Prevention and Control of Nutritional Anaemia

A South Asia Priority

All correspondence should be addressed to: UNICEF Regional Office for South Asia P Box 5815.Regional Office for South Asia The contents of this booklet do not necessarily reflect the policies or the views of UNICEF. UNICEF-ROSA Dr. Ellen Girerd-Barclay. city or .O. Regional Health & Nutrition Adviser. The designations employed in this publication and the presentation of the material do not imply on the part of UNICEF the expression of any opinion whatsoever concerning the legal status of any country or territory. Nepal . Telephone: 977-1-417082. or concerning the delimitation of its frontiers or boundaries. Kalpana Tiwari.UNICEF acknowledges the contribution of the following persons to this publication Dr. Fax: 977-1-419479 e-mail: rosa@unicef. or of its authorities. UNICEF-ROSA Cover photo: Young South Asian mother feeding her anaemic child Photo: Miriam Krantz/UNICEF-ROSA 2002 United Nations Children’s Fund . Kathmandu. Nutrition Consultant.

approximately 20 percent of women. or a decreased volume of red blood cells. women and men with nutritional anaemia. which are induced by genetic disorders). which transports oxygen (hemoglobin). People throughout the region suffer from non-nutritional anaemias (such as sickle-cell anaemia and thalassaemia.1 Prevention and Control of Nutritional Anaemia: A South Asia Priority Prevention and Control of Nutritional Anaemia: A South Asia Priority What is Nutritional Anaemia. some due to a deficiency of either a single or several essential nutrients and others from conditions that are not related to nutrition such as infections. and How is it Measured? Worldwide. 50 percent of pregnant women. a decreased amount of substance in red blood cells. What Causes it. but these are few in comparison to the number of people children. Iron is normally obtained through the food in the diet and by the recycling of iron from old red blood cells. It may be due to a decreased number of red blood cells. There are over a dozen different types of anaemia. the oxygen carrying pigment in the blood. Iron is an essential component of hemoglobin. and 3 percent of men are iron deficient. “Nutritional Anaemia” describes a condition in which the haemoglobin or red blood cell content of the blood is lower than normal because of too little iron and is the most common anaemia in South Asia. Dual burden of a mother Miriam Krantz/UNICEF TYPES OF ANAEMIA • anaemia of B12 deficiency • anaemia of chronic disease • anaemia of folate deficiency • drug-induced immune hemolytic anaemia • hemolytic anaemia • hemolytic anaemia due to g6pd deficiency • idiopathic aplastic anaemia • idiopathic autoimmune hemolytic anaemia • immune hemolytic anaemia • iron deficiency anaemia • pernicious anaemia • secondary aplastic anaemia • sickle cell anaemia . Anaemia is the decreased ability of the red blood cells to provide adequate oxygen to body tissues.

and parasite infestations. As the primary care givers of the entire family. health & care Higher maternal morality Inadequate food. infants. health and care. health & care Reduced mental capacity Miriam Krantz/UNICEF Figure 1: Malnutrition and Life Cycle Malnutrition is intergenerational. Programmes to fight malnutrition must link the nutritional status of the infant. It is also caused by lead poisoning in children. . children. anaemia is usually due to gastrointestinal blood loss associated with ulcers. the use of aspirin or nonsteroidal anti-inflammatory medications (NSAIDS). people at all stages of the life cycle (Figure 1) must be able to have better access to food.2 Prevention and Control of Nutritional Anaemia: A South Asia Priority Malnourished Inadequate food. girls and women also need to be in good health and nutritional status to properly perform these roles. colon cancer. and people with a poor dietary intake of iron through a diet of little or no meat or eggs for several years. Risk Child Stunted Woman factors related to blood loss are Pregnancy peptic ulcer disease. In order to improve nutrition. health & care The causes of iron deficiency are: too little iron in the diet. Women and girls are especially affected by malnutrition during the life cycle. Nutritional Anaemia develops slowly after the normal stores of iron have been depleted in the body and in the bone marrow. long term Adolescent Stunted aspirin use. and loss of blood (including from heavy menstrual bleeding). Higher mortality rate Impaired mental development Reduced capacity to care for baby Increased risk of adult chronic disease Low Birth Weight Untimely/inadequate weaning Frequent infections Inadequate food. pregnant or lactating women who have an increased requirement for iron. Therefore a good start in life for a new baby is dependent on the health and nutrition of his/her mother. and the grandmother. Women. the adolescent. and from one generation to the next. the mother. High-risk groups include: women of child-bearing age who have blood loss through menstruation. In men and postmenopausal women. and on her development and well being when she was a girl. because of reproduction babies. and repeated blood donation. and even her grandchildren. health & care Inadequate foetal nutrition Inadequate catch up growth Malnourished Reduced mental capacity Low Weight Gain Inadequate food. in general. placing them at higher risk for nutritional anaemia. uterine cancer. This means that the nutritional status of a mother has an effect on that of her children. have smaller stores of Iron & Vitamin C rich foods iron than men and have increased loss through menstruation. poor absorption of iron by the body. and adolescents in rapid growth Elderly Baby phases.

as does consuming iron-rich foods with "enhancers" . lentils and beans. iron supplements should be taken orally. and some essential minerals. Animals should be kept in separate. flour. vegetarian sources include breastmilk. The best way to avoid getting intestinal parasites is to wash hands frequently. bread. Much iron is lost through parasitic infestation.3 Prevention and Control of Nutritional Anaemia: A South Asia Priority Preventing Nutritional Anaemia Non-vegetarian dietary sources of iron are red meat. If the diet is deficient in iron. using soap and safe water. Living areas should be swept and washed regularly. In some parts of South Asia. eating utensils and pots and pans. . deworming should be carried out on a regular basis (at least every six months. and always after using the toilet and before eating food.) Depending on the type of worm (s) that is prevalent. such as tannin and caffeine. and if necessary treated with disinfectant. bed nets should always be used where malarial mosquitoes are prevalent. whole grains and products made from these foods. preferably fenced areas. as well as vegetables and fruits must be thoroughly washed. In areas with high rates of parasitic infestation. and egg yolks. prevent iron from being absorbed and should be consumed separately from iron sources. and stored in hygienic conditions. and latrines used by all members of the family. to avoid contamination where children are likely to play. and some cereals are fortified with iron. Keeping the environment clean and free from excreta (human and animal) is also important to prevent parasites. more frequently if necessary. fish. During periods of increased requirements such as pregnancy and lactation. Since malaria increases the risk of anaemia. liver.foods that contain vitamin C. dietary intake of iron should increase and women should take iron supplements. albendazole (single dose) or mebendazole are the drugs of choice. especially on or near the ground. and cleaned. Dishes. since deficiencies in folate and iron can cause anaemia. Iron supplements are generally combined with Folate or folic acid. Sprouting grains and beans enhance the bioavailability of the iron they contain. Iron inhibitors.

4 Prevention and Control of Nutritional Anaemia: A South Asia Priority Symptoms and Signs of Anaemia • • • • • • pale skin.frontal A grandmother as a caretaker low haematocrit and hemoglobin in a RBC low serum ferritin (serum iron) level • • • Note: There may be no symptoms if anaemia is mild. Usually. and other solutions are nearly always required. low birth weight. healthier hygiene and sanitation practices. Iron supplements. concave nails unusual food cravings (called pica) decreased appetite (especially in children) headache . is serious and even life-threatening. tongue and inner surface of eyelids (conjunctiva) fatigue irritability weakness shortness of breath low blood pressure with position change from lying or sitting to standing (orthostatic hypotension) sore tongue brittle nails. especially severe deficiency. it cannot be overcome by increasing dietary intake alone. prematurity Treatment Identification of the cause of deficiency is essential. deworming. Oral iron supplements are in the form of ferrous Miriam Krantz/UNICEF • • • • . Consequences of Nutritional Anaemia • • • • • Impaired cognitive performance at all stages of life Significant reduction of physical work capacity and productivity Increased morbidity from infectious diseases Greater risk of death of pregnant women during the perinatal period Negative foetal outcome: intrauterine growth retardation. along with improved diet and eating habits. Iron deficiency. lips.

The best absorption of iron is on an empty stomach. Milk and antacids containing calcium may interfere with absorption of iron and should not be taken at the same time as iron supplements. but many people are unable to tolerate this and may need to take the supplement with food. Iron supplements are needed during pregnancy and lactation because normal dietary intake cannot supply the required amount for the mother and the growing foetus. a sudden increase in blood iron can cause shock. but even this solution is not without serious risk. contained mostly in the bone marrow. The Prevalence of Nutritional Anaemia in South Asia Countries % of women % of pregnant % of children affected • • • • • • • • Afghanistan Bangladesh1 Bhutan2 India3 Maldives4 Nepal 5 Pakistan6 Sri Lanka7 70.0 under 5 affected 73.3 81.0 49.8 62.7 45.6 29-33 39.0 74. Taking vitamin C supplements or eating vitamin C-rich foods at the same time as iron supplements can increase absorption and is essential in the production of hemoglobin. but the iron tablets should be continued for another 6 to 12 months to replenish the body's iron stores.5 78.0 51. there are usually no complications.5 Prevention and Control of Nutritional Anaemia: A South Asia Priority sulfate. The haematocrit should return to normal after 2 months of daily iron supplementation.0 .4 67.7 68.9 45.0 59. so regular follow-up is encouraged. After a prolonged period of iron deficiency. however nutritional anaemia may recur. Intravenous or intramuscular iron is available for patients when iron taken orally is not tolerated. and even death.0 62. Anaemic persons may have an increased susceptibility to infection.0 women affected 77.0 74. In mild and moderate anaemia. Severely anaemic persons may require blood transfusions.

6 Prevention and Control of Nutritional Anaemia: A South Asia Priority What are the Causes of Nutritional Anaemia in South Asian Women and Children? In Women: • Insufficient quantity of iron-rich foods and “iron enhancers” in the diet (foods rich in vitamin C such as citrus fruits). the highest prevalence of anaemia is found in South Asia. intestinal worms) Poor environmental sanitation. unsafe drinking water and inadequate personal hygiene • • In Children: • • Low iron stores at birth due to anaemia in mother Early introduction of inappropriate. Ninety percent of these individuals live in developing countries. until adulthood. foods containing only non-heme iron) Excessive quantity of “iron inhibitors” in diet. calcium-rich foods) Iron loss during menstruation Poor iron stores from infancy and childhood deficiencies Iron loss from post-partum haemorrhage Increased iron requirement due to tissue. . around the world suffer from nutritional anaemia. tea.g. heavy physical workloads Iron loss due to parasite load (e. malaria.g. and low bioavailability of dietary iron (e. especially during mealtimes (e. insufficient iron intake. non-fortified substitutes of breast milk Non-exclusive breastfeeding and too early introduction of inappropriate complementary food (resulting in diminished breast milk intake. blood and energy requirements during pregnancy. coffee. unsafe drinking water and inadequate personal hygiene • • • • • • • • • • • • • Why is Nutritional Anaemia a Priority? More than 350 million women and up to twice as many infants.g. in some areas. and heightened risk of intestinal infections) Late introduction of appropriate (iron-rich) complementary foods Insufficient quantity of iron and iron enhancers in diet. and low bioavailability of dietary iron (e. and. Recent anaemia studies in several states of India. children and adolescents.g.g. malaria. intestinal worms) Poor environmental sanitation. and in some areas. and among these. due to heavy workloads Teenage pregnancy Repeated pregnancies with less than 2 years’ interval Iron loss due to parasite load (e. Bangladesh and Nepal indicate that up to 90 percent of infants and young children and 75 percent of pregnant women may be suffering from nutritional anaemia. non-heme iron)1 Increased iron requirements related to rapid growth and development during infancy and childhood.

Project IDEA has ongoing activities in China. Georgia. Specific objectives include: . . "Forging Effective Strategies to Combat Iron Deficiency" was held on 7-9 May 2001.evaluating the effectiveness of implemented programmes on a continuing basis. • Project Iron Deficiency Elimination Action (IDEA) of International Life Sciences Institute(ILSI) Micronutrient Deficiencies Program: develops and implements country-specific fortification strategies to reduce the incidence of iron deficiency anaemia. Indonesia. September 1990: 71 Heads of State and Government and 88 other senior officials pledged to reduce the rate of iron deficiency anaemia in pregnant women by one third of the 1990 levels by 2000. and evaluation of programmes.7 Prevention and Control of Nutritional Anaemia: A South Asia Priority Nutritional Anaemia Prevention and Control on the Global Agenda • The World Summit for Children . intervention. . Vietnam. Egypt and Zambia. Project IDEA's meeting.developing intervention strategies and methodologies to combat deficiency anaemia. .New York. INACG held its second international meeting on "Why Iron is Important and What to Do about it: A New Perspective" in Hanoi. a followup to the 1990 World Submmit for Children. India. • International Nutritional Anaemia Consultative Group (INACG): Chief purpose is to guide activities aimed at reducing nutritional anaemia in the world. USA. providing participants from many countries an opportunity to share expertise. SSC. . in Atlanta.performing research needed to support the assessment. Vietnam (1516 February 2001).assessing the regional distribution and size of nutritional anaemia. • The Global Alliance for Improved Nutrition (GAIN): a new alliance of public and private sector partners was launched during The Special Session on Children (SSC) meeting seeking to save lives and improve health by eliminating vitamin and mineral deficiences. was held on 8-10 May 2002 at the United Nations in New York. Mexico.

oral supplementation. safety. The objectives of the groups are to: • create a group of thinkers in each South Asian country dedicated to identifying long and medium term strategies and solutions to nutritional anaemia. What is UNICEF Doing in South Asia to prevent and Control Nutritional Anaemia ? UNICEF-Regional Office for South Asia (UNICEF-ROSA) In 2000. 3-5 February 1999. Outcome: The group agreed on requirements for assessment and the integration of multiple interventions. Geneva. education for dietary change. iron supplementation. communication for dietary change. the Commonwealth of Independent States and the Baltic States and WHO Regional Office for Europe). flour fortification. UNICEF-New York. UNICEF-ROSA initiated the South Asia Nutrition Group for/ on Anaemia-related Micronutrients (SANGAM). A sub-group of SANGAM. 7-9 October 1998. policies. . guidelines and actions which hinder the prevention and control of nutritional anaemia in all women throughout the life cycle in South Asia.8 Prevention and Control of Nutritional Anaemia: A South Asia Priority What is UNICEF doing Globally? • UNICEF/United Nations University/World Health Organisation/the Micronutrient Initiative Technical Workshop on Preventing Iron Deficiency in Women and Children. • determine gaps and inadequacies in current strategies. especially in women in South Asia. linkages to other ongoing programmes and monitoring and evaluation of programmes and documentation. better monitoring. evaluation and research. Switzerland. South Asian Thinkers/Think Tank On Preventing Anaemia (STOP Anaemia) has been established in Nepal to develop and conduct operational research on practical methods to prevent and control nutritional anaemia. integrated programmes to cover all high-risk groups. Outcome: Recommendations for actions for complementary feeding. integration with public health programmes. food fortification. • UNICEF/WHO Regional Consultation on Prevention and Control of Iron Deficiency Anaemia in Women and Children (UNICEF Regional Office for Central and Eastern Europe.

South Asian women with anaemia (Mild. a consultation on anaemia and adolescents. the group will prepare. and Severe) Per cent > 75 50 . . in addition to young children. and including youth and older adults. two field visits and 10 STOP Anaemia meetings have been held in Nepal. pregnant and lactating women. involving related sectors (sanitation and hygiene) and including therapy for deworming. So far. The group is carrying out operational research on anaemia control and reduction.9 Prevention and Control of Nutritional Anaemia: A South Asia Priority STOP Anaemia Focus Group Discussion on Anaemia with Adolescents • identify the constraints to achieving prevention and control of nutritional anaemia.75 25 . The dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan.49 < 25 Missing Data The boundaries and names shown and the designations used on these maps do not imply official endorsement or acceptance by the United Nations. In 2001. Moderate. together with UNICEF-India. including behavioural change. using a life-cycle approach.

• Documented links between adolescent and women's nutrition. and six-monthly deworming with a single dose of albendazole is provided to all under-five children.UNICEF and Royal Government of Bhutan conducted an assessment of the anaemia situation in 2001.10 Prevention and Control of Nutritional Anaemia: A South Asia Priority • Reported on UNICEF-ROSA.and other micronutrientrich foods are promoted in communities. and a community-based nutrition programme has been initiated to address all forms of nutritional deficiencies at the community level. Kitchen gardens for improving the availability of iron. and school children. April 6. • Strengthen and expand SANGAM and STOP Anaemia groups. Kathmandu. weekly iron supplementation to all adolescent girls in partnership with the school health programme will be initiated. • 2002-2006: . • Initiate operational research in Nepal and India on a holistic approach to reducing anaemia. 2001. creating awareness of nutritional anaemia. UNICEF. low birth weight (LBW). nutritional anaemia and LBW for implementation in 2002-2004. . safe motherhood and maternal mortality reduction and basic education. • Develop and coordinate South Asia Behaviour Change Intervention (SA BCI) programmes for adolescents’ and women's nutrition. nutritional anaemia.South Asia Country Offices Bhutan • 1997-2001: .Current activities: Daily iron/folate supplementation is provided to pregnant women from the first antenatal visit to two months after delivery. • Conducted advocacy with high-level decision-makers during HighLevel meeting on Investing in Children. UNICEF-South Asia and partners' nutritional anaemia activities at ACC/Sub-Committee on Nutrition meeting in Nairobi. the community-based nutrition intervention programme will be expanded nation-wide in a phased manner. sentinel surveillance for anaemia and other nutritional deficiencies will be introduced. and initiate electronic networking on anaemia control. and bringing about behaviour changes in nutrition. 19 .23 May 2001. prevention and treatment.

• At community level: provides advocacy for iron supplementation during pregnancy where the Decentralised Planning for the Child Programme is implemented. Other strategies are being tested in Orissa. iron supplementation for pregnant mothers and micro planning through the Comprehensive Nutrition Programme (CNP). based on a once-per-week supervised iron/folate supplement for school girls. establishes links to outreach activities. The initial plan was for outreach from school girls to out-of-school girls. Nepal • At national level with His Majesty’s Government of Nepal. Tamil Nadu and Rajasthan. mass deworming for school children. An updated situation analysis of wheat flour in .11 Prevention and Control of Nutritional Anaemia: A South Asia Priority India • Adolescent anaemia projects are operational in 11 states. with strategies for community outreach. Maldives • Promotion of personal hygiene and environmental sanitation. ensure the availability of iron/folate supplements for MoH and monitoring the availability of supplements throughout the country in collaboration with John Snow International. monitors the acceptability of supplements. development of radio and TV spots for broadcast throughout the country in order to increase general awareness about anaemia and to promote the use of iron supplements during pregnancy. encourages women to attend antenatal clinics. Programmes are implemented through schools. Pakistan • A project agreement was signed between the Government and UNICEF in 1998 to initiate iron fortification of wheat flour to prevent or reduce iron deficiency anaemia. developing a health facility treatment protocol for iron supplementation and promoting decentralisation of iron distribution outside of the health facilities utilising the existing extensive network of community-based female community health volunteers.

Sri Lanka • Technical support is provided to national. deliver and monitor responsive services based on assessment of the national and local situation. provincial and community level staff to plan. • Supplements are provided where necessary particularly to the Participatory Nutrition Improvement Project. commercialisation. and developed a detailed proposal for testing the potential of fortifying wheat flour.12 Prevention and Control of Nutritional Anaemia: A South Asia Priority relation to production. • Provides support and recommendations to community and government for inputs into water supply and human waste disposal facilities in deprived and difficult areas. consumption and potential for iron fortification was carried out. . distribution. UNICEF and partners organised a consultative meeting with representatives from the Pakistan Flour Mills Association to motivate and build support for iron fortification.

10. Ceylon J Med. 1996. Mudalige R and Nestel P Combating iron deficiency: Prevalence of anaemia in Sri Lanka. Preventing iron deficiency in women and children: Technical consensus on key issues. First Call for Children. Information on anaemia prepared by member countries of South-East Asia region. 1994. October 1998. UNICEF-NY. Prevention and control of iron deficiency anaemia in women and children. Nepal Micronutrient Status Survey 1998. 5. Male. 1999. Department of Public Health. . 2. 3. 8. National Survey of Rural Bangladesh. A UNICEF/ UNU/WHO/MI Technical workshop.1992. UNICEF-NYHQ: 2000. Report of the UNICEF/ WHO Regional Consultation. 7. 9. 39. 4. 6. National Nutrition Survey. Maldives. Sci.13 Prevention and Control of Nutritional Anaemia: A South Asia Priority References 1.International Conference on nutrition. National Family Health Survey (NFHS-2) India1998-99. National Survey for Pakistan (NHSP) 1990-94. 1981-1983. FAO/WHO.

and other physical activities. unsafe drinking water and inadequate personal hygiene. sports.Miriam Krantz/UNICEF Boys and girls. Causes of anaemia are related to inadequate dietary intake of iron. increased illness. reduced capacity. low birth weight and premature births….including mental retardation and poor school performance. tiredness. Anaemia has terrible effects on health and wellbeing . iron loss due to parasite load. and poor ability to do labour.some are irreversible . poor environmental sanitation. men and women are all at risk of anaemia. LET'S STOP ANAEMIA NOW! . and excessive physical workloads. poor iron stores. greater risk of death of women during maternity and birth.

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