


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Conflicts of interest

There are no conflicts of interest.

  References Top

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World Health Organization. Anaemia in Women and Children: WHO Global Anaemia Estimates, 2021. Available from https://www.who.int/data/gho/data/themes/topics/anaemia_in_women_and_children [Last accessed on December 29, 2022].  Back to cited text no. 2
International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-5) 2019–21. . Available from http://rchiips.org/nfhs/NFHS5_FCTS/India.pdf. [Last accessed on 29 Dec 2022].  Back to cited text no. 3
International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-4) 2015–16. Available from http://rchiips.org/nfhs/pdf/NFHS4/India.pdf. [Last accessed on 29 Dec 2022].  Back to cited text no. 4
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Nuredin I, Mohammed NI, Wason J, Mendy T, Nass SA, Ofordile O, Camara F, et al. A novel nano-iron supplement versus standard treatment for iron deficiency anaemia in children 6–35 months (IHAT-GUT trial): A double-blind, randomised, placebo-controlled non-inferiority phase II trial in The Gambia. eClinicalMedicine 2023;56:2589-5370.  Back to cited text no. 9
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Talegawkar SA, Jin Y, Sedlander E, Ganjoo R, Behera S, DiPietro L, et al. A social norms-based intervention improves dietary diversity among women in rural India: The Reduction in Anemia through Normative Innovations (RANI) Project. Nutrients 2021;13:2822.  Back to cited text no. 16
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