Iron Deficiency Anemia In India

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REDUCE ANEMIA IN INDIA BY IMPROVING DIETS, NOT BY CHANGING STANDARDS!

In June 2021, a group of researchers from India published an article in Lancet Global Health call­ing for a general reexamination of the World Health Organization’s (WHO’s) current hemoglobin standards for anemia.¹ Claiming to have used a “nationally repre­sentative sample” of children from India’s Comprehensive National Nutrition Survey (CNNS),² the authors obtained “intriguing” findings, forming the basis of their call for new standards and a cutoff point lower than the current WHO standards.

Based on the revised calculations, they also concluded that the preva­lence of anemia in India is actually much lower than that which has been measured in national surveys. Although India currently uses the WHO reference standards to diagnose anemia (see Table 1),³ the Lancet authors claim that compared with the existing WHO standards, their analysis of CNNS data shows a lower prevalence of anemia in all ages by 1–2 g/dL— and even more so in one- to two-year-old boys and girls, and girls aged ten years or older. Applying the new “standard” that they propose would lower anemia prevalence by 19.2 percentage points for the entire CNNS sample, thus making anemia appear to be less of a public health problem in the country.

WHO Report On Anemia In India

TABLE 1. WHO Standards: Hemoglobin Levels for Diagnosis of Anemia (g/dl)

AGE GROUP	NO ANEMIA	MILD	MODERATE	SEVERE
Children 6-59 months	11 or more	10–10.9	7–9.9	<7
Children 5-11 years of age	11.5 or more	11–11.4	8–10.9	<8
Children 12-14 years of age	12 or more	11–11.9	8–10.9	<8
Non-pregnant women (15 or older)	12 or more	11–11.9	8–10.9	<8
Pregnant women (15 or older)	11 or more	10–10.9	7–9.9	<7
Men	13 or more	11–12.9	8–10.9	<8

 

MOVING THE GOALPOSTS

The large Indian National Family Health Survey (NFHS-5) for 2019–2021 tells a different story about anemia.⁴ According to that survey, the prevalence of anemia in children in the six-to fifty-nine-month age group is, on average, 67 percent, and is slightly higher among rural (68 percent) compared to urban (64 percent) children. For adolescents and adults fifteen through forty-nine years of age, the NFHS-5 reports that 58 percent of women and 25 percent of men are anemic.

Against these alarming statistics, and with­out any apparent concern for the clinical conse­quences, the authors of the Lancet paper suggest that their modified hemoglobin goalposts are suitable for national use. This suggestion has been picked up with alacrity by economists in India who express disbelief that in spite of In­dia’s “economic prosperity,” the rates of anemia have not shown a decline.⁵ They assert that the existing standards show India in a poor light and also divert resources that the economists feel could be better spent.

These attempts to lower hemoglobin standards have elicited strong objections from some clinicians (specifically pediatricians and obstetricians), nutritionists, activists and public health professionals. My colleagues, Dr. Veena Shatrugna and Siddharth Joshi, and I have submitted a note protesting the lowering of standards—endorsed by two hundred sixty signatories—to the WHO, UNICEF, the Indian Council of Medical Research (ICMR), the Na­tional Institute of Nutrition (NIN), the Indian Academy of Pediatricians (IAP) and the Federa­tion of Obstetric and Gynaecological Societies of India (FOGSI), but to date there has been no response.⁶ The following sections describe some of the objections raised in the letter.

DERIVE STANDARDS FROM HEALTHY POPULATIONS

Anemia cut-offs, to be applicable to a coun­try, should be based on hemoglobin levels of healthy populations with no social, economic or nutritional constraints to hemoglobin syn­thesis. This means that the methodology of clearly defined inclusion and exclusion should yield a study population that has access to all nutrients necessary for hemoglobin synthesis. A subsample from a survey such as the CNNS cannot be used to set standards.

A breakdown of the CNNS shows that it comprises the very same population that the WHO identifies as disproportionately affected by iron-deficiency anemia—“the most vulner­able, poorest and least educated groups.” Three-fourths (75 percent) of CNNS participants were from rural areas, more than half (55 percent) consumed a lacto-vegetarian diet (without eggs, meat, chicken or fish) and a majority belonged to traditionally marginalized caste groups. Even though 38 percent of the study popula­tion reported consuming a “non-vegetarian” diet, consumption of meat and eggs can often be too little and too infrequent. Detailed diet surveys would provide more accurate estimates of intake than the food frequency measures used in the CNNS. (Note: In India, meat eaters are referred to as “non-vegetarians,” though techni­cally they also consume all the foods eaten by vegetarians. There is a social movement to call them meat eaters, but national surveys persist in using the “non-vegetarian” terminology.) It is, therefore, not surprising that this poorly nourished population does indeed have lower hemoglobin levels—but then to recommend this as a standard for the rest of the country is unethical, to say the least.

Anemia Statistics In India

TO REDUCE ANEMIA, IMPROVE INDIAN DIETS

For better nutrition in infants, complemen­tary feeding should be initiated by six months. According to India’s NFHS-5, however, only 52 percent of urban infants and 44 percent of rural infants have received solid or semi-solid food by ages six to eight months. This means that almost half of the population does not have a proper un­derstanding about weaning and complementary feeding practices. Moreover, as can be seen in Figure 1, most weaning foods are made from milk or are grain-based. Consumption of foods such as pulses, legumes, meat, eggs, poultry or lentils is less than 26 percent among infants six-to twenty-three months old and is even less (20 percent or less) among breastfed infants. Only 47 percent of children ages six to twenty-three months had consumed vitamin A-rich foods in the day or night prior to the interview, and only 21 percent had consumed iron-rich foods.

The NFHS-5 indicates that daily consump­tion of specific foods for men and women ages fifteen to forty-nine years is 49 percent for milk or curd, up to 50 percent for pulses or beans, 52 percent for dark green leafy vegetables and only 5 to 7 percent for eggs or fish (Figure 2).

Comparing Figures 2 and 3 shows that men and women in that age group are more likely to consume milk/curd, pulses/beans and dark green leafy vegetables daily, whereas nutrient-dense foods like eggs, fish, chicken and meat are more likely to be consumed weekly. Thus, even with some consumption of iron-rich foods, the frequency is less, and this may be a reason for the high rates of anemia in the country. Overall, moreover, the NFHS-5 found that 29 percent of women and 17 percent of men are lacto-vegetarians who do not consume meat or eggs at all.

 

CONSIDER INTAKE AND ABSORPTION

Iron deficiency is estimated to be respon­sible for half of all anemia cases globally, and most of this is due to insufficient intake. Apart from iron, other nutritional deficiencies that can contribute to anemia include deficiencies of folate or folic acid; vitamins B₁₂ (cobalamin), B₂ (riboflavin) and B₆ (pyridoxine); vitamins A, C, D and E; and copper.⁷

In food, iron is present in two forms: heme and non-heme. When the meal contains meat, approximately 25 percent of heme iron will be absorbed. The absorption can increase to up to 40 percent in cases of iron deficiency. In comparison, absorption of non-heme iron from plant foods is just 2 to 10 percent, depending on the balance between inhibiting and enhanc­ing factors.⁸ According to the UN’s Food and Agriculture Organization (FAO), ascorbic acid, meat, fermented vegetables or fermented soy sauce enhance absorption, whereas phytates (as in bran, oats, unpolished rice, cocoa and peas), iron-binding phenolic compounds (such as tea, coffee, red wines, cocoa), calcium (milk, cheese) and soy protein inhibit absorption.⁹

In India, the low availability of iron as well as the presence of inhibitors (tannins and phytates) in predominantly cereal-based diets are important causes of iron-deficiency anemia. Low intake of meat is another cause. In research published in 2023 by Indian and American economists, the researchers examined data across twenty-six Indian states and found that banning the sale or possession of beef was associated with a relative increase in anemia by as much as 27 percent among women in commu­nities that traditionally have consumed beef.¹⁰ The spate of cattle slaughter bans across India should also be viewed from this perspective.^11,12 In addition to the more bioavailable heme iron, beef also contains proteins of superior quality, important fatty acids and several other nutrients essential for hemoglobin synthesis.

ADDRESS SOCIAL DETERMINANTS OF ANEMIA

The occurrence of anemia is related to many socioeconomic, behavioral and environmental determinants—low income, poor education, discrimination, poor living conditions, inadequate access to water and poor sanitation, to name just a handful. Poverty, a major determinant of health in general, is associated with poor living and working conditions, adverse health and nutrition behaviors, food insecurity, poor quality of diet (including limited access to animal foods) and inadequate access to health care services, including anemia prevention and treatment.¹³

Studies indicate that anemia levels decrease—and the consumption of milk, curd, fruit, eggs, fish, chicken or meat increases—with higher levels of maternal schooling and household wealth. The CNNS shows that around 42 percent of mothers who participated in the survey had never even attended school, and only 14 percent had completed twelve or more years of schooling.

In the CNNS, 35 percent of children under age five were stunted, 33 percent were underweight and 24 percent of adolescents were thin for their age. Stunting and undernutrition have a multifactorial causa­tion, with protein deficiency an important factor. The same pathways contribute to anemia and, therefore, using a population with such high levels of malnutrition to devise or revise anemia standards is a definite cause for concern.

TAKE NUTRIENT DENSITY SERIOUSLY

That the people of India do indeed have multiple nutritional deficien­cies is a fact that is well established. The NFHS-5 shows that only 12.8 percent of children between the ages of six and twenty-three months receive an adequate diet.¹⁴ The main barriers identified to consuming nutrient-dense foods are related to availability, affordability, accessibility, knowledge and cultural preferences.

In spite of the high levels of anemia, there is no serious attempt by the government to promote iron-rich foods, particularly those of animal origin. There is a need for different sectors to work together to effectively address anemia by examining existing data and offering a combination of solutions that includes poverty alleviation, education, female empower­ment and access to health care. Denial of eggs¹⁵ in school mid-day meals and cattle slaughter bans¹² across the country are already adversely affect­ing access to nutrient-dense foods. Lowering hemoglobin standards to make the country “look good” will only lead to further denial of India’s nutritional crisis and its tragic health consequences.

REFERENCES

1. Sachdev HS, Porwal A, Acharya R, et al. Haemoglobin thresholds to define anaemia in a national sample of healthy children and adolescents aged 1–19 years in India: a population-based study. Lancet Glob Health. 2021;9(6):e822- e831.
2. Ministry of Health and Family Welfare (MoHFW), Government of India, UNI­CEF, Population Council. Comprehensive National Nutrition Survey (CNNS) National Report. New Delhi: MoHFW, 2019. https://nhm.gov.in/WriteRead­Data/l892s/1405796031571201348.pdf
3. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. World Health Organization, May 31, 2011. https://www.who.int/publications/i/item/WHO-NMH-NHD-MNM-11.1
4. International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-5), 2019-21: India: Volume 1. Mumbai: IIPS, 2021. https://dhsprogram.com/pubs/pdf/FR375/FR375.pdf
5. Sanyal S, Dudani C. Anaemia, a weak case. The Economic Times, Apr. 13, 2023. https://economictimes.indiatimes.com/opinion/et-commentary/anaemia-a-weak-case/articleshow/99473960.cms?from=mdr
6. Karpagam S, Shatrugna V, Joshi SK. Nutrition revolution by reducing hemo­globin cut-offs? Anemia is not a numbers game. June 2023. Available at https://drive.google.com/file/d/1FQfqpNIPIahoCmIMwmVGYlKU9AVEIgoG/view
7. Kraemer K, Zimmermann MB (Eds.). Nutritional Anemia. Basel, Switzerland: Sight and Life Press, 2007.
8. Piskin E, Cianciosi D, Gulec S, et al. Iron absorption: factors, limitations, and improvement methods. ACS Omega. 2022;7(24):20441-20456.
9. Food and Agriculture Organization of the United Nations, World Health Or­ganization. “Iron.” Chapter 13 in Human Vitamin and Mineral Requirements: Report of a joint FAO/ WHO expert consultation: Bangkok, Thailand. Rome: FAO, 2001, pp. 195-221. https://www.fao.org/3/y2809e/y2809e13.pdf
10. Dasgupta A, Majid F, Orman WH. The nutritional cost of beef bans in India. Journal of Development Economics. 2023;163:103104.
11. Karpagam S, Joshi SK. Criminalizing livelihoods, legalising vigilantism: the adverse impact of the Karnataka Prevention of Slaughter and Pres­ervation of Cattle Act, 2020. Bangalore: Ahara Namma Hakku, 2021. https://aharanammahakku.home.blog/2021/11/15/report-the-adverse-impact-of-the-karnataka-prevention-of-slaughter-and-preservation-of-cattle-act-2020/
12. Karpagam S. The Karnataka Prevention of Slaughter and Preservation of Cattle Act—2020. Wise Traditions. Fall 2021;22(3):30-33. https://www.westonaprice.org/health-topics/karnataka-prevention-of-slaughter-and-preservation-of-cattle-act-2020/
13. World Health Organization. Nutritional Anaemias: Tools for Effective Prevention and Control. WHO, Nov. 13, 2017. https://www.who.int/publications-detail-redirect/9789241513067
14. International Institute for Population Sciences (IIPS). National Family Health Survey-5, 2019-21: India Fact Sheet. IIPS, 2021. https://rchiips.org/nfhs/NFHS-5_FCTS/India.pdf
15. Karpagam S. Eggs in midday meal scheme in Karnataka, India: the science and the propaganda. Wise Traditions. 2023;24(2):40-43. https://www.westonaprice.org/health-topics/eggs-in-midday-meal-scheme-in-karnataka-india-the-science-and-the-propaganda/

This article appeared in Wise Traditions in Food, Farming and the Healing Arts, the quarterly journal of the Weston A. Price Foundation, Spring 2024

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