ID

AThis document deals primarily with

indicators for monitoring interventions to

combat iron deficiency, including iron

deficiency anaemia, but it also reviews

the current methods of assessing and

preventing iron deficiency in the light

of recent significant scientific advances.

Criteria for defining IDA, and the

public severity of anaemia based on

prevalence estimates, are provided.

Approaches to obtaining dietary

information, and guidance in designing

national iron deficiency prevention

programmes, are presented.

Strategies for preventing iron deficiency

through food-based approaches, i.e.

dietary improvement or modification

and fortification, and a schedule for

using iron supplements to control iron

deficiency and to treat mild-to-moderate

iron deficiency anaemia, are discussed.

For each strategy, desirable actions

are outlined and criteria are suggested

for assessment of the intervention.

Attention is given to micronutrient

complementarities in programme

implementation, e.g., the particularly

close link between the improvement

of iron status and that of vitamin A.

Finally, this document recommends

action-oriented research on the control

of iron deficiency, providing guidance

in undertaking feasibility studies

on iron fortification in most countries.
ID

AThis document deals primarily with

indicators for monitoring interventions to

combat iron deficiency, including iron

deficiency anaemia, but it also reviews

the current methods of assessing and

preventing iron deficiency in the light

of recent significant scientific advances.

Criteria for defining IDA, and the

public severity of anaemia based on

prevalence estimates, are provided.

Approaches to obtaining dietary

information, and guidance in designing

national iron deficiency prevention

programmes, are presented.

Strategies for preventing iron deficiency

through food-based approaches, i.e.

dietary improvement or modification

and fortification, and a schedule for

using iron supplements to control iron

deficiency and to treat mild-to-moderate

iron deficiency anaemia, are discussed.

For each strategy, desirable actions

are outlined and criteria are suggested

for assessment of the intervention.

Attention is given to micronutrient

complementarities in programme

implementation, e.g., the particularly

close link between the improvement

of iron status and that of vitamin A.

Finally, this document recommends

action-oriented research on the control

of iron deficiency, providing guidance

in undertaking feasibility studies

on iron fortification in most countries.
IRON DEFICIENCY ANAEMIA

Iron Deficiency Anaemia

Assessment, Prevention

and Control

A guide for programme managers
IRON DEFICIENCY ANAEMIA

© WORLD HEALTH ORGANIZATION, 2001

This document is not a formal publication of the World Health Organization (WHO),

and all rights are reserved by the Organization. The document may, however, be

freely reviewed, abstracted, reproduced and translated, in part or in whole, but not

for sale nor for use in conjunction with commercial purposes. The views expressed

in documents by named authors are solely the responsibility of those authors.
IRON DEFICIENCY ANAEMIA

Executive summary

This document deals primarily with indicators for monitoring interventions to

combat iron deficiency, including iron deficiency anaemia. However, it also

reviews the current methods of preventing iron deficiency in the light of recent

significant scientific advances. It summarizes regional prevalences of

anaemia, and briefly discusses the principal factors affecting its prevalence.

Indicators for assessing iron deficiency are presented, together with their

thresholds of abnormality in various age, gender, and physiological status;

the relationships between them; and their applicability in different settings according to resource availability.

It also presents approaches for obtaining dietary information and guidance on

designing national iron deficiency prevention programmes. Iron requirements

and recommended iron intakes from diets of different bioavailability are

summarized.

Criteria for defining iron deficiency anaemia are provided, and a slight

modification from those previously recommended by WHO is proposed.

Also proposed are criteria for defining the public health severity of anaemia,

on the basis of prevalence estimates. Acceptable methods for assessing

anaemia and iron status, both on the basis of clinical examinations and blood

tests, are discussed. Threshold values for the interpretation of these indices

are given.

Strategies for preventing iron deficiency through food-based approaches,

i.e. dietary improvement or modification and fortification, are discussed.

For example, modifiers that affect the bioavailability of food-iron sources are

reviewed, and suggestions for altering meal patterns to improve absorbability

are offered.

A schedule for using iron supplements to control iron deficiency, and to treat

mild-to-moderate IDA according to age, gender, and physiological status,

is provided. For each strategy, desirable actions are outlined and criteria

suggested for assessment of the intervention. In this connection, indicators

for use in monitoring programme implementation are described.

i

iii
IRON DEFICIENCY ANAEMIA

iv

In most countries, some aspects of each of the main types of intervention

will be needed to control the problem of iron deficiency. Particular attention is devoted to micronutrient complementarities in programme

implementation. For example, the particularly close link between improving

iron status and improving vitamin A status is explored.

Finally, recommendations are made for action-oriented research on the

control of iron deficiency, and for undertaking feasibility studies on iron

fortification in countries. Increased advocacy, exchange of information,

development of human resources, and action-oriented research are

recommended for accelerating the achievement of the goals for reducing

iron deficiency.
IRON DEFICIENCY ANAEMIA

Contents

Chapter Title Page

i Executive summary iii

ii Table of contents v

iii List of tables viii

iv List of figures ix

v Abbreviations x

vi Acknowledgements xi

vii Preface xii

 1 Introduction 1

2 Concepts used in defining

iron nutritional status 3

3 Functional consequences

of iron deficiency 7

3.1 Cognitive development 7

3.2 Resistance to infection 8

3.3 Work capacity and productivity 9

3.4 Pregnancy 9

3.5 Growth 9

3.6 Endocrine and neurotransmitters 10

3.7 Heavy-metal absorbtion 10

4 Economic implications

of iron deficiency 11

5 Prevalence and epidemiology

of iron deficiency 15

5.1 Prevalence 15

5.2 Epidemiology 17

ii

v
IRON DEFICIENCY ANAEMIA

vi

6 Assessment, surveillance, and indicators 23

6.1 Individual and population-based assessment 23

6.2 Purposes of biological assessments 24

6.3 Selection of subjects for assessment 25

6.4 General issues in defining

iron status indicators 26

6.5 The spectrum of iron nutritional status 27

6.6 Application of iron-related indicators

to specific settings 29

7 Methods of assessing iron status 33

7.1 Assessment of anaemia 33

7.2 Specific tests or procedures

for assessing iron status 37

7.3 Defining iron deficiency

when multiple indices are available 41

7.4 Haemoglobin response to iron

and other supplements or interventions 42

7.5 Assessing population iron status

by using haemoglobin distributions 43

8 Prevention strategies 47

8.1 Food-based approaches 47

8.2 Iron supplementation 56

9 Action-oriented research needs 67

9.1 Dietary improvement 67

9.2 Iron fortification 68

9.3 Iron supplementation 69

10 General recommendations 71

10.1 For governments 71

10.2 For supporting organizations and institutions 72

References 75

Contents (continued)

Chapter Title Page
IRON DEFICIENCY ANAEMIA

vii

Contents (concluded)

Annex Title Page

1 List of participants:

IDA Consultation, Geneva 89

2 The practical significance

 of iron overload for iron fortification

 and supplementation programmes 93

3 Variations in haemoglobin and

haematocrit levels 97

4 Approaches for obtaining information

on availability, dietary patterns, and

consumption of iron-containing foods 103

5 Strategies and guidelines for

national IDA control programmes 107
IRON DEFICIENCY ANAEMIA

iii

viii

Tables

 Number Title Page

1 Relative effectiveness and cost per Disability

Adjusted Life Year of various prevention strategies 14

2a Estimated percentages of anaemia prevalence, based

on blood haemoglobin concentration (1990-1995) 15

2b Estimated prevalence of anaemia by WHO Region, based

on blood haemoglobin concentration (1990-1995) 16

3 Proposed classification of public health significance

of anaemia in populations, on the basis of prevalence

estimated from blood levels of haemoglobin or

haematocrit 17

4 Iron requirements and recommended iron intakes

by age and gender group 18-19

5 Assessing iron status on the basis of resource

availability in a country 30

6 Haemoglobin and haematocrit levels below which

anaemia is present in a population 33

7 Relative extent of iron stores on the basis of

 serum ferritin concentration 38

8 Changes in iron status by age group on the basis

of erythrocyte protoporphyrin 39

9 Proportion of anaemic pregnant women

who responded to oral iron and vitamin A

supplements and became non-anaemic 42
IRON DEFICIENCY ANAEMIA

1 Conceptual diagram of the relationship 5

between iron deficiency and anaemia

in a hypothetical population

2 Projected prevalence of iron deficiency

based on prevalence of iron deficiency anaemia 28

3a Haemoglobin distribution in Palestinian

 vs US children, women, and men 44

3b Haemoglobin distribution in Ethiopian

 vs US children, women, and men 45

iv

ix

Tables (continued)

 Number Title Page

10 Dosage schedules for iron supplementation

to prevent iron deficiency anaemia 58

 11 Possible side-effects associated with

iron medication 61

12 Iodine, iron, and vitamin A deficiencies:

etiology, vulnerable groups, and appropriate

 groups for surveillance purposes 65

Number Title Page

Figures
IRON DEFICIENCY ANAEMIA

v Abbreviations

x

CDC Centers for Disease Control and Prevention (USA)

CSM Corn-soy-milk

DALY Disability adjusted life years

ID Iron deficiency

IDA Iron deficiency anaemia

EP Erythrocyte protoporphyrin

FAO Food and Agriculture Organization of the United Nations

G6PD Glucose-6 phosphate dehydrogenase

Hb Haemoglobin

Hct Haematocrit

IDD Iodine deficiency disorders

INACG International Nutritional Anaemia Consultative Group

IQ Intelligence quotient

Na-Fe EDTA Sodium ferric ethylenediaminetetraacetic acid

JECFA Joint FAO/WHO Expert Committee on Food Additives

MCH Maternal and child health

MCHC Mean corpuscular haemoglobin concentration

MCV Mean corpuscular volume

MDIS Micronutrient Deficiency Information System

NGO Nongovernmental organization

PHC Primary health care

RBC Red blood cells

SF Serum ferritin

SI Serum iron

TIBC Total iron binding capacity

TR Transferrin receptor

TS Transferrin saturation

T3 Triiodothyronine

UNICEF United Nations Children’s Fund

UNU United Nations University

VAD Vitamin A deficiency

WHO World Health Organization

WSB Wheat-soy blend
IRON DEFICIENCY ANAEMIA

 vi Acknowledgements

xi

The World Health Organization gratefully acknowledges the valuable

contributions of the participants in the WHO/UNICEF/UNU consultation

(Annex 1). Special thanks are also due to Leif Hallberg, Nevin Scrimshaw,

Fernando Viteri and Ray Yip for references to the literature and portions of text,

and for reviewing the draft report; and to Ken Bailey and Barbara Underwood,

former staff members in the Department of Nutrition for Health and

Development, who participated in the document’s early development.

Thanks are also due to James Akré, Henrietta Allen, Graeme Clugston

and Anna Verster for their contributions. Bruno de Benoist coordinated the

overall production of the document, while Ross Hempstead was responsible

for editing and layout.
IRON DEFICIENCY ANAEMIA

 vii Preface

xii

This document is based in large part on a consultation convened in Geneva

from 6-10 December 1993, jointly organized by the World Health Organization

(WHO), the United Nations Children’s Fund (UNICEF), and the United Nations

University (UNU).

Since the meeting there have been significant new data emerging in key

areas, which have been published in scientific literature and presented in

international meetings. It was recognized that this information was relevant

and should also be included. Therefore, the final text has been updated

and contains new material, together with the conclusions reached and

recommendations made by the Consultation.

Iron deficiency, and specifically iron deficiency anaemia, remains one of

the most severe and important nutritional deficiencies in the world today.

Every age group is vulnerable. Iron deficiency impairs the cognitive

development of children from infancy through to adolescence. It damages

immune mechanisms, and is associated with increased morbidity rates.

During pregnancy, iron deficiency is associated with multiple adverse

outcomes for both mother and infant, including an increased risk of

haemorrhage, sepsis, maternal mortality, perinatal mortality, and low birth

weight. It is estimated that nearly all women are to some degree iron deficient,

and that more than half of the pregnant women in developing countries suffer

from anaemia. Even in industrialized countries, the iron stores of most

pregnant women are considered to be deficient. Finally, as much as a

30% impairment of physical work capacity and performance is reported in

iron-deficient men and women.

The economic implications of iron deficiency and of the various intervention

strategies to combat it, suggest that food-based approaches and targeted

supplementation are particularly cost-effective. The highest benefit-to-cost

ratio is attained with food fortification.
IRON DEFICIENCY ANAEMIA

xiii

In the last two decades, the importance of iron deficiency and anaemia

as a public health problem has been increasingly recognized by health

authorities and policy makers. This is reflected in the goals on the reduction

of iron deficiency anaemia endorsed by Heads of State, ministers in the

World Declaration and Plan of Action from the World Summit for Children (1990)

and in the World Declaration and Plan of Action for Nutrition from the

International Conference on Nutrition (1992).

The document aims at providing scientists and national authorities

worldwide with an up-to-date and authoritative review of iron deficiency

anaemia, together with guidelines and recommendations. It is also intended

for managers of national programmes dealing with the prevention and control

of micronutrient malnutrition, as well as for policy makers. It is meant to help

them to implement effective measures for fighting iron deficiency anaemia.

We hope that the information included in this manual will contribute to our

common effort to eliminate iron deficiency anaemia.
IRON DEFICIENCY ANAEMIA
IRON DEFICIENCY ANAEMIA

111 Introduction

1

In 1992, World Health Resolution WHA45.33 urged Member States to:

For their part, WHO and UNICEF, together with key partners, convened a

series of consultations on appropriate indicators for assessing and monitoring

micronutrient deficiencies and their control programmes. Consultations on

iodine deficiency disorders and vitamin A deficiency were held first, in 1992

(1,2).

A third consultation on iron deficiency was held a year later, in December 1993,

providing the basis for the present document. Also included is important new

information emerging since the consultation

establish, as part of the health and nutrition monitoring system,

a micronutrient monitoring and evaluation system capable of

assessing the magnitude and distribution of iodine, vitamin A

and iron deficiency disorders, and monitor the implementation

and impact of control programmes . . .

Iron deficiency affects a significant part, and often a majority, of the population

in nearly every country in the world. Programmes for the prevention of iron

deficiency, particularly iron supplementation for pregnant women, are under

way in 90 of 112 countries that reported to WHO in 1992 (3). Most of

these programmes, however, are neither systematically implemented nor well

monitored or evaluated.

Scientific consensus on the prevention of iron deficiency anaemia was

described in a 1989 WHO monograph (4). Since then, however, knowledge

of the consequences of iron deficiency - even in the absence of anaemia -

has evolved, while fortification technology has improved considerably.

Furthermore, national, regional, and global efforts to overcome micronutrient

malnutrition have gathered accelerated momentum. As a result, an overall

review of the strategies for preventing iron deficiency - together with a closer

examination of prevalence indicators and methods of monitoring programmes

of prevention - have become appropriate and timely.
IRON DEFICIENCY ANAEMIA

The general objective of the 1993 consultation was to review and accelerate

global processes for preventing iron deficiency, with the goal of substantially

reducing the problem during the forthcoming decade.

The specific objectives of the consultation were as follows:

 To review appropriate target groups for iron deficiency

and anaemia assessment and surveillance, and

appropriate prevalence indicators, criteria, and thresholds.

 To review and make general recommendations on suitable

laboratory methods for assessment of key indicators.

 To identify the steps by which the main strategies - improved

food consumption and dietary practices, food fortification,

supplementation, and public health measures - could be

more effectively implemented at each level.

 To identify appropriate indicators for monitoring programme

implementation.

 To identify high-priority, action-oriented, and operational

research needed to enable and accelerate effective

programme implementation.

 To determine critical needs in human resources development

for prevention of iron deficiency.

2
IRON DEFICIENCY ANAEMIA

Iron status can be considered as a continuum from iron deficiency with anaemia,

to iron deficiency with no anaemia, to normal iron status with varying amounts

of stored iron, and finally to iron overload - which can cause organ damage

when severe. Iron deficiency is the result of long-term negative iron balance.

Iron stores in the form of haemosiderin and ferritin are progressively

diminished and no longer meet the needs of normal iron turnover.

From this critical point onward, the supply of iron to the transport protein

apotransferrin is compromised. This condition results in a decrease in

transferrin saturation and an increase in transferrin receptors in the circulation

and on the surface of cells, including the erythron.

All tissues express their need for iron in exactly the same way, i.e. by the same

type of transferrin receptors on cell surfaces in proportion to actual iron need.

Accordingly, a compromised supply of iron to the erythron is associated with a

similarly insufficient supply of iron to all other tissues.

Functionally, the lack of mobilizable iron stores will eventually cause a

detectable change in classical laboratory tests, including measurement of

haemoglobin, mean corpuscular haemoglobin concentration, mean

corpuscular volume, total iron-binding capacity, transferrin saturation, and

zinc-erythrocyte protoporphyrin.

Iron deficiency is defined as a condition in which there are no mobilizable

iron stores and in which signs of a compromised supply of iron to tissues,

including the erythron, are noted. The more severe stages of iron deficiency

are associated with anaemia.

When iron-deficient erythropoiesis occurs, haemoglobin concentrations are

reduced to below-optimal levels. When individual haemoglobin levels are below

two standard deviations (-2SD) of the distribution mean for haemoglobin in an

otherwise normal population of the same gender and age who are living at the

same altitude, iron deficiency anaemia is considered to be present.

112

3

 Concepts used in defining

iron nutritional status
IRON DEFICIENCY ANAEMIA

In a normal population, 2.5% of the population would be expected to be below

this threshold. Hence, iron deficiency anaemia would be considered a public

health problem only when the prevalence of haemoglobin concentration

exceeds 5.0% of the population (see Table 3).

The prevalence of iron deficiency anaemia in a population is therefore a

statistical rather than a physiological concept, although it reflects

that proportion of the population that has iron-deficient erythropoiesis.

Iron deficiency anaemia should be regarded as a subset of iron deficiency.

That is, it represents the extreme lower end of the distribution of iron

deficiency.

Because anaemia is the most common indicator used to screen for iron

deficiency, the terms anaemia, iron deficiency, and iron deficiency anaemia

are sometimes used interchangeably. There are, however, mild-to-moderate

forms of iron deficiency in which, although anaemia is absent, tissues are still

functionally impaired.

In addition, although iron deficiency anaemia accounts for most of the

anaemia that occurs in underprivileged environments, several other possible

causes should be noted. These include haemolysis occurring with malaria;

glucose-6-phosphate dehydrogenase deficiency; congenital hereditary defects

in haemoglobin synthesis; and deficits in other nutrients, e.g. vitamins A, B12,,

and C, and folic acid.

Blood loss such as that associated with schistosomiasis, hookworm infestation,

haemorrhage in childbirth, and trauma, can also result in both iron deficiency

and anaemia. Lastly, as with vitamin A deficiency, inhibition of the normal

metabolism of iron can result in anaemia. These causes of anaemia are not

addressed in detail in this guidebook.

The relationship between anaemia and iron deficiency in a population is

illustrated in Figure 1 on the opposite page (5). In particular, it is noted that

the extent of the overlap between iron deficiency and iron deficiency anaemia

varies considerably from one population to another and according to gender

and age groups.

The degree of overlap between rates of total anaemia and of iron deficiency

anaemia also varies with the population observed. The greatest overlap

occurs in populations in which dietary iron absorbability is low or blood loss

is common due to hookworm infestation.

4
IRON DEFICIENCY ANAEMIA

Figure 1. Conceptual diagram of the relationship

between iron deficiency and anaemia in a hypothetical population

Iron

deficiency

Anaemia

Iron

deficiency

anaemia

Total

population

Source: Adapted from Yip R. Iron nutritional status defined. In: Filer IJ, ed.

Dietary Iron: birth to two years. New York, Raven Press, 1989:19-36.

5
IRON DEFICIENCY ANAEMIA
 IRON DEFICIENCY ANAEMIA

Functional consequences

of iron deficiency

The pallor of anaemia was associated with weakness and tiredness long

before its cause was known. Now it is recognized that even without anaemia,

mild to moderate iron deficiency has adverse functional consequences (6).

Iron deficiency adversely affects

 the cognitive performance, behaviour, and physical

growth of infants, preschool and school-aged children;

 the immune status and morbidity from infections

of all age groups; and

 the use of energy sources by muscles and thus

the physical capacity and work performance

of adolescents and adults of all age groups.

Specifically, iron deficiency anaemia during pregnancy

 increases perinatal risks for mothers and neonates; and

 increases overall infant mortality.

Moreover, iron-deficient animals and humans have impaired gastrointestinal

functions and altered patterns of hormone production and metabolism.

The latter include those for neurotransmitters and thyroidal hormones which

are associated with neurological, muscular, and temperature-regulatory

alterations that limit the capacity of individuals exposed to the cold to

maintain their body temperature. In addition, DNA replication and repair

involve iron-dependent enzymes.

3.1 Cognitive development

In experimental animals, iron has been shown to play a key role in brain function.

Several areas of the brain contain iron, sometimes in large quantities.

Iron-deficient animals show alterations both in neurotransmitters and behaviour

that do not usually respond to iron replenishment.

7

13
IRON DEFICIENCY ANAEMIA

There is strong evidence that findings from animal studies also apply to

humans. For example, iron deficiency anaemia has been conclusively seen

to delay psychomotor development and impair cognitive performance of infants

in Chile (7), Costa Rica (8), Guatemala (9), and Indonesia (10); of preschool

and school-aged children in Egypt (11), India (12), Indonesia (13,14), Thailand

(15), and the USA (16,17).

Adolescent girls whose diet was supplemented with iron felt less fatigued;

their ability to concentrate in school increased and their mood improved (18).

Neurological malfunction in young children, adolescents, and adults - as

determined by electrophysiological measurements - has also been documented

as being associated with iron deficiency (19).

In Costa Rica, children who had moderate anaemia as infants achieved lower

scores on intelligence (IQ) tests and other cognitive performance upon entry

in school than did children who were non-anaemic during infancy. This finding

emerged even when the tests were controlled for a comprehensive set of

socioeconomic factors (11). This result was recently confirmed in Chile (20).

On the other hand, in Thailand the poor performance in Thai language and

mathematics tests of children with low haemoglobin levels was not reversed

by iron supplementation (15).

Thus, iron deficiency can impair cognitive performance at all stages of life.

Moreover, the effects of iron deficiency anaemia in infancy and early

childhood are not likely to be corrected by subsequent iron therapy.

An estimated 10-20% of preschool children in developed countries, and an

estimated 30-80% in developing countries, are anaemic at 1 year of age (21).

These children will have delayed psychomotor development, and when they

reach school age they will have impaired performance in tests of language

skills, motor skills, and coordination, equivalent to a 5 to 10 point deficit in IQ.

3.2 Resistance to infection

Morbidity from infectious disease is increased in iron-deficient populations

(22-26), because of the adverse effect of iron deficiency on the immune

system (27-30). In these situations, leukocytes have a reduced capacity

to kill ingested microorganisms (31-34) and lymphocytes a decreased ability

to replicate when stimulated by a mitogen. Also in such cases, there occurs

a lowered concentration of cells responsible for cell-mediated immunity (31,

35-37) and a depressed skin-test response to common antigens (31,35).

Iron supplementation and milk or cereal fortification among deficient children

has been reported to reduce morbidity from infectious disease (38).

8
 IRON DEFICIENCY ANAEMIA

3.3 Work capacity and productivity

A linear relationship has been reported between iron deficiency and work

capacity for agricultural workers in Colombia (39), Guatemala (40), Indonesia

(41), Kenya (42,43), and Sri Lanka (44-46). Work capacity returned rapidly to

normal with iron supplementation. Similarly, iron supplementation increased

work output among road workers and rubber tappers in Indonesia (24);

tea pickers in Indonesia (26,41) and Sri Lanka (44-46); agricultural workers in

India (47), Guatemala (40), and Colombia (39); and industrial workers in Kenya

(48), China (49), and other countries. Gains in productivity and take-home pay

ranged from 10% to 30% of previous levels.

Compared with non-anaemic women, anaemic female workers in China were

15% less efficient in performing their work. They spent 6% less energy on

their out-of-work activities, had 4% lower maximal work capacity, and had

12% lower overall productivity, as compared to levels achieved after anaemia

was corrected by iron treatment for 4 months (49). Similarly, non-anaemic

iron-deficient adolescent female runners significantly improved their levels

of endurance and physical performance after supplementation with iron,

as compared with those of a placebo control group (50).

3.4 Pregnancy

Iron deficiency in childbearing women increases maternal mortality (51),

prenatal and perinatal infant loss, and prematurity (52,53). Forty percent of

all maternal perinatal deaths are linked to anaemia. Favourable pregnancy

outcomes occur 30-45% less often in anaemic mothers, and their infants have

less than one-half of normal iron reserves (54).

Such infants require more iron than is supplied by breast milk, at an earlier

age, than do infants of normal birth weight (55). Moreover, if pregnancy-induced

iron deficiency is not corrected, women and their infants suffer all the

consequences described above.

3.5 Growth

Growth improved in iron-deficient children who were given supplementary

iron in Indonesia (56), Kenya (57), and Bangladesh (58), as well as in

the United Kingdom (59) and the United States (60). Whether or not an effect

of iron supplementation is observed apparently depends on local factors.

These include frequency of diarrhoea and other infections, age at iron

depletion, and other dietary factors.

9
IRON DEFICIENCY ANAEMIA

3.6 Endocrine and neurotransmitters

Iron deficiency alters the production of triiodothyronine (T3) and thyroid

function in general, and the production and metabolism of catecholamines

and other neurotransmitters. This results in impaired temperature response

to a cold environment.

In both experimental animals and human subjects, those with iron deficiency

anaemia more readily become hypothermic and have a depressed thyroid

function (61-65). This condition may be the cause of some of the discomfort

from cold felt by poorly nourished individuals at temperatures in which

well-nourished persons are quite comfortable.

3.7 Heavy-metal absorption

An important consequence of iron deficiency is an apparent increased risk of

heavy-metal poisoning in children. Iron-deficient individuals have an increased

absorption capacity that is not specific to iron. Absorption of other divalent

heavy metals, including toxic metals such as lead and cadmium, is also

increased (66).

Prevention of iron deficiency, therefore, reduces the number of children

susceptible to lead poisoning. Such prevention may also help to reduce their

lead burden after exposure to high levels of lead from chipped lead paints,

pollution from automobile fumes (such as occurs in many cities), or other

excessive exposure to lead in the environment (67).

10
 IRON DEFICIENCY ANAEMIA

11

National socioeconomic development, as well as personal health and

self-fulfilment, are impaired by iron deficiency. The negative impact on

national development can be estimated from:

 the number of individuals affected in various

age and gender categories;

 the severity of the deficiency; and

 the duration and consequences of the condition.

The economic implications of such conditions include:

 the costs incurred by the public and private sectors

in therapeutic measures for the prevalent level of anaemia;

 the societal consequences of increased maternal mortality

and resultant restraints on productivity; and

 the long-term projected negative consequences of

impaired mental development on human capital formation.

The estimation of disability adjusted life years (DALYs) is an expression of

years of life lost (YLL) and years lived with disability (YLD). DALYs provide

an overall view of the magnitude of economic losses to a population (68).

Other indirect social and health consequences of impaired health and

vitality are difficult to estimate and are often not considered. For example,

among resource-poor societies the premature death of a mother and the lower

income-generating capacity of iron-deficient and anaemic workers translates

into greater rates of disease and overall undernutrition.

11 4 Economic implications

of iron deficiency
IRON DEFICIENCY ANAEMIA

This vicious circle impairs individual, family, and community, as well as overall

socioeconomic development. Consequently, estimates of only the economic

cost of iron deficiency are conservative understatements of the true handicap

imposed on society.

Costs of interventions specifically directed at nutrition and health education,

dietary diversification, and other public health interventions that also result

in improvements in iron nutrition, are not considered here. Data are lacking to

allow even a rough approximation of the effectiveness of these measures for

controlling iron deficiency. However, the general consensus is that if these

interventions are competently carried out, they are highly cost-effective and

sustainable.

There is a general scarcity of information both on the actual cost of programmes

for the control of iron deficiency, and on the benefits obtained by its correction.

Various programme budgetary considerations include the costs of:

 iron compounds required to treat anaemia

and control iron deficiency;

 provision of iron fortification programmes;

 facilities, personnel time, logistics support; and

 programme monitoring and evaluation.

Iron compounds are no more than 7% of the total cost of supplementation

programmes. In the case of iron fortification, the proportion of the cost of the

most expensive iron compound may reach 27% of the total cost of the product

because of the much lower cost of the other components. Generally, ongoing

expenditures incurred in the treatment of anaemic subjects, and those involved

in purchasing pharmaceutical preparations containing iron, are ignored, even

though these may be significant.

The percentage efficiency of each intervention to control iron deficiency

should also be considered when developing cost-benefit estimates.

For example, successfully implemented iron supplementation programmes

are considered to be at least 70% effective in the short term. As another

example, general iron fortification programmes are considered to be 93%

effective in the long term.

12
 IRON DEFICIENCY ANAEMIA

Estimates of benefits are made on the basis of projections from the correction

of deficits caused by iron deficiency. These projections include lives saved;

incomes increased; and deficits prevented in mental performance at all ages,

including learning capacity at school. Resultant savings in treatment costs

when iron deficiency is prevented should also be considered when calculating

benefits to society.

Once both costs and benefits of various programmes have been estimated,

the cost-benefit ratio of interventions can be derived. Several attempts have

been made to develop models for comparative purposes among interventions

(69,70), as applied to an ‘average’ developing world population. These

models involve prevalence of iron deficiency by age group, using neither the

lower nor the higher costs of the various intervention components.

Estimates of fixed costs, e.g. depreciation and maintenance of health-post

buildings and vehicles, monitoring, and costs of health-post personnel,

are estimated on the assumption that programmes to control iron deficiency

share these costs with three other programmes: family planning, antenatal

care, and maternal-infant care. Accordingly, each programme incurs only

one-quarter of the total estimated fixed costs.

When programmes are primarily community-based, costs are estimated to be

further reduced by three-quarters. The ‘average’ fortification programme will

include the cost of the most expensive compound, iron-EDTA (sodium iron

ethylenediaminetetraacetic acid).

Table 1 on the following page presents estimates of the relative effectiveness

and cost of various strategies, in terms of DALYs gained by each, and the cost

per DALY.

13
IRON DEFICIENCY ANAEMIA

Table 1. Relative effectiveness and cost

per Disability Adjusted Life Year (DALY)

of various prevention strategies

 Intervention Number of Cost

 DALYs gained per DALY

Per day Per week

 Short-term

Benefits or costs

Prenatal

supplementation 511 100 51

Widespread

supplementation 4665 88 24

Universal fortification plus

prenatal supplementation 5038 16 11

Universal fortification plus

residual supplementation 5394 39 16

 Long-term

Human capital formation

Supplementation 2679 37 17

Fortification 3332 9 -

Source: Murray & Lopez (68).

14
1 IRON DEFICIENCY ANAEMIA

Prevalence and epidemiology

of iron deficiency

15

5.1 Prevalence

Iron deficiency is the most common and widespread nutritional disorder in

the world (71). As well as affecting a large number of children and women

in non-industrialized countries, it is the only nutrient deficiency which is

also significantly prevalent in virtually all industrialized nations. There are

no current global figures for iron deficiency, but using anaemia as an indirect

indicator it can be estimated that most preschool children and pregnant women

in non-industrialized countries, and at least 30-40% in industrialized countries,

are iron deficient (21, 51).

Nearly half of the pregnant women in the world are estimated to be anaemic:

52% in non-industrialized - as compared with 23% in industrialized - countries

(see Table 2a, below, and 2b, following page). In industrialized countries,

however, most pregnant women are thought to suffer from some degree of

iron deficiency. For example, 75% of pregnant women attending universities in

Paris showed evidence of depleted iron stores (72).

Children 20.1 39.0

(0-4 years)

Children 5.9 48.1

(5-14 years)

Pregnant 22.7 52.0

women

All women ` 10.3 42.3

(15-59 years)

Men 4.3 30.0

(15-59 years)

Elderly 12.0 45.2

(+60 years)

Industrialized Non-industrialized

countries countries

Table 2a. Estimated percentages of anaemia prevalence (1990-95)

based on blood haemoglobin concentration (21, 51)

Percentage of total affected population in:

5
IRON DEFICIENCY ANAEMIA

16Table 2b. Estimated prevalence of anaemia (1990-1995) by WHO Region based on blood haemoglobin concentration (21,51)

 Total affected population, in thousands

WHO

Regions Children Children Pregnant All women Men Elderly

(0-4 years) (5-14 years) Women (15-59 years) (15-59 years) (+60 years)

Africa 45 228 85 212 10 800 57 780 41 925 13 435

Americas 14 200 40 633 4 500 53 787 19 443 12 617

South-East

Asia 111 426 207 802 24 800 214 991 184 752 60 208

Europe 12 475 12 867 2 400 27 119 13 318 18 095

Eastern

Mediterranean 33 264 37 931 7 700 60 196 41 462 11 463

Western

Pacific 29 793 156 839 9 700 158 667 174 400 78 211

Overall 245 386 541 284 59 900 572 540 475 300 194 029
 IRON DEFICIENCY ANAEMIA

17

Category of public health significance Prevalence of anaemia (%)

Severe > or = 40

Moderate 20.0 – 39.9

Mild 5.0 – 19.9

Normal < or = 4.9

a Based on cut-off levels of haemoglobin and haematocrit given in Table 6.

5.2 Epidemiology

The prevalence of iron deficiency varies greatly according to host factors:

age, gender, physiological, pathological, environmental, and socioeconomic

conditions. Iron requirements and recommended iron intakes are summarized

in Table 4, and the factors that influence them are discussed beginning on

page 20.

Anaemia is particularly prominent in south Asia. In India, for example, up

to 88% of pregnant and 74% of non-pregnant women are affected. Throughout

Africa, about 50% of pregnant and 40% of non-pregnant women are anaemic.

West Africa is the most affected, and southern Africa the least. In Latin America

and the Caribbean, prevalences of anaemia in pregnant and non-pregnant

women are about 40% and 30% respectively. The highest levels are in the

Caribbean, reaching 60% in pregnant women on some islands (51, 21).

Prevalence data for various age groups are not available for all countries.

However, the prevalence rate among preschool children is usually similar to,

or higher than, the rate among pregnant women. Epidemiological mapping

of prevalence requires cut-off levels, or criteria for grading the public health

severity of anaemia. Table 3 provides a provisional schema for this purpose.

In most industrialized countries, the prevalence of anaemia among pregnant

women is around 20%. It is therefore considered reasonable to classify these

populations as having a medium prevalence, since a prevalence of up to 5%

may not necessarily be regarded as abnormal in any population.

Table 3. Proposed classification of public health significance of

anaemia in populations on the basis of prevalence estimated

from blood levels of haemoglobin or haematocrit a
IRON DEFICIENCY ANAEMIA

Table 4. Iron requirements and

recommended iron intakes by age and gender group

 Age

 (years)

0.5-1

 1-3

 4-6

7-10

11-14

15-17

 18+

11-14b

11-14

15-17

 18+

Mean

body

weight

 (kg)

 9.0

13.3

19.2

28.1

45.0

64.4

75.0

46.1

46.1

56.4

62.0

62.0

62.0

Groups

Children

Males

Females

Post

menopause

Lactating

Required

 iron intake

 for growth

 (mg/day)

 0.55

 0.27

 0.23

 0.32

 0.55

 0.60

0.55

 0.55

0.35

Median iron losses

 (mg/day)

Basal

 0.17

 0.19

 0.27

 0.39

 0.62

 0.90

 1.05

 0.65

 0.65

 0.79

 0.87

 0.87

1.15

Menstrual

0.48

0.48

0.48

18

a Total absolute requirements include requirement for growth,

basal losses and, in female, menstrual losses. b Non-menstruating. c Bioavailability of dietary iron during this period varies greatly.
 IRON DEFICIENCY ANAEMIA

Table 4 (continued). Iron requirements and

recommended iron intakes by age and gender group

Recommended iron intakes to cover

requirements of 97.5% of populations

for diets of different bioavailability

 (mean +2 SD) (mg/day)

 Level of dietary iron bioavailabilty %

Total

absolute

requirementsa

(median)

(mg/day)

 0.72

 0.46

 0.50

 0.71

 1.17

 1.50

 1.05

 1.20

 1.68

 1.62

 1.46

 0.87

1.15

High

15%

 6.2c

 3.9

 4.2

 5.9

 9.7

12.5

 9.1

 9.3

21.8

20.7

19.6

 7.5

10.0

Intermediate

 12%

 7.7c

 4.8

 5.3

 7.4

12.2

15.7

 11.4

 11.7

27.7

25.8

24.5

 9.4

12.5

Low

10%

9.3c

 5.8

 6.3

 8.9

14.6

18.8

13.7

14.0

32.7

31.0

29.4

11.3

15.0

Very low

 5%

 18.6c

 11.6

 12.6

 17.8

 29.2

 37.6

 27.4

 28.0

 65.4

 62.0

 58.8

 22.6

 30.0

19

Adapted from: Vitamin and mineral requirements in human nutrition,

FAO/WHO (to be published)

Source: References (4,73).
IRON DEFICIENCY ANAEMIA

5.2.1 Age

Full-term infants are normally born with adequate iron stores in the liver and

haematopoietic tissue, because of destruction of fetal red blood cells soon

after birth. This leads to deposition of iron in these tissues, especially if the

cord is ligated after it stops pulsating.

Breast milk is relatively low in iron, although the iron in breast milk is much

better absorbed than that in cows’ milk. Iron deficiency commonly develops

after six months of age if complementary foods do not provide sufficient

absorbable iron, even for exclusively breastfed infants.

Iron requirements on a body weight basis are proportional to growth velocity.

Accordingly, in addition to women in their reproductive years as a result of

physiological losses, iron deficiency is most common in the preschool years

and during puberty. Another peak may occur in old age, when diets frequently

deteriorate in quality and quantity.

5.2.2 Gender

Following menarche, adolescent females often do not consume sufficient iron

to offset menstrual losses. As a result, a peak in the prevalence of iron

deficiency frequently occurs among females during adolescence.

5.2.3 Physiological state

Substantial amounts of iron are deposited in the placenta and fetus during

pregnancy. This results in an increased need of about 700-850 mg in body

iron over the whole pregnancy.

Overall, iron absorption is increased during pregnancy, when menstruations

stop. Pregnant women still do not absorb sufficient additional iron, however,

and the risk of iron deficiency increases.

Lactation results in loss of iron via breast milk. Consequently, for some women

a deficiency developed during pregnancy may be perpetuated during

lactation. In terms of iron balance, however, lactational amenorrhea more

than compensates for iron lost through breast milk.

20
 IRON DEFICIENCY ANAEMIA

21

5.2.4 Pathological state

Common infections, especially those which are chronic and recurrent,

may impair haematopoiesis and consequently cause anaemia. Malaria by

haemolysis and some parasitic infections, e.g. hookworm, trichuriasis,

amoebiasis, and schistosomiasis (both vesical and intestinal forms),

cause blood loss directly. This blood loss contributes to iron deficiency.

Other important causes of anaemia include genetic factors, e.g thalassemia,

sickle cell trait, and glucose-6-phosphate dehydrogenase deficiency (G6PD).

Because these genetic factors are not due to iron deficiency, they are not

discussed in this guidebook.

These other causes of anaemia are mentioned, however, as a reminder that

they should be considered when choosing and focusing on population groups

for assessment and surveillance purposes. In this way, more appropriate

interventions can be developed.

It should also be noted that these genetic conditions, except for thalassemia

major - which is rare - do not prevent the development of iron deficiency,

and may coincide with it.

5.2.5 Environmental factors

A given diet may be low in iron or may contain adequate amounts of iron

which are of low bioavailability (see Chapter 8). Other nutrients necessary for

haematopoiesis may also be deficient. These include folic acid, vitamins A,

B12, and C, protein, and copper and other minerals (73).

Trauma or childbirth can result in acute or chronic blood loss, with consequent

iron deficiency and anaemia

5.2.6 Socioeconomic status

Iron deficiency is most common among groups of low socioeconomic status.
IRON DEFICIENCY ANAEMIA
 IRON DEFICIENCY ANAEMIA

23

6.1 Individual and population-based assessment

Surveillance of iron deficiency involves an ongoing process of recording

and assessing iron status in an individual or a community. Worldwide,

the most common method of screening individuals or populations for iron

deficiency involves determining the prevalence of anaemia by measuring

blood haemoglobin or haematocrit levels.

A major limitation of each of these two tests, however, lies in the fact that

anaemia is not a specific indication of iron deficiency. As noted in Chapter 5,

other nutrient deficiencies and most infectious diseases can also result in

significant anaemia.

One common practice in assessing whether or not anaemia is due to iron

deficiency involves monitoring the response in haemoglobin or haematocrit

levels after 1 or 2 months of oral supplementation with iron. An increase of

10 g/l in haemoglobin or 3% in haematocrit is indicative of iron deficiency.

Individual management in resource-poor countries is likely to be based mainly

upon either haemoglobin or haematocrit assessment - or both - and upon their

response to initial iron therapy.

Another limitation of haemoglobin or haematocrit measurements is that levels

change only when they are very low at the outset, and when iron deficiency is

already severe. In resource-adequate situations, the usual practice involves

the use of further, specific, and more sensitive tests for individual

assessment. These include serum ferritin, transferrin saturation, and others.

This guidebook, however, deals primarily with population-based assessments.

It does not elaborate on the selection, specificity, and sensitivity of various

tests for individual assessment.

11

6 Assessment, surveillance,

 and indicators
IRON DEFICIENCY ANAEMIA

24

6.2 Purposes of biological assessments

Biological assessments are made to:

 Determine the magnitude, severity, and distribution of iron

deficiency and anaemia, and preferably its main causes.

This information can serve as a basis for planning policies

and interventions, and as a baseline against which to

assess their impact.

 Identify populations more affected or at greater risk.

This information enables national authorities to select

priority areas for action, especially if resources are limited.

 Monitor trends in prevalence and evaluate the impact of

interventions. Other programme indicators are also needed

for monitoring programme implementation.

 Measure progress towards achieving the goals

adopted by the International Community.

 Provide the basis for advocacy programmes for iron deficiency

and anaemia prevention in affected and vulnerable populations.

The approaches used in surveillance range from the routine collection and

analysis of indicators in health centres (especially antenatal clinics) and analysis

of laboratory records, to periodic special community-based assessments and

the integration of iron status or anaemia assessment in other population-based

surveys.

Clinic-based data are generally not representative of an entire population.

However, periodic assessments using the same methods in the same service

context may enable trends to be effectively followed. Any assessment

should include an analysis of factors causing or contributing to anaemia,

in addition to iron deficiency.
 IRON DEFICIENCY ANAEMIA

6.3 Selection of subjects for assessment

6.3.1 Vulnerability

Vulnerability to iron deficiency varies greatly with each stage of the life cycle.

This variation is due to changes in iron stores, level of intake, and needs

relating to growth or iron losses. In general, children aged 6 months through

5 years of age (74) and women of childbearing age (75) - especially during

pregnancy - are the most vulnerable groups.

Unless born preterm or with low birth weight, most infants are at low risk

before 6 months of age because their iron stores are usually still adequate

from the perinatal period. Accordingly, the earliest age to begin assessment

of iron status is normally between 6 and 9 months; assessment may begin

earlier (e.g. from 4 months) in communities with low iron status.

Among children under 5 years of age, the greatest prevalence of iron

deficiency occurs during the second year of life, due to low iron content in

the diet and rapid growth during the first year. In areas with a high prevalence

of hookworm infestation, school-aged children as well as adults can also

develop significant iron deficiency (76).

6.3.2 Accessibility

For monitoring purposes, infants and pregnant women are the most

accessible groups because they frequently attend primary health care and

maternal and child health clinics where assessments can be conducted.

Non-pregnant women can sometimes be monitored through family planning

services. School-aged children can be reached through school health

services. Preschool children and adult men are the least accessible groups

because they have no regular contact with the health care system.

6.3.3 Representativeness

For survey or surveillance purposes, the sampled population should be

representative of those populations targeted for a universal or specific

intervention programme. Although there are significant variations in iron

status and prevalence of anaemia across age groups and strata, iron status

across communities with similar dietary patterns tends to be comparable among

those of the same socioeconomic status. Traditionally-designed nutritional

surveys based on 30 to 60 clusters are adequate for assessing iron status.

25
IRON DEFICIENCY ANAEMIA

Prevalence rates for one subgroup (by age or gender) cannot be used as a

proxy for the rest of the population because risks of iron deficiency vary widely.

In most developing countries, the prevalence of iron deficiency is high for both

infants and women of childbearing age because of low iron intake relative to

increased iron requirements.

In industrialized countries, however, infants are relatively more affected.

Occasionally there are populations in which infants and preschool children

have high rates of iron deficiency anaemia even though the rate is low among

adult women (77). Dietary patterns of infants, preschool children, and adults

in such situations are very different. Hence, high iron intake among adults

offers no assurance of adequate iron in the diets of infants or preschool

children.

In most settings where malaria, hookworm, or schistosomiasis are not

significant contributors to anaemia in adults, high prevalence rates of iron

deficiency anaemia are usually only found in women of childbearing age.

Adult men who are free of diseases associated with blood loss are not

appreciably affected by relatively low iron intake; they have lower normal

iron requirements to compensate for iron losses (78).

6.4 General issues in defining iron status indicators

Even though there may be many causes of anaemia, dietary iron deficiency

is usually either the main or a major contributing factor. Other significant

nutritional deficiencies (e.g. low intakes of folic acid and vitamins A, B12, and

C) and infectious diseases (e.g. malaria and hookworm) may also contribute

to anaemia.

Iron deficiency anaemia reflects the severe end of the spectrum of depletion.

Where rates greater than 30-40% occur in a defined age-gender group,

most non-anaemic individuals in that group will be sufficiently iron-deficient

to be at risk of adverse functional consequences (78). In these situations,

even without specific assessment or in the presence of other factors

contributing to anaemia, the institution of a broad spectrum of interventions

to improve the iron nutrition of vulnerable sub-populations is justified.

Several well-established laboratory indices for assessing and monitoring iron

status are available. Of these, however, only haemoglobin or haematocrit

tests can be routinely performed in field settings. More precise, multiple

biochemical tests of iron status can only be conducted in resource-adequate

countries or under special research or survey conditions (79).

26
 IRON DEFICIENCY ANAEMIA

27

The usefulness and limitations of using anaemia as a surrogate for iron

status has been established by studies which have concurrently assessed

iron status and performed other available iron-related tests. These other tests

include mean corpuscular volume, mean corpuscular haemoglobin, serum

ferritin, transferrin saturation, erythrocyte protoporphyrin, and (more recently)

transferrin receptors.

6.5 The spectrum of iron nutritional status

In normal individuals, the iron used for haemoglobin formation accounts for

about two-thirds of total body iron. In men, about one-third of body iron may

be deposited as haemosiderin or ferritin in stores that can be mobilized when

there occurs a need to supply iron in a functionally active form.

About 14% of iron is used for other vital physiological functions (80).

In addition, a small pool of iron in plasma is in transit, and bound to the iron

carrier transferrin (81).

Measurements of haemoglobin, serum ferritin, serum iron, and transferrin

(total iron-binding capacity) enable iron status to be characterized in detail

(82). However, each of these determinations has well-recognized limitations

under field conditions, i.e. single or combined measurements of iron status

show that response to therapeutic trials is greater than expected.

As previously noted, iron deficiency anaemia represents the extreme low end

of the spectrum of iron status. The severity of anaemia is differentiated by the

severity of the reduction in haemoglobin level.

The term “anaemia” is sometimes used synonymously with “iron deficiency

anaemia”. Clearly, however, these terms do not cover the same reality. There

are about 2-5 times more iron-deficient than iron-deficient-anaemic individuals.

There are also many causes of anaemia besides iron deficiency, particularly

in tropical regions.

In any case, however, iron deficiency is the predominant nutritional deficiency

causing anaemia and is present even when other causes of anaemia are

recognized. There are, however, mild-to-moderate forms of iron deficiency

in which anaemia is absent.
IRON DEFICIENCY ANAEMIA

Data collected in US national surveys revealed that 30-40% of children under

5 years of age, and women of childbearing age who had evidence of iron

deficiency, were also anaemic (83). This relationship provides a basis for

estimating the prevalence of iron deficiency - with or without anaemia - by

using the prevalence of iron deficiency anaemia.

Assuming that this relationship is valid for other populations with a higher

prevalence of iron deficiency, some degree of iron deficiency would be present

in about 50% of the population of these age and gender groups if anaemia

prevalence exceeds 20%, and in virtually the entire population of the same age

and gender groups if anaemia prevalence exceeds 40% (Figure 2).

In addition, the relative proportion of anaemia due to iron deficiency increases

as the prevalence of anaemia increases. Up to a prevalence of iron

deficiency anaemia of 40%, the prevalence of iron deficiency will be about

2.5 times that of anaemia.

Figure 2. Projected prevalence of iron deficiency

based on prevalence of iron deficiency anaemia

Source: Yip R, based on the second US National Health and Nutrition Survey (NHANES II),

and Pizarro et al. (84).

100

 90

 80

 70

 60

 50

 40

 30

 20

 10

 0

 Prevalence of anaemia (lower portion) (%)

28

 5 10 15 20 30 40 50 60 70 80

Prevalence of iron deficiency (%)

without anaemia

 anaemia
 IRON DEFICIENCY ANAEMIA

6.6 Application of iron-related indicators

to specific settings

Variations in the prevalence of iron deficiency worldwide, the availability of

laboratories for testing, and the occurrence of factors other than iron

deficiency that cause anaemia, require that iron-related indicators be

divided into three categories. These categories of indicators are applied

in settings considered to be resource-poor, resource-intermediate, or

resource-adequate. Resource-adequate settings correspond to the

commonly-used term “developed country”, while the other two settings are

usually classified as situations which are typical of “less developed” countries.

The reason for this differentiation lies in the wide variation of resources

among and within “less developed” countries. For example, the towns and

cities may be resource-intermediate while the rural areas more resource-poor.

Table 5 summarizes which iron status indicators to apply, according to

resource availability. It is also assumed that the three levels of resources,

i.e. poor, intermediate, and adequate, roughly correspond to the three degrees

of severity of anaemia: severe, moderate, and mild.

The hypothetical relationship noted above does not apply to prevalence rates

for overall anaemia. Anaemia from other causes must be excluded before the

proportion of the population that is iron-deficient can be derived from Figure 2.

The programmatic implications of this projection are as follows. When the

prevalence of iron deficiency anaemia reaches the 20-30% level in the

age-gender group under evaluation, it may be more effective - and possibly

more efficient - to provide universal supplementation to that entire group

than to screen for individual case-management purposes.

A decision analysis using the US national survey data reached a similar

conclusion (85). The same analysis also concluded that screening becomes

ineffective by the time the prevalence of anaemia is lower than 5%, because

most of the cases are not related to iron deficiency.

Screening for programmatic purposes should therefore be considered for

anaemia prevalences between 5% and 20%. A prevalence within this range

suggests appropriate interventions based on dietary modifications, provision

of iron-fortified foods, targeted iron supplementation, and control of infections.

29
IRON DEFICIENCY ANAEMIA

Resource conditionsa

Level of Poor Intermediate Adequate

resources

Prevalence Severe Moderate Mild

of anaemia

 Clinical decisions

Screening Clinical Haemoglobin Haemoglobin

examinationb or haematocrit or haematocrit

for screening for screening

Additional testsc:

Serum ferritin

Transferrin saturation

Confirmation Haemoglobin Haemoglobin Haemoglobin

or diagnostic or haematocrit or haematocrit or haematocrit

response to response to

Clinical response iron administration iron administration

to iron Serum ferritin

administration Erythrocyte

protoporphyrine

Transferrin saturation

Transferrin receptor

 Public health and population-based decisions

Special Haemoglobin Haemoglobin Haemoglobin

assessment or haematocrit or haematocrit or haematocrit

or survey Optional: Mean cell volume

Mean cell volume Serum ferritin

Serum ferritin Transferrin saturation

Transferrin Erythrocyte

 saturation protoporphyrine

Erythrocyte Transferrin

protoporphyrined receptor

Diagnosis of causes

of anaemia Response to iron supplement e,f

Long-term Haemoglobin Haemoglobin Haemoglobin

surveillance or haematocrit or haematocrit or haematocrit

from PHC or from PHC or from clinicsg

MCH centres MCH centres

at selected sites

30

Table 5. Assessing iron status on the basis

of resource availability in a country
 IRON DEFICIENCY ANAEMIA

b Severe prevalence of anaemia (> 40%) justifies universal iron supplementation

without screening individuals. The clinical assessment of anaemia lacks sensitivity

and, therefore, a prevalence of 2%-3% of cases clinically detected represents

a severe problem.

c Serum ferritin or transferrin saturation in addition to haemoglobin or haematocrit

is of interest in individuals for detecting mild forms of iron deficiency or iron overload.

d Specific iron biochemistry tests may lose some sensitivity in populations that also have

high rates of infections.

e Anaemia response to treatment for malaria or hookworm should be considered in areas

with a known incidence of these conditions.

f Where nutritional deficiencies, such as of folic acid, vitamin C, or vitamin A, are believed

to contribute to anaemia, multiple supplementation should be considered.

g Consistent use of the same procedures, (e.g. compilation of data from clinics,

even if inadequate for statistical assessment) may nevertheless reveal trends useful

for population surveillance.

Footnotes to Table 5 (opposite)

a Relative terms that correspond approximately to the level of development according to UN

Classification (United Nations Development Programme. Human Development Report.

New York, Oxford University Press, 1999).

31
IRON DEFICIENCY ANAEMIA
 IRON DEFICIENCY ANAEMIA

7.1 Assessment of anaemia

7.1.1 Criteria of anaemia

It is well known that normal haemoglobin distributions vary with age and

gender, at different stages of pregnancy, and with altitude and smoking (86,87).

There is also evidence of a genetic influence. In the United States, for

example, individuals of African extraction have haemoglobin values 5 to 10 g/l

lower than do those of European origin. This contrast is not related to iron

deficiency (88).

The correct interpretation of haemoglobin or haematocrit values, therefore,

requires the consideration of modulating factors in selecting appropriate

cut-off values. Those values at sea level for haemoglobin and haematocrit

corresponding to anaemia, are presented in Table 6. Table A3 in Annex 3

reflects haemoglobin and haematocrit levels at various altitudes.

Table 6. Haemoglobin and haematocrit levels below which

anaemia is present in a populationa

a Conventional conversion factors: 100 g haemoglobin = 6.2 mmol haemoglobin = 0.30 l/l haematocrit.

Adapted from reference (89), by splitting the age group for children 5-14 years and applying a

haemoglobin cut-off level for those 5-11 years which has been lowered by 5 g/l to reflect the findings

in non-iron-deficient children in the USA (cf. Table A1 in Annex 3).

7

33

Age or gender group Haemoglobin Haematocrit

g/l mmol/l l/l

Children 6 months to 59 months 110 6.83 0.33

Children 5–11 years 115 7.13 0.34

Children 12–14 years 120 7.45 0.36

Non-pregnant women

(above 15 years of age) 120 7.45 0.36

Pregnant women 110 6.83 0.33

Men (above 15 years of age) 130 8.07 0.39

Methods of

assessing iron status
IRON DEFICIENCY ANAEMIA

Severe anaemia in pregnancy is defined as haemoglobin <70 g/l and requires

medical treatment. Very severe anaemia is defined as haemoglobin <40 g/l.

Very severe anaemia in pregnant women is a medical emergency due to the

risk of congestive heart failure; maternal death rates are greatly increased.

Annex 3 provides age-related criteria for normal haemoglobin and haematocrit

levels developed by the Centers for Disease Control and Prevention in Atlanta,

USA (79). Criteria for stages of pregnancy, and adjustment factors for altitude

and smoking are also provided. For populations of African extraction, recent

analysis indicates that achieving a similar screening performance (sensitivity

and specificity) requires a haemoglobin criterion that is 10 g/l (0.62 mmol/l)

lower than those shown in Table 6 (90,91).

7.1.2 Clinical examination to detect severe anaemia

Severe anaemia is a major risk factor associated with greatly increased

morbidity and mortality for young children and pregnant women. Prompt

recognition of the condition, and treatment and clinical follow-up of individuals,

are crucial in avoiding complications such as high-output heart failure.

Subjects with severe anaemia can usually be detected by clinical examination

for significant pallor of the eyelids, tongue, nail beds, and palms.

For clinically detecting haemoglobin levels of 50-80 g/l during childhood,

a sensitivity and specificity of 60%-70% is reported. For those <50 g/l,

a sensitivity of 93% and a specificity of 57% is reported (92). Among Ethiopian

refugee women in Somalia, a sensitivity of 53% and specificity of 91% are

reported (78). In young children, palm pallor is preferred to eyelid pallor as a

clinical diagnostic sign, due to the frequency of conjunctivitis which causes

redness even in anaemic subjects.

In resource-poor settings where routine laboratory testing of haemoglobin or

haematocrit is not feasible, clinical signs should be regularly used to screen

individual women and children. The purpose of this screening should be to

identify high-risk subjects before the onset of life-threatening complications.

Considering the increased risk of human immunodeficiency virus (HIV)

transmission via blood transfusion, and the risk of short-term mortality from

transfusion itself (93), clinical examination to identify and manage cases of

severe anaemia may provide one strategy to reduce the need for transfusion.

The use of clinical indicators is recommended for screening for treatment of

subjects with severe anaemia, but it is not recommended for population-based

surveys of anaemia.

34
 IRON DEFICIENCY ANAEMIA

7.1.3 Haemoglobin measurement

The prevalence of anaemia in a population is best determined by using a

reliable method of measuring haemoglobin concentration (94). Compared with

the cost and difficulty of biochemically assessing the prevalence of iodine

deficiency and vitamin A deficiency, the determination of the prevalence of

anaemia in a population is relatively simple and inexpensive.

The only methods generally recommended for use in surveys to determine

the population prevalence of anaemia by haemoglobinometry are the

cyanmethemoglobin method in the laboratory and the HemoCue system.

The cyanmethemoglobin method for determining haemoglobin

concentration is the best laboratory method for the quantitative

determination of haemoglobin. It serves as a reference for

comparison and standardization of other methods (94).

A fixed quantity of blood is diluted with a reagent (Drabkins solution)

and haemoglobin concentration is determined after a fixed time

interval in an accurate, well-calibrated photometer.

The HemoCue system is a reliable quantitative method for

determining haemoglobin concentrations in field surveys (95),

based on the cyanmethemoglobin method. The HemoCue system

consists of a portable, battery-operated photometer and a supply

of treated disposable cuvettes in which blood is collected.

The system is uniquely suited to rapid field surveys because the

one-step blood collection and haemoglobin determination do not

require the addition of liquid reagents. Survey field staff without

specialized laboratory training have been successfully trained to use

this device.* This equipment can be obtained through UNICEF.

The HemoCue system gives satisfactory accuracy and precision

when evaluated against standard laboratory methods (96).

Long-term field experience has also shown the instrument to be stable

and durable. These features make it possible to include haemoglobin

determinations in multipurpose health and nutrition surveys.

35

* In 1998, the cost of the photometer was approximately US$320 and a supply

of disposable cuvettes US$0.30 per test.
IRON DEFICIENCY ANAEMIA

There exists a range of other quantitative and semi-quantitative methods for

determining haemoglobin concentration. A report of the strengths and

weaknesses of the various methods that may have an application in clinical

practice is available.1 Again, however, only the two methods described above

are generally recommended.

36

7.1.4 Haematocrit or packed cell volume

Haematocrit or packed cell volume is a commonly performed clinical

assessment frequently used in surveys of anaemia because of its simplicity

and the widespread availability of the necessary equipment. Haematocrit

measurement is an acceptable and recommended method for anaemia

determination, but has no advantage compared to haemoglobin measurement.

Moreover, reliable haematocrit determination requires a stable power supply.

For haematocrit determination, blood is collected in anticoagulant-treated

capillary tubes and spun in a small, specially designed centrifuge. The volume

of packed cells as a portion of the total volume of blood is measured and

expressed as l/l whole blood.

Many referral hospitals have electronic cell counters. Provided that they are

well calibrated and maintained, these devices can yield rapid and reliable

indications of mean cell volume (MCV) and the number of red blood cells (RBC)

from which a “calculated haematocrit” (MCV x RBC concentration) can be

obtained. In general, centrifuge haematocrit and calculated haematocrit

based on electronic counters are closely matched.

Although in most populations the prevalence of anaemia determined by using

haematocrit or haemoglobin concentration (using the cut-off values given in

Table 6), will be similar, results may not be identical. This difference in anaemia

prevalence, obtained by using these two methods, may add to the complexity

of a survey report and make the results more difficult for decision-makers to

interpret. Accordingly, there is little advantage in determining haematocrit as

well as haemoglobin during surveys.

A potential source of error in haemoglobin and haematocrit determination lies

in inadequate technique in obtaining capillary blood. Care must be taken to

ensure adequate puncture of the tissue and spontaneous blood flow from the

wound. The key to accuracy is blood sampling from finger- or heel-prick (97).

1 Anemia detection in health services. Guidelines for Program Managers, 2nd edition.

Program for Appropriate Technology in Health (PATH), OMNI, USAID, December 1996.
 IRON DEFICIENCY ANAEMIA

37

7.2 Specific tests or procedures for assessing

iron status

Iron status can be determined by several well-established tests in addition to

measurement of haemoglobin or haematocrit. Unfortunately, however, there

is no single standard test to assess iron deficiency without anaemia. The use

of multiple tests only partially overcomes the limitation of a single test (79) and

is not an option in resource-poor settings.

Moreover, iron-related tests do not all correlate closely with one another

because each reflects a different aspect of iron metabolism (98). In anaemic

individuals, such tests are used to confirm or help clarify the type or cause of

anaemia.

Although these tests are utilized for special surveys in populations, they

are not routinely conducted on a large scale because of their relatively high

cost. This cost usually limits their use to settings with adequate resources.

Even where feasible, most iron biochemical tests are of limited use in

resource-poor settings. In such situations, other nutrient deficiencies and high

rates of infections can interfere with the interpretation of such tests relative to

iron status.

The following sections describe specific tests or procedures for assessing

iron status.

7.2.1 Serum ferritin

The serum ferritin level is the most specific biochemical test that correlates

with relative total body iron stores. A low serum ferritin level reflects depleted

iron stores and hence is a precondition for iron deficiency in the absence of

infection. Serum apoferritin is an acute-phase reactant protein and is therefore

elevated in response to any infectious or inflammatory process. Consequently,

serum ferritin in the normal range reflects only iron sufficiency in the absence

of these conditions. Interpretation of serum ferritin levels is thus problematic

in populations in which, with the exception of parasitic infections and malaria,

the incidence of infection or inflammation is high.

Interpretation of serum ferritin as an indicator of the relative extent of depletion

of iron stores is presented in Table 7 (following page). The generally accepted

cut-off level for serum ferritin, below which iron stores are considered to be

depleted, is <15 μg/l. Kits used for serum ferritin determination should be

carefully calibrated against the WHO standard shown in Table 7.
IRON DEFICIENCY ANAEMIA

38

Significant variations in serum ferritin levels relating to vulnerability to iron

deficiency occur across age and gender groups. Infants, young children, and

pregnant women usually have serum ferritin values near or in the range

reflective of depletion; however, a low level per se does not imply functional

iron deficiency. Only when the mobilizable iron supply for physiological

function is inadequate is iron deficiency considered present.

Serum ferritin measurement is the preferred method for detecting depleted

iron stores. However, it is of limited usefulness during pregnancy because it

diminishes late in pregnancy, even when bone marrow iron is present.

7.2.2 Erythrocyte protoporphyrin

Levels of erythrocyte protoporphyrin, the precursor of haem, become elevated

when the iron supply is inadequate for haem production. With adequate iron,

erythrocyte protoporphyrin levels, like those of haemoglobin, are maintained

within a well-defined normal range in healthy individuals. Table 8, on the

following page, reflects the several equivalent units in which erythrocyte

protoporphyrin cut-off levels can be expressed. In general, an elevated

erythrocyte protoporphyrin level correlates well with low serum ferritin, and

can serve to screen for moderate iron deficiency without anaemia (99).

Table 7. Relative extent of iron stores

on the basis of serum ferritin concentration

 Iron stores Serum ferritin (μg/l)

 Less than 5 years of age More than 5 years of age

 Male Female Male Female

Depleted iron stores < 12 < 12 <15 <15

Depleted iron stores

in the presence < 30 < 30 - -

of infection

Severe risk - - > 200 >150

of iron overload (adult male) (adult female)
 IRON DEFICIENCY ANAEMIA

39

Three commonly encountered conditions, in addition to iron deficiency,

can cause a significant elevation of erythrocyte protoporphyrin: infection or

inflammation, lead poisoning, and haemolytic anaemia. For this reason,

the measurement of erythrocyte protoporphyrin is most useful in settings

where iron deficiency levels are common and where infections, lead poisoning

and other forms of anaemia are rare.

Until recently, erythrocyte protoporphyrin was measured by a complex and

costly procedure that limited its use to that of a reference method. A simplified

haematofluorometer that directly measures erythrocyte protoporphyrin

fluorescence is now available. This device has enabled the widespread use

of erythrocyte protoporphyrin testing in outpatient settings in the USA (100).

The severity of iron deficiency on the basis of erythrocyte protoporphyrin

measurement is reflected in Table 8, below. Erythrocyte protoporphyrin levels

are considered normal if only mild iron depletion is present (i.e. with serum

ferritin levels of 12-24 mg/l). In the absence of infection, measurement of

erythrocyte protoporphyrin is the preferred method for detecting iron deficiency

once serum ferritin drops below the cut-off value, indicating inadequate iron

supply to tissues.

Table 8. Changes in iron status by age group

on the basis of erythrocyte protoporphyrin

Iron status Erythrocyte protoporphyrin

< 5 years of age ⊕5 years of age

Iron overload or excess Normal Normal

Normal Normal Normal

Mild iron deficiency Normal Normal

without anaemia

Moderate iron deficiency >70 μg/dl red blood cell >80 μg/dl red blood cell

without anaemia >2.6 μg/g haemoglobin >3.0 μg/g haemoglobin

>61 mmol/mol haem >70 mmol/mol haem

Severe iron deficiency >70 μg/dl red blood cell >80 μg/dl red blood cell

with anaemia >2.6 μg/g haemoglobin >3.0 μg/g haemoglobin

>61 mmol/mol haem >70 mmol/mol haem
IRON DEFICIENCY ANAEMIA

40

7.2.3 Serum iron, transferrin, and transferrin saturation

Iron deficiency results in a reduction in serum iron (SI) levels, an elevation

in transferrin (total iron-binding capacity [TIBC]) levels, and hence a net

reduction in transferrin saturation (i.e. SI/TIBC). However, the diurnal

variation both in serum iron and transferrin saturation is considerable.

In addition, there is a marked overlap in these indices between normal and

iron-deficient subjects. This overlap diminishes the usefulness of these

indices in establishing or rejecting a diagnosis of iron deficiency.

Transferrin saturation is of great value, however, as the first screening step

for hereditary haemochromatosis. Cut-off values of between 60% and 70%

have been widely used for this purpose. In screening for iron deficiency,

individuals with more marked anaemia (responding to iron therapy with a

haemoglobin increase >20 g/l) usually have a transferrin saturation <16%.

7.2.4 Serum transferrin receptors

The measurement of serum transferrin receptors is a recent addition to

the available selection of tests for iron deficiency. However, epidemiological

studies have yielded limited information concerning the usefulness of this test

in discriminating between iron-deficient and iron-replete subjects.

An increase in serum transferrin receptors is a sensitive response during the

early development of iron deficiency. Serum transferrin receptor levels increase

progressively as the supply of iron to the tissues becomes progressively more

deficient (101).

Major advantages of measuring serum transferrin receptors involve the facts

that the assay is not significantly affected by infection or inflammatory

processes, and it does not vary with age, gender, or pregnancy (102, 103).

However, serum transferrin receptor levels may be elevated when there is

increased red cell production, turnover, or both, such as in the case of

haemolytic anaemia (104).

There are several methods for measuring serum transferrin. The most

commonly used method is based on the ELISA assay (enzyme-linked

immunosorbant assay). The values obtained will vary according to the

method used, however, since there is no uniform standard available for their

measurement. Similarly, there is currently no universally agreed reference

value for serum transferrin.
 IRON DEFICIENCY ANAEMIA

41

7.2.5 Red cell indices

Among all the red cell indices measured by electronic blood counters, mean

corpuscular volume and mean corpuscular haemoglobin are the two most

sensitive indices of iron deficiency. Reduction in mean corpuscular volume

occurring in parallel with anaemia is a late phenomenon in the development of

iron deficiency. Reference values for mean corpuscular volume and mean

corpuscular haemoglobin are presented in Table A5 in Annex 3.

7.2.6 Bone marrow iron stain

A bone marrow stain for iron has been regarded as the reference against

which to evaluate other iron tests. Absence of stainable iron reflects absent

iron stores. For this reason, the bone marrow stain correlates best with serum

ferritin, which is another measure of iron stores (105). For obvious reasons,

bone marrow iron-staining is not useful in simple population-based surveys.

7.3 Defining iron deficiency when multiple indices

are available

As shown in Tables 6-8 in this Chapter, and Tables A1-A5 in Annex 3, there

are for different population groups generally accepted cut-off values to define

“iron deficiency” for each specific test described in the preceding sections.

As indicated above, however, each test has limitations in terms of its sensitivity

and specificity.

The best indicator for detecting iron deficiency is serum ferritin when measured

in the absence of infection. Under the same conditions, elevated erythrocyte

protoporphyrin indicates iron-deficient erythropoiesis or elevated levels of lead.

However, erythrocyte protoporphyrin is less specific than serum ferritin.

Transferrin saturation is even less reliable as an indicator of iron deficiency

because of intra- and inter-day variability in serum iron. Mean corpuscular

haemoglobin begins to decrease when iron reserves are depleted and iron

deficiency has developed. However, mean corpuscular haemoglobin may not

reach abnormally low levels until some time after iron deficiency sets in.

As a consequence of the limitations of each test, when they are considered

jointly to define iron deficiency, sensitivity is low although specificity increases.

Examples of such joint consideration include the model based on low transferrin

saturation and high erythrocyte protoporphyrin, and the ferritin model based on

low serum ferritin and transferrin saturation and high erythrocyte protoporphyrin.
IRON DEFICIENCY ANAEMIA

42

These models underestimate iron deficiency as observed by haemoglobin

response to iron administration. They therefore present no advantage over

measurement of serum ferritin for diagnosing iron deficiency in populations.

A definition of iron deficiency based on multiple indicators is useful for

population-based assessment when it is feasible to measure several indices.

The best combination would be haemoglobin, serum transferrin receptors,

and serum ferritin or bone-marrow iron. Such a combination would reflect

functional impairment, tissue avidity for iron, and iron storage, respectively.

Usually, this approach is not feasible in settings with resource constraints

(see Table 5).

7.4 Haemoglobin response to iron and other

supplements or interventions

One established approach to the diagnosis of iron deficiency in individuals

or populations involves monitoring changes in haemoglobin or haematocrit after

oral iron supplementation (106). An increase of at least 10 g/l in haemoglobin

or 0.03 l/l in haematocrit after 1 or 2 months of supplementation is indicative of

iron deficiency.

In settings where there are multiple causes of anaemia, iron supplementation

may only partially correct the haematological deficit. For example, a combined

iron and vitamin A supplement for pregnant women in Indonesia was needed

where both deficiencies were common (107). Table 9 shows the response

according to the combination of supplements given.

Table 9. Proportion of anaemic pregnant women who responded

to oral iron and vitamin A supplements and became non-anaemic

Source: Suharno et al. (107)

Treatment Number of Anaemic cases that responded

 subjects (haemoglobin >110 g/l

Placebo 62 16%

Vitamin A only 63 35%

Iron only 63 68%

Iron and vitamin A 63 97%
 IRON DEFICIENCY ANAEMIA

43

This Indonesian example illustrates the importance of assessing the potential

multiple etiology of anaemia. This is necessary in populations with a high

prevalence of possible etiologic factors, in order to decide whether multiple

interventions are needed concurrently. These concurrent interventions may

involve the use of other micronutrients in addition to iron; or the control of

malaria, hookworm, or other infections; or both.

7.5 Assessing population iron status by using

haemoglobin distributions

Estimates of haemoglobin are commonly included in nutrition surveys of

children, whereas surveys specific for anaemia usually examine both children

and women. The prevalence of anaemia serves as an index of the severity

of iron deficiency in the whole population.

Where multiple factors may contribute significantly to anaemia, it is possible

to differentiate anaemia attributable to iron deficiency from anaemia due

to other factors. The latter include deficiencies of folic acid, vitamins A, B12,

and C; or infections including malaria, hookworm, and schistosomiasis.

This differentiation can be achieved by observing blood smears, by means of

a small supplementation trial, or by conducting specific tests.

Where poor availability of dietary iron is the main etiologic factor, children and

women are disproportionately affected, while the haemoglobin levels of adult

men are virtually unaffected. Where other factors contribute significantly,

adult men are less likely to be spared.

A useful approach inolves comparison of the haemoglobin distribution among

children, women, and men from the population under study with a non-anaemic

reference population. This approach allows inferences to be made as to which

factors are likely to be responsible for a high anaemia prevalence.

One example involves the comparison of haemoglobin distributions among

children, women, and men in a Palestinian refugee population in which iron

deficiency was the sole cause of anaemia. Another involves an Ethiopian

refugee population in which a combination of both iron and vitamin C

deficiencies coexisted, with the vitamin C deficiency affecting men as well as

women and children. Figures 3a and 3b (78) on the following two pages

compare the haemoglobin distributions for each of these two refugee

populations with US reference distributions.
IRON DEFICIENCY ANAEMIA

Figure 3a. Haemoglobin distribution

in Palestinian vs US children, women, and men

44

Source: Yip (78)
 IRON DEFICIENCY ANAEMIA

Figure 3b. Haemoglobin distribution

in Ethiopian vs US children, women, and men

45

Source: Yip (78)
IRON DEFICIENCY ANAEMIA
IRON DEFICIENCY ANAEMIA

 8 Prevention strategies

Iron deficiency, like most nutritional deficiencies of public health concern,

is mainly a consequence of poverty. Even in developed countries, it affects

a significant proportion of people in groups which are particularly vulnerable.

Prevention strategies must, if they are to be sustainable, involve the input and

resources of a wide range of sectors and organizations. This is especially

true for iron deficiency. For example, the agriculture, health, commerce,

industry, education, and communication sectors should be included in any

strategy. These, in turn, should work in concert with communities and with

local nongovernmental organizations.

Efforts should be targeted to:

 reduce poverty;

 improve access to diversified diets;

 improve health services and sanitation; and

 promote better care and feeding practices.

These are fundamental elements of any programme to improve nutritional

well-being in general, but are especially important in the improvement of iron

status in particular.

8.1 Food-based approaches

8.1.1 Dietary improvement

Food-based approaches represent the most desirable and sustainable method

of preventing micronutrient malnutrition. Such approaches are designed to

increase micronutrient intake through the diet.

47
IRON DEFICIENCY ANAEMIA

Food-based approaches should therefore include strategies to:

 improve the year-round availability of micronutrient-rich foods;

 ensure the access of households, especially those at risk,

to these foods; and

 change feeding practices with respect to these foods.

One of the greatest strengths of these food-based strategies lies in their potential

to result in multiple nutritional benefits. These benefits can, in turn, achieve

both short-term impact and long-term sustainability.

In practice, food-based approaches should first address the production,

preservation, processing, marketing, and preparation of food. Secondly, they

should address feeding practices, such as intra-family food distribution and

care for vulnerable groups.

Applied to iron deficiency, efforts should be directed towards promoting the

availability of, and access to, iron-rich foods. Examples include meat and

organs from cattle, fowl, fish, and poultry; and non-animal foods such as

legumes and green leafy vegetables.

Similarly, focus should be upon foods which enhance the absorption or utilization

of iron. Examples include those of animal origin, and non-animal foods - such

as some fruits, vegetables, and tubers - that are good sources of vitamins A

and C, and folic acid. Finally, effective nutrition education - and information on

health and nutrition for both supply and demand aspects of programmes - may

be needed to increase the demand for and consumption of such foods.

The first step in this process involves obtaining and analysing information on

the various foods consumed and on the way they are processed, mixed, and

prepared for a meal. Annex 4 suggests proposed strategies for obtaining such

information, adapted from the approach currently used with success in some

programmes to promote consumption of foods rich in vitamin A.

The interpretation of values concerning iron status which have been obtained

using this methodology will vary according to the bioavailability of iron from

local food mixtures and meal patterns. Accordingly, this approach should be

adapted to, and its value assessed under, local conditions.

48
IRON DEFICIENCY ANAEMIA

Once all the information has been analysed, appropriate recommendations

can be made for changing dietary components and the timing of their

consumption, altering food processing or preparation, or changing meal

patterns. The focus should be on changes that will improve the bioavailability,

as well as the amount, of iron in the diet.

Interpretation of bioavailability is limited by the scarcity of accurate information

concerning the content of phytates and iron-binding polyphenols in various foods.

Such information is urgently needed to facilitate the promotion of correct food

choices.

Recommendations should be adapted to regional and local variations in diet,

the age group concerned, seasonal availability, and other factors that cause

food intake and meal patterns to vary. It should be noted that food-frequency

questionnaires are not a sufficient base from which to draw inferences on likely

iron status unless they are combined with information on meal composition

and food consumption patterns.

Methods of food preparation and processing influence the bioavailability of iron.

Cooking, fermentation, or germination can, by thermal or enzymatic action,

reduce the phytic acid and the hexa- and penta-inositol phosphate content.

All inositol phosphates inhibit iron absorption in proportion to the total number

of phosphate groups. Processing procedures that lower the number of

phosphate groups improve bioavailability of non-haem iron (108).

Building food-based approaches around the needs and activities of women

can be especially effective. This is particularly important in recognition of

the multiple roles women play as food providers and primary caregivers.

For example, promoting home gardens and small animal husbandry, and

improving food preservation and home or community processing technologies,

can be especially useful in improving iron status. These interventions are

enhanced by efforts to generate additional income for women and by effective

nutrition education.

The primary goal of dietary modification to improve and maintain the iron status

of a population involves changes in behaviour, leading to an increase

in the selection of iron-containing foods and a meal pattern favourable to

increased bioavailability. Although sometimes difficult to achieve, such changes

in dietary habits can bring about important sustainable improvements, not only

in iron status but also for nutrition in general. Such changes must be rooted in

issues that take into account food security, actual availability, and education.

49
IRON DEFICIENCY ANAEMIA

Bioavailability of food iron is strongly influenced by enhancers and inhibitors

in the diet. Presently, there is no satisfactory in vitro method for predicting

the bioavailability of iron in a meal.

Iron absorption can vary from 1% to 40%, depending on the mix of enhancers

and inhibitors in the meal. Therefore, the adequacy - i. e. bioavailability - of iron

in usual diets can be improved by altering meal patterns to favour enhancers,

lower inhibitors, or both.

Enhancers of iron absorption include:

 haem iron, present in meat, poultry, fish, and seafood;

 ascorbic acid or vitamin C, present in fruits, juices,

potatoes and some other tubers, and other vegetables

such as green leaves, cauliflower, and cabbage; and

 some fermented or germinated food and condiments,

such as sauerkraut and soy sauce (note that cooking,

fermentation, or germination of food reduces the amount

of phytates).

Inhibitors of iron absorption include:

 phytates, present in cereal bran, cereal grains,

high-extraction flour, legumes, nuts, and seeds;

 food with high inositol content;

 iron-binding phenolic compounds (tannins); foods

that contain the most potent inhibitors resistant to

the influence of enhancers include tea, coffee,

cocoa, herbal infusions in general, certain spices

(e.g. oregano), and some vegetables; and

 calcium, particularly from milk and milk products.

50
IRON DEFICIENCY ANAEMIA

Examples of simple but effective alterations in meal patterns that

enhance iron absorption might include:

 separate tea drinking from mealtime - one or two hours later,

the tea will not inhibit iron absorption because most of the food

will have left the stomach;

 include in the meal fruit juices such as orange juice, or another

source of ascorbic acid such as tubers, cabbage, carrots,

or cauliflower;

 consume milk, cheese, and other dairy products as

a between-meal snack, rather than at mealtime; and

 consume foods containing inhibitors at meals lowest

in iron content, e.g. a breakfast of a low-iron cereal

(bread or corn tortilla) consumed with tea or milk products;

this meal pattern can provide adequate calcium without

hampering iron nutrition.

Other actions that indirectly affect iron status might include:

 parasitic disease control programmes, in particular those

directed to hookworm, schistosomiasis and malaria control;

these programmes can enhance iron deficiency anaemia

control programme effectiveness in a population with

moderate to severe levels of infection; and

 incentive policies and improved farming systems that favour

the development, availability, distribution, and use of foods

that enhance iron absorption.

51
IRON DEFICIENCY ANAEMIA

52

A step-by-step practical approach, that might be followed in any setting,

would be to:

 assess food availability and eating practices, and describe a typical

daily meal pattern with emphasis on populations at highest risk;

 analyse the content of the foods and meals, in terms of iron

and potential enhancers and inhibitors;

 estimate bioavailability (109);

 determine ways in which nutritional status can be modified,

through composition of meals (given local food availability, costs,

and cultural factors); timing of the consumption of certain foods;

and food preparation practices;

 implement appropriate dietary modifications; and

 assess iron status (haemoglobin or haematocrit levels) before

and after implementing modified practices.

Indicators of the progress of programme implementation through dietary

improvement should be developed and interpreted locally and nationally.

These indicators should be periodically reviewed and adapted to reflect changing

programme needs. The indicators should be simple and inexpensive, in

order to be feasible. One or two indicators to monitor each primary type of

intervention are likely to be sufficient. Rapid appraisal techniques are often

appropriate for this purpose.

8.1.2 Food fortification

There is a consensus that enrichment (or fortification) of food is an effective

long-term approach to improving the iron status of populations. Once a

fortification programme is established, it is a cost-effective and sustainable

means of achieving this purpose. The technical, operational, and financial

feasibility should, however, be carefully assessed before embarking on such

a fortification programme.

An effective iron fortification programme requires the cooperative efforts of

governments, the food industry (producers, processors, and marketers) and

consumers. Appropriate food vehicles and fortificants must be selected.
IRON DEFICIENCY ANAEMIA

Legislation that permits, regulates, or requires the addition of iron fortificants to

foods is essential, as are effective enforcement mechanisms. Legislative

action to ensure the quality and safety of iron-fortified foods, and honest and

fair practices in marketing them, may also be needed.

Essential requirements for implementing fortification strategies include the

identification of an appropriate food vehicle that reaches the target population,

that is centrally processed, and that is widely available and consumed in

relatively predictable amounts by vulnerable population groups. It is essential

that the final product not be significantly changed in terms of its organoleptic

quality, shelf life, or price; and that the food as prepared be acceptable to the

population.

The dietary habits of the population are an important consideration in selecting

a food for fortification. For example, possible appropriate food vehicles

range from wheat flour or pasta and condiments like sugar, salt, curry powder,

haldi, monosodium glutamate (MSG), to bouillon cubes and soy sauce.

In subsistence farming areas in most developing countries, a fortified-food

approach has limited potential because few households ever consume

commercially processed foods. Instead, fortified food supplements can be

effectively and widely distributed through general food distribution programmes,

e.g. school lunch or other supplemental or emergency feeding programmes.

Several iron fortificants have been used successfully in a variety of national

programmes. Examples are as follows.

 Rice in the Philippines is fortified with a standard ferrous

sulphate mix.

 Where bread and pasta are abundantly consumed, and flour

is milled in only a few places, several iron fortificants have been

added successfully during the milling process. Ferrous sulphate

is adequate if the turnaround time between milling and bread

consumption is relatively short (3 to 4 months), as in Chile.

.

 If flour (wheat or maize) is stored for a long time, metallic

iron (Sweden, UK, and USA) or ferrous fumarate (Venezuela)

have been used. When flour is used as a vehicle, the general

population is the target group, but this approach does not reach

infants and young children, who usually consume little bread.

53
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54

Iron-EDTA

Sodium iron ethylenediaminetetraacetic acid (NaFeEDTA), known as iron-EDTA,

is a potentially valuable fortificant that has hitherto had limited use. Compared

to other fortificants, it is better absorbed and not sensitive to many food iron

inhibitors. Accordingly, it is particularly interesting in populations whose staple

foods are based on cereals and legumes.

Because iron-EDTA is well absorbed and not reactive, it does not cause fat

(e.g. in bread) to become rancid. Therefore, it is suitable for use in other (not

previously fortified) foods. It is also chemically stable, which allows for long

storage of foods. Condiments such as curry powder in South Africa have

been successfully fortified with iron-EDTA, as has sugar in Guatemala (110).

However, additional information is needed on its efficacy and safety before it

can be recommended.

Studies on multiple fortification have been boosted by the advent of several

new technologies including the development of iron-EDTA. Double fortification

with iron-EDTA and vitamin A in Guatemala (110) and with iodide and metallic

iron in India (111) has already been examined.

The concern that iron-EDTA might inhibit bioavailability (i.e. that it might promote

the loss) of other minerals such as zinc or calcium, is allayed by studies in

humans with stable isotope tracers (112). In a long-term study in Guatemala,

zinc blood levels actually rose after 30 months following the consumption of

iron-EDTA fortified sugar (110).

In fact, other animal and human data confirm improved absorption of

zinc-iron-EDTA. However, further research is necessary to understand how

iron-EDTA interacts with other micronutrients.

In some industrialized countries, EDTA has been extensively used as a

stabilizer. The Joint FAO/WHO Expert Committee on Food Additives (JECFA)

examined the existing data on iron-EDTA and found no objection to its use at a

level of 2.5 mg/kg of body weight per day (113).

Fortified foods for young children

Normal-birth-weight infants who are exclusively breastfed do not need iron

supplements for the first 4 to 6 months of life. When complementary feeding

begins, and certainly after 6 months of age, infants need an additional source

of iron to maintain adequate iron nutrition and prevent iron deficiency anaemia.
IRON DEFICIENCY ANAEMIA

Since cereals are widely used as early complementary foods, they should be

fortified during their commercial preparation, by extrusion, cooking, or mixing

processes. Centrally processed milk-based foods designed for infants and

preschool children should also be fortified. Other forms of iron have been used

for infant cereals: small-particle-size metallic iron is the form most widely used.

An iron complex with ammonium-orthophosphate - which is less reactive and

has better absorbability - is used successfully in Sweden, and its use should

be explored elsewhere. Iron pyrophosphate and orthophosphate should not

be used, because of their poor bioavailability.

Finally, the practice of including iron-rich complementary foods for young children

should be encouraged, both at home and in the community. Ferrous sulphate

is the most widely used fortificant for cows’ milk or modified infant formula.

Emergency foods

In emergency situations, the provision of food supplements that are adequate

in energy and protein but not in essential micronutrients, may provoke or

aggravate micronutrient deficiencies. For example, while the growth of young

children may be enhanced, without provision of the additional micronutrients

needed to support that growth, clinical deficiencies may be precipitated.

As recommended by the WHO/FAO International Conference on Nutrition

(Rome, 1992), the nutrient content of emergency food aid for refugees and

displaced persons should

Such fortification might include not only iron, but also vitamins A, C, or both,

the B vitamins, iodine, and other nutrients, depending on the anticipated risk

of these deficiencies and based upon local circumstances. However, the

cost of providing fortified foods is high - if funds are limited, their use for

this purpose might entail a reduction of overall food supplies available for

distribution, as well as delays in delivery.

55

meet the nutritional requirements, if necessary through fortification or

ultimately through supplementation. Governments, in collaboration with

the international community, should provide sustainable assistance to

refugees and displaced persons, giving high priority to the prevention

of malnutrition and the outbreak of micronutrient deficiency diseases.
IRON DEFICIENCY ANAEMIA

56

Food aid

When supplemental foods are used under normal conditions, as for example

in food-for-work or supplementary feeding programmes, they should be

fortified with iron to prevent the risk of deficiency. The World Food Programme

provides vitamin A-fortified skimmed milk and iodized salt in countries with

populations at risk of these deficiencies. Cereal-legume blends, including

corn-soy-milk and wheat-soy, are also commonly fortified with minerals and

vitamins.

Few governments have a clear policy or programme for dietary improvement

or food fortification to alleviate iron deficiency. In view of the new knowledge

and technologies available, it is timely for all countries whose population

is affected by iron deficiency - and who have not yet defined a food-based

strategy - to undertake a feasibility study of the possibilities for dietary

improvement and food fortification (114).

8.2 Iron supplementation

Iron supplementation is the most common strategy currently used to control

iron deficiency in developing countries. This is likely to remain the case until

either significant improvements are made in the diets of entire populations

or food fortification is achieved.

Supplementation is most often used to treat existing iron deficiency anaemia.

It should also be considered as a preventive public health measure to control

iron deficiency in populations at high risk of iron deficiency and anaemia.

Supplementation programmes, especially for pregnant women, operate in

developed as well as in developing countries. For example, Sweden has been

implementing iron supplementation and fortification of many foods for many

years. This practice may explain a relatively low prevalence of iron deficiency

anaemia in that country.

Various delivery systems and modalities, under conditions of varied efficiency,

reach a wide range of target groups. Small controlled studies of supplementation

have been shown to be particularly successful, and a few large-scale

supplementation programmes clearly demonstrating positive biological impact

are reported from some developing countries. Countries should identify specific

problems and constraints limiting the effectiveness of supplementation

programmes and those key elements responsible for successes and failures.

Only then will information be sufficient to introduce effective and efficient

solutions, if traditional approaches and practices are to continue.
IRON DEFICIENCY ANAEMIA

57

Traditionally, target groups for supplementation programmes have been

pregnant women and infants. This practice is due to the short- and long-term

health benefits of these programmes for both groups. To a large extent, they

are reached with relative ease through the health system in urban areas.

However, it has become increasingly evident that the main target group for

supplementation to prevent iron deficiency should be all women of childbearing

age (in addition to infants older than 6 months, preschool children, and

adolescent girls). This target group should not be limited to pregnant women,

who are often accessible only through the health system and late in pregnancy.

One problem is that all of these groups are often difficult to contact through the

health services. An exception involves adolescent girls, who may be reached

through the school system.

Therefore, efforts should concentrate on supplementation programmes for

women of childbearing age. If women enter pregnancy with adequate iron

reserves, iron supplements provided during pregnancy will be more efficient at

improving the iron status of the mother and of the fetus. As a result, the risk of

maternal anaemia at delivery and of anaemia in early infancy will be reduced.

8.2.1 Iron supplementation to prevent iron deficiency anaemia

It is important to differentiate between supplementation that aims at preventing

anaemia by correcting iron deficiency before iron deficiency anaemia is

manifest, and therapeutic supplementation, which aims at correcting

established iron deficiency anaemia (115).

Therapeutic supplementation should be part of the health care delivery

system. Supplementation to prevent iron deficiency without anaemia may be

a community-based initiative which needs innovative approaches in order to

deliver timely preventive supplements to groups at risk.

Women’s organizations, schools, and religious and community leaders are all

potentially important players in delivering supplements to correct iron deficiency.

Approaches based on self-purchase of supplements through community

stores should also be evaluated.

Several trials utilizing supplements on a weekly - rather than daily - basis are

now in progress (116, 117). However, the demonstrated effectiveness of weekly

programmes, based on self-administered iron supplements under programme

conditions, is awaited before being recommended as a public health measure.
IRON DEFICIENCY ANAEMIA

58

Age groups

Low-birth-weight

infants

Children from 6 to

23 months of age

Children from 24 to

59 months of age

School-aged children

(above 60 months)

Women of

childbearing age

Pregnant women

Lactating women

Indications for supplementation

Universal supplementation

Where the diet does not include

foods fortified with iron or where

anaemia prevalence is above 40%

Where anaemia prevalence

is above 40 %

Where anaemia prevalence

is above 40 %

Where anaemia prevalence

is above 40 %

Universal supplementation

Where anaemia prevalence

is above 40 %

Dosage schedule

Iron: 2 mg/kg

body weight/day

Iron: 2 mg/kg

body weight/day

Iron: 2 mg/kg body

weight/day up to 30 mg

Iron: 30 mg/day

Folic acid: 250 

μg/day

Iron: 60 mg/day

Folic acid: 400 

μg/day

Iron: 60 mg/day

Folic acid: 400 

μg/day

Iron: 60 mg/day

Folic acid: 400 

μg/day

Table 10. Dosage schedules for iron supplementation

to prevent iron deficiency anaemia

Duration

From 2 months of age up to

23 months of age

From 6 months of age up to

23 months of age

3 months

3 months

3 months

As soon as possible after

gestation starts - no later than

the 3rd month - and continuing

for the rest of pregnancy

3 months post-partum
IRON DEFICIENCY ANAEMIA

Dosage schedules for iron supplementation (Table 10, opposite)

Low-birth-weight infants

A daily dosage of 2 mg iron/kg of body weight in the form of a liquid preparation

should be given to all low-birth-weight infants, starting at 2 months and

continuing to 23 months of age (universal supplementation).

Infants and children below 2 years of age

Where the diet does not include fortified foods, or prevalence of anaemia in

children approximately 1 year of age is severe (above 40%), supplements of

iron at a dosage of 2 mg/kg of body weight/day should be given to all children

between 6 and 23 months of age. There have been some reports of stained

teeth after iron supplementation with some solutions. Good oral hygiene and

the use of ferrous carbonate can prevent this condition. Ferrous carbonate is

not soluble, but present as a suspension or a solution of iron-EDTA (118).

Children above 2 years of age

The recommended WHO regimen (4) - based on daily supplementation as

summarized in Table 10 - should be followed. However, supervised weekly,

or biweekly supplementation of preschool and school-aged children and

adolescent girls has been reported to be effective in several countries

(115,119,120).

Women of childbearing age: pregnant women

A total amount of about 700-850 mg of iron is needed to meet the iron

requirements of a mother and fetus during pregnancy, at delivery, and during

the perinatal period. Iron needs during the first trimester are lower than

pre-pregnancy needs; they increase the most during the second half of the

pregnancy and especially during the last trimester. For unknown reasons,

dietary iron absorption in iron-sufficient women is reduced during the first

trimester and increased in the second half of pregnancy.

The average woman of reproductive-age needs about 350-500 mg additional

iron to maintain iron balance during pregnancy. Potentially, this iron could

be provided either from the mother’s iron stores or from iron supplements.

However, it is not reasonable to expect that this additional iron can come from

iron stores, since they very seldom reach this level in women in either

developed or developing countries (the mean iron content of the body

reserves - ferritin and haemosiderin - is often only around 200-250 mg).

59
IRON DEFICIENCY ANAEMIA

Furthermore, in developing countries 25-30% of women have no iron reserves

at all. Because the situation is especially serious among pregnant teenagers,

it is important to promote all measures - with emphasis on pubertal girls - that

will improve iron reserves before pregnancy.

All pregnant women (universal supplementation) should be given 60 mg iron

and 400 μg folic acid daily during the second half of pregnancy to control iron

deficiency anaemia. There is some evidence, however, that smaller doses of

30 mg daily could achieve similar results (86,121).

Combined with other micronutrients, folic acid should always be given with

iron during pregnancy. This combination is important because of the increased

folic acid requirement of pregnant women and the fact that both deficiencies

are common in pregnancy. In addition, folic acid supplementation prior to

pregnancy will also have an impact on maternal folic acid status, which is

expected to reduce the risk of neural tube defects (120).

Women of childbearing age: lactating women

In populations with a severe prevalence of anaemia (>40%), it is recommended

that iron supplementation begin during pregnancy. Supplementation should

continue during lactation for at least three months post-partum, at the same

dosage - 60 mg iron and 400 μg folic acid daily - as during pregnancy.

Women of childbearing age: non-pregnant women

In areas where the prevalence of anaemia among women of childbearing

age is severe (> 40%), preventive iron supplementation of 60 mg/day iron with

400 μg folic acid for 3 months should be considered.

Adolescents

Where prevalence of anaemia in pubertal girls is severe (>40%), preventive

iron supplementation of 60 mg/day iron with 400 μg folic acid for 3 months

should be considered. Adolescent boys should also receive preventive iron

supplementation where prevalence of anaemia among them is severe (>40%).

As with adolescent girls, supplementation should continue throughout

adolescence, following the same schedule of 60 mg/day iron with 400 μg folic

acid for 3 months.

60
IRON DEFICIENCY ANAEMIA

8.2.2 Problems associated with iron supplementation

Delivery system

Much of the success of an iron supplementation programme depends on

the effectiveness of the delivery system. The framework of the programme

will be provided by the health system of the country in question. It may also

include primary health care facilities and community health workers, such as

traditional birth attendants and volunteers (121). Ideally, iron supplementation

should be community-based: the community should embrace the need for the

programme and provide support on its behalf.

To this end, involving other human resources in the community should be

seriously considered. These include the school system, women’s clubs,

religious organizations, and nongovernmental organizations, together with

formal and informal community leaders. Involvement and participation of the

private health system will also help to achieve maximum coverage.

Adherence

Irregular consumption of prescribed iron supplements, due in part to side-effects

(Table 11), has plagued most supplementation programmes. For this reason,

definitive results of tests of iron preparations with fewer side-effects are eagerly

awaited. Even if new iron preparations are more expensive than ferrous sulphate,

they may ultimately be more cost-effective if they improve adherence (122).

Table 11. Possible side-effects associated with iron medication

 Epigastric discomfort, nausea, diarrhoea, or constipation

may appear with a daily dose of 60 mg or more. If these

symptoms occur, supplement should be taken with meals.

 Faeces may turn black, which is not harmful. Treatment

should continue.

 All iron preparations inhibit the absorption of tetracyclines,

sulphonamides, and trimethoprim. Thus, iron should not

be given together with these agents.

 High-dose vitamin C supplements should not be taken with

iron tablets, because this would likely cause epigastric pain.

61
IRON DEFICIENCY ANAEMIA

The side-effects of iron tablets generally increase with higher dosages.

These side-effects can be reduced if supplements are taken with meals,

but absorption is reduced by about 40% (125). If the supplement is administered

in the form of a single tablet, it is best ingested at bedtime.

Adherence frequently diminishes due to intolerence when more than one iron

tablet of 60 mg is required. Under such circumstances, prescribing one daily

tablet instead of two is justified as a general policy or for the particular

subjects who experience intolerance. One tablet taken consistently is

preferable to the risk of total rejection or non-acceptance of supplements.

Awareness and motivation

Motivating the target group to take iron tablets according to the prescribed

schedule, thereby improving adherence, is of utmost importance. Accordingly,

communities, families, mothers, and health workers need to be well informed

about the health benefits - as well as the side-effects - of iron supplementation

for both the mother and fetus.

One approach is a comprehensive education and information programme,

organized through the health and other community infrastructures. Such a

programme should emphasize the benefits of iron supplementation and

provide advice concerning possible side-effects. Community leaders,

volunteer health workers or local cadres, schoolteachers, and students can

reinforce these messages as a demonstration of their involvement in and

commitment to the community.

The training of community workers involved in programme implementation is

essential. Social marketing techniques can be used to great advantage.

Of course, the design of messages should take into account local terms,

perceptions, and cultural factors related to anaemia.

Quality and packaging of iron supplements

Improvements are needed in the quality of iron tablets, especially in their stability

(e.g. avoidance of cracking, and disintegration, and absorption of moisture)

and other physical characteristics (e.g. their colour and odour). Development

of improved packaging to minimize deterioration before distribution,

and innovative and safe ways of dispensing the tablets, is also needed.

The design and testing of all of these aspects of iron supplementation are

significant in improving adherence. They are especially important in preventing

accidental iron poisoning, particularly in children.

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IRON DEFICIENCY ANAEMIA

Risk of iron overload with iron supplementation

The above-mentioned supplementation strategies are not considered to be

associated with any increased risk of iron overload (see Annex 2).

Monitoring and evaluation

Iron supplementation programmes should be carefully assessed, and their

efficiency and effectiveness monitored, to improve critical aspects of the

system.

8.2.3 Other complementary public health interventions

Iron supplementation programmes should be integrated into broader public

health programmes which are directed to the same population target groups.

Iron supplementation during pregnancy and lactation is a major component in

reducing maternal morbidity and mortality. Emphasis should therefore be

placed upon increasing the capacity of antenatal, postnatal, and child health

clinics to provide iron supplementation for mothers and children.

For maximum effectiveness, links should be established with programmes

such as those targeting:

 malaria prophylaxis;

 hookworm control;

 immunization;

 environmental health;

 control of micronutrient malnutrition; and

 community-based primary health care.

Community participation within the framework of the concept of primary health

care (and beyond) should be actively encouraged.

63
IRON DEFICIENCY ANAEMIA

64

8.2.4 Integration with other micronutrient control programmes

Preventive supplementation is particularly well-suited to strategies that

combine multiple micronutrient interventions. Accordingly, efforts should be

intensively directed to this area. Programmes that involve preparations

containing iron, folic acid, and vitamins A and C, directed to infants, children,

and pregnant and lactating women, are highly desirable.

Similarly, much more attention should be focused on the use of multiple

micronutrient-fortified food preparations in supervised feeding programmes

(e.g. in schools and emergency situations). The involvement in this effort of

the pharmaceutical and food industries and of food-aid donors should be

fostered. Also encouraged should be the active participation of educational

institutions, such as home-science colleges and departments.

In emergency situations (e.g. among refugees, displaced, or war-affected

populations) infants and young children are particularly vulnerable to iron

and other micronutrient deficiencies. Food aid provided in these situations

should be nutritionally adequate to prevent iron deficiency anaemia and other

micronutrient deficiency disorders.

To determine appropriate complementary action in micronutrient programmes,

it is necessary to conduct a careful analysis based on a conceptual framework

that compares:

 the etiology of each micronutrient deficiency;

 vulnerable groups;

 groups most appropriate for assessment and monitoring

purposes (surveillance groups); and

 suitable intervention strategies.

Table 12 compares complementary actions involving the three micronutrient

deficiencies currently of major public health significance, i.e. iodine, iron, and

vitamin A. Combined approaches to overcoming micronutrient malnutrition

- especially deficiencies in vitamin A and C, folic acid, iron, and zinc -

should be emphasized (105,124,125), especially since the foods to be

promoted and other necessary actions are often similar for these nutrients.
IRON DEFICIENCY ANAEMIA

Table 12. Iodine, iron and vitamin A deficiencies:

etiology, vulnerable groups, and appropriate groups

for surveillance purposes

Iodine deficiency Iron deficiency Vitamin A deficiency

 Etiology

Geographic Dietary Dietary

Increased losses Increased losses

Vulnerable groups

Entire population Pregnant and Pregnant and

lactating women lactating women

Infants Infants less than

6 months old

Preschool children Preschool children

Women of

childbearing age,

including adolescent girls

Surveillance groups

School-aged Pregnant women Preschool children

children Preschool children

65

8.2.5 Iron supplementation to correct iron deficiency anaemia

As mentioned earlier in this chapter, it is important to differentiate between

supplementation for the prevention of iron deficiency anaemia and

supplementation for its correction. The amounts of iron supplementation

recommended to treat iron deficiency anaemia for adults is 120 mg/day

iron for 3 months. For infants and younger children, it is 3 mg/kg/day, not to

exceed 60 mg daily.
IRON DEFICIENCY ANAEMIA
IRON DEFICIENCY ANAEMIA

67

Action-oriented research needs

This chapter identifies needs for action-oriented research in the fields of iron

deficiency and anaemia. These research needs are presented in relation to

the various intervention strategies described in the preceding chapters.

9.1 Dietary improvement

 Develop simple methods of dietary assessment, including

screening foods or meals for their value as important sources

of bioavailable iron and other nutrients.

 Develop laboratory methods for assessing iron bioavailability

from individual meals.

 Update analytical databases on food, condiments,

and spices, with respect to iron content and availability,

as well as content of folic acid, vitamin C, tannins,

phytates, vitamin A, and carotenoids.

 Evaluate traditional forms of food preparation that may

favourably affect bioavailability of iron, which are

decreasing in use (e.g. fermentation); and explore

ways in which these methods can be made more

practical and/or less time-consuming.

 Investigate methods of improving dietary patterns

(e.g. food selection and preparation, addition of

enhancers or removal of inhibitors of iron absorption).

 Research practical methods of food preparation

that will reduce the content of tannins and phytates,

such as the use of commercial phytase, malting

of cereals, prolonged cooking at high and low

temperatures, germination and fermentation.

9
IRON DEFICIENCY ANAEMIA

 Expand knowledge about interactions among and between

nutrients and/or non-nutrient factors (e.g. condiments and

vitamins A and C, which influence micronutrient bioavailability,

especially that of iron).

 Conduct operational research to improve community

nutrition and related education, and implement a social

marketing approach with the ultimate goal of improving

the quality and quantity of the food supply and its use.

 Explore methods of introducing adventitious iron sources,

such as the use of iron cooking pots.

 Evaluate approaches to improving the delivery and

adoption of agricultural inputs and technologies by

nutritionally vulnerable or iron-deficit households.

 Develop means to extend outreach to women farmers

through agriculture extension services.

 Explore methodologies for improving the marketing

of foods rich in iron and vitamins A and C.

 Improve methods for documenting the cost-effectiveness

of horticultural interventions.

9.2 Iron fortification

 Expand research on iron-EDTA to include not only its current

areas of application, but also its use in non-traditional vehicles

(e.g. an adequate fortificant, its effect on absorption of

other minerals, and the effectiveness of its absorption

to influence meal iron bioavailability compared with that

from ferrous sulphate).

 Continue research to determine how EDTA promotes the

absorption of the non-haem iron pool.

68
IRON DEFICIENCY ANAEMIA

69

 Continue to explore the potential for multiple fortification

of foods with micronutrients.

 Improve fortification technology to make fortification feasible

in remote areas and in the community (e.g. premixes for

home fortification use and microencapsulation).

 Conduct pilot fortification studies to assess biological

effectiveness, acceptability, and costs.

 Develop methods for quality assurance control

of fortification.

9.3 Iron supplementation

 Assess relative effectiveness of weekly supplements

in various vulnerable population groups and under

various conditions of programme implementation.

 Conduct operational research on ways to improve

the effectiveness and efficiency of preventive and

therapeutic iron supplementation programmes.

 Explore new approaches to iron supplementation,

which may have better absorption and fewer side-effects.

 Determine the cost-effectiveness of universal

supplementation of infants in areas where a high

prevalence of iron deficiency is found among them.

 Conduct operational research on practical surveillance

systems, use of sentinel sites, etc.

 Undertake operational research on community-based

infrastructures for the distribution of iron and folic acid to

pregnant women, and monitoring its effects among them.
IRON DEFICIENCY ANAEMIA

70

 Study effects of zinc supplementation in areas where

iron deficiency is highly prevalent.

 Conduct bioavailability tests on preparations containing

multiple micronutrients.

 Study combined pharmaceutical micronutrient preparations

and super-fortified foods, including their feasibility, stability,

and effectiveness.

 Study the role, effectiveness, and cost-effectiveness

of treating hookworm infections as a means of alleviating

or preventing anaemia and iron deficiency.
IRON DEFICIENCY ANAEMIA

In order to reduce substantially the prevalence of iron deficiency anaemia,

and in support of national programmes for the prevention of iron deficiency,

the following actions are recommended:

10.1 For governments

 Undertake appropriate studies to collect or update

information on the prevalence and severity of anaemia

in various age groups and by gender in the principal

ecological zones and socioeconomic groups of the country;

results should be made rapidly available and used

as the basis for advocacy and programme planning

and monitoring.

 Formulate and implement, as part of the national plan

of action for nutrition, a programme for the prevention

of iron deficiency, based on a combination of dietary

improvement, food fortification (where feasible) and

iron supplementation; public health measures integrated

into maternal and child health, and primary health care

programmes as described in Annex 5, should also

be part of the plan.

 Establish a surveillance system to ensure appropriate

monitoring of iron status and of programme implementation,

using indicators outlined in this report; locally applicable

programme indicators should be further developed.

 Undertake a feasibility study of iron fortification programmes

with emphasis upon reaching at least the major vulnerable

populations.

71

10 General recommendations
IRON DEFICIENCY ANAEMIA

72

 Review, and strengthen as necessary, national legislation

or regulations dealing with fortification and the marketing

of appropriate fortified foods; strengthen appropriate food

control and quality assurance systems; and foster effective

working relationships with the food industry and consumer

groups.

 Develop appropriate support activities, e.g. human

resources development (training of programme managers,

sector specialists, extension agents, and laboratory

and field staff, each for his or her respective role);

advocacy; information, education, and communication;

and applied research; and provide at least the minimum

facilities necessary to those activities, including those for

anaemia assessment.

 Develop suitable managerial mechanisms, including

integration into appropriate community programmes,

e.g. those promoting sustainable agriculture and rural

development, primary health care, maternal and child health,

and prevention of other micronutrient deficiencies.

 Mobilize the effective participation of community groups,

the private sector, and nongovernmental organizations,

in these programmes.

10.2 For supporting organizations

and institutions

 Stimulate and provide technical, material, and

financial support for the formulation, implementation, and

monitoring and evaluation of national and local programmes.

 Assist in mobilizing and training necessary human

resources.
IRON DEFICIENCY ANAEMIA

 Provide support for appropriate applied and operational

research.

 Ensure the organization of necessary global, regional,

and subregional advocacy, and of appropriate meetings,

communications, and information systems.

 Develop rosters of available human resources in various

categories, and in all countries, and ensure the widespread

circulation of those rosters.

 Initiate, if possible, systems for continuous collection

and periodic dissemination of information on the prevention

of iron deficiency, and systems to ensure adequate

communication on iron deficiency prevention initiatives,

especially through widely circulated periodicals, bulletins,

and newsletters.

 Ensure that adequate and appropriate global and national

information systems are established in connection with

iron deficiency, including information on the implementation

of prevention programmes.

 Foster action-oriented research, and networking to increase

collaborative efforts and cross-cultural trials.

73
IRON DEFICIENCY ANAEMIA
 IRON DEFICIENCY ANAEMIA

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Acta Medica Scandinavica Supplementum, 1962, 358:39-45.

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Nutrition, 1990, 51:76-79.

General references

Beard J, Stoltzfus R, eds. Iron-deficiency anaemia:

reexamining the nature and magnitude of the public health problem.

Proceedings of the WHO-INACG Conference, Belmont, MD, USA, 2000.

Journal of Nutrition, 2001, Supplement 131:2S-II.

Stoltzfus RJ, Dreyfus MD. Guidelines for the use of iron supplements

to prevent and treat iron deficiency anemia. INACG/ WHO/UNICEF.

Washington, ILSI Press, 1998.

UNU, UNICEF, WHO, MI. Preventing iron deficiency in women and children.

Consensus on key technical issues. Report of a UNU/UNICEF/WHO/MI

Technical Workshop, New York, 1998. Micronutrient Initiative, 1999.

WHO, UNICEF, MI. Fortification of flour with iron in countries of the Eastern

Mediterranean, Middle East, and North Africa. Report of a Joint

WHO/UNICEF/MI strategic Development Workshop on Food Fortification

with special reference to iron fortification of flour, Muscat, Oman,

26-30 October 1996. Alexandria, WHO/EMRO, 1998.

86
 IRON DEFICIENCY ANAEMIAannexes
IRON DEFICIENCY ANAEMIA
 IRON DEFICIENCY ANAEMIA

Dr Endang Achadi

(Vice Chairperson)

Center for Child Survival

University of Indonesia

Kampus FKMUI

Depok, West Java, Indonesia

Dr Alawia El Amin

Nutrition Department

Ministry of Health

Khartoum, Sudan

Tel: +249-11-78704

Dr R. Florentino

Director

Food and Nutrition Research

Institute

Department of Sciences

& Technology

Pedro Gil Street

Ermita, Manila 1000

Philippines

Tel/Fax: +632-823-8934

Dr Abdel Aziz Abdel Galil

Nutrition Institute

Cairo, Egypt

Dr L. Hallberg

Department of Medicine II

University of Göteborg

Sahlgrenska Sjukhuset

S-413 45 Göteborg, Sweden

Tel: +46-31-601103

Fax: +46-31-822152

Email: nutrition@clinnutr.gu.se

1

 List of participants:

IDA Consultation, Geneva 1993

89

ANNEX

Dr K. Suboticanes-Buzina

Noncommunicable Diseases

WHO, 20 Avenue Appia

1211 Geneva 27, Switzerland

Tel: + 41-22-791.2111

Fax: +41-22-791.0746

Dr Aye Thwin

National Nutrition Centre

84-88 Mahabandula Street

Pazundaung Township

Yangon, Myanmar

Tel: + 45-1-290891

Dr F. Viteri

Department of Nutritional Sciences

Morgan Hall, University of California

Berkeley, CA 94720, USA

Tel: +510-642-6900

Fax: +510-642-0535

Email: viteri@nature.berkeley.edu

Dr Tomas Walter

Chief, Unidad de Hematologia

Instituto de Nutricion y

Technologia de los Alimentos

Universidad de Chile

P.O. Box 138-11

Santiago 11, Chile

Dr Chen Wenzhen

Beijing Obstetrics and

Gynaecology Hospital, Beijing

Municipal Maternal Health Institute

17 Qihelou East City District

Beijing 10006

People’s Republic of China
IRON DEFICIENCY ANAEMIA

Professor K.A. Harrison

Department of Obstetrics

and Gynaecology

University of Port Harcourt

Lagos, Nigeria

Dr Yongyout Kachondham

Institute of Nutrition

Mahidol University

Phutthamonthon 4

Nakhon Pathom 73170

Thailand

Dra Nelly Zavaleta

Instituto de Investigacion Nutricional

Avda La Universidad

Cdra 6 – La Molina

P.O. Box 18-0191

Lima, Peru

Mr W. Clay

Food and Agriculture Organization

of the United Nations

Via delle Terme di Caracalla

I-00100 Rome, Italy

Tel. +39.6.57051

Fax: +39.6.52253152

Dr H. Dirren

Nestlé Research Centre (CRN)

Vers chez les Blancs

1000 Lausanne 26, Switzerland

Tel: +41-21-7858624

Fax: +41-21-7858925

Email: henri.dirren@rdls.nestle.com

Dr R. Parr

(Formerly at International Atomic

Energy Agency - P.O. Box 100

A-1400 Vienna, Austria)

Tel: +43-1-2060-21657

Fax: +43-1-20607-21657

Email: parr@ripol.iaea.or.at

Dr D. Robinett

Program for Appropriate

Technology for Health

Seattle, Washington, USA

Dr R. Seifman (formerly at

United States Agency

for International Development,

Washington, DC)

Human Development II –

Africa Region

The World Bank

1818 H. Street, N.W.

Washington, D.C. 20433, USA

Tel: +01-202-458-2897

Fax: +01-202-473-8216

Email: rseifman@world bank.org

Dr Steven Simon (formerly at

Micronutrient Initiative, Ottawa)

UNICEF Representative

P.O.Box 20678

Gaborone, Botswana

Tel: +267-351-909

Fax: +267-351.233

Email: ssimon@unicef.org

Dr R. Theuer

International Nutritional Anaemia

Consultative Group

c/o Nutrition Foundation

New York, New York, USA

Dr R. Yip (Chairperson)

(formerly at Center for Disease

Control and Prevention, Atlanta,

Georgia, USA), Programme Officer

United Nations Children’s Fund

12 Sanlitun Lu, Beijing 100600,

People’s Republic of China

Tel: +86-10-65323131

Fax: +86-10-65323107

Email: ryip@unicef.org

90
 IRON DEFICIENCY ANAEMIA

SECRETARIAT

UNICEF

Mr D. Alnwick

(formerly Head, Health Section

United Nations Children’s Fund)

Manager, Roll Back Malaria

WHO

1211 Geneva 27, Switzerland

Tel: +41-22-791.2769

Fax: +41-22-791.4824

Email: alnwickd@who.int

UNU

Dr N. Scrimshaw, Director

Food & Nutrition Programme

for Human & Social Development

The United Nations University

Charles St. Station

P.O. Box 500

Boston, MA 02114-0500, USA

Tel: +617-227-8747

Fax: +617-227-9405

WHO

Dr F.S. Antezana

(formerly Assistant

 Director-General)

WHO

1211 Geneva 27, Switzerland

Tel: +41-22-791.2111

Fax: +41-22-791.0746g

Email: antezanaf@who.int

Dr K.V. Bailey

(formerly Medical Officer,

Programme of Nutrition, WHO)

5 Lamington Street

Deakin 2600

A.C.T., Australia

Tel/Fax: +61-6-281-4822

Dr D. Benbouzid

(formerly Medical Officer,

Programme of Nutrition, WHO)

107 Chemin Cairoly

01630 Segny, France

Tel: +33-4-50.42.12.18

Dr R. Buzina

(formerly Medical Officer,

Programme of Nutrition, WHO)

WHO

1211 Geneva 27, Switzerland

Tel: +41-22-791.3316

Fax: +41-22-791.4156

Email: buzinar@who.int

Dr G.A. Clugston

Director, Nutrition for Health and

Development

WHO

1211 Geneva 27, Switzerland

Tel: +41-22-791.3326

Fax: +41-22-791.4156

Email: clugstong@who.int

Dr B. de Benoist,

Medical Officer, Nutrition

for Health and Development

WHO

1211 Geneva 27, Switzerland

Tel: +41-22-791.3412/3492

Fax: +41-22-791.4156

Email: debenoistb@who.int

91
IRON DEFICIENCY ANAEMIA

Dr J. Herrman

Programme for the

 Promotion of Chemical Safety

WHO

1211 Geneva 27, Switzerland

Tel: +41-22-791.3569

Fax: +41-22-791.0746

Email: herrmanj@who.int

Dr R. Johnson

(formerly at Maternal and Newborn

Health/Safe Motherhood, WHO)

6107 Buckingham Manor Drive

Baltimore, MD 21210, USA

Dr L. Savioli

Schistosomiasis and Intestinal

Parasites

WHO

1211 Geneva 27, Switzerland

Tel: +41-22-791.2664

Fax: +41-22-791.0746

Email: saviolil@who.int

Dr B.A. Underwood

(formerly at Programme of Nutrition,

WHO, Geneva)

Food and Nutrition Board

Institute of Medicine, NAS

2101 Constitution Ave., N.W.

Washington, D.C. 20418, USA

Tel: +202-334-1732

Fax: +202-334-2316

Email: bunderwo@nas.edu

92

Ms J. Van der Pols

WHO/EMRO

Nasr City

Cairo, Egypt

Tel: +202-670-2535

Fax: +202-670-2492/2494

Dr A. Verster,

Director, Health Protection and

Promotion

WHO/EMRO

Nasr City

Cairo, Egypt

Tel: +202-670-2535

Fax: + 202-670-2492/2494

Email: verstera@who.sci.eg
 IRON DEFICIENCY ANAEMIA

 The practical significance

 of iron overload for iron fortification

 and supplementation programmes

As is the case for several other essential nutrients, it is important to take note

of the possibility of too much as well as too little iron. Data on the relationships

between iron excess and infections, the occurrence of genetic and metabolic

disorders leading to iron overload, and some controversial reports of a

relationship between iron stores and chronic diseases have been misinterpreted

to suggest that interventions aimed at reducing iron deficiencies are undesirable.

This has adversely affected efforts to improve iron nutrition, even in areas with

serious iron deficiency. Failure to clarify these issues can interfere with needed

programmes of iron supplementation and fortification for populations at risk

of iron deficiency. None of the relationships cited above is a contraindication

to efforts to improve iron nutrition through diets supplying more available iron,

by iron fortification of appropriate vehicles, or by supplementation at

recommended levels.

Iron and infection

It is not only the host that needs iron for biochemical functions, but also the

infectious agent. Without it, replication is inhibited. In fact, withholding iron

from the infectious agent is an important mechanism of normal resistance

to infections (1,2). Conalbumin and lactoferrin have stronger iron-binding

properties than do most bacterial siderophores and are normally highly

unsaturated and function as iron-withholding rather than iron-transporting

agents. Lactoferrin, known to be released upon degranulation of leucocytes

in septic areas, is an important component of human milk and resists

proteolytic destruction in the gastrointestinal tract (3). The extremely high

iron-binding capacity of serum transferrin is also important because it removes

free iron ions from plasma.

annex

 2

93
IRON DEFICIENCY ANAEMIA

In iron-deficient or severely malnourished individuals, humeral and

cell-mediated immunity is reduced and leucocyte function is impaired. Under

these conditions the withholding of iron required for replication of an infectious

agent becomes even more important (4). The exacerbation of malaria with a

high case-fatality rate in Somali refugees given therapeutic doses of iron

has been described (5,6). Parenteral iron given to children with kwashiorkor,

who are characterized by low transferrin levels and impaired immunity,

has also been associated with mortality from overwhelming infection (6,7).

However, in field studies in which 100 mg of iron was given daily to adults

or proportionately less to school and preschool children, a prompt and

sustained decrease in morbidity from diarrhoea and respiratory disease was

consistently observed (8,9).

Iron supplementation at this level evidently promotes recovery of immune

function without providing enough iron to increase the severity of existing or

subsequent infections. The fact that therapeutic doses of either oral or

parenteral iron should not be given to individuals of any age with severe anaemia

or severe protein-energy malnutrition is in no way a contraindication to the

doses normally used in supplementation. The danger of an adverse effect on

resistance to infection is irrelevant to levels of iron intake associated with

fortification, even with multiple fortified food sources.

Iron and chronic disease

There has been increasing concern in recent years that a subset of the

population in developed countries or upper-income populations in developing

countries with overall adequate iron status may be adversely affected by high

levels of iron in the food supply. There are two aspects to this concern: one

related to individuals with undiagnosed iron overload metabolic disorders; and

the other to an observed association between laboratory indicators of high iron

stores and a variety of chronic diseases.

Normal individuals have a mechanism for reducing iron absorption when iron

stores are adequate that prevents iron overload. In fact, food iron absorption in

normal populations is estimated to be nearly nil when serum ferritin levels are

greater than 60 g/l. However, the gene for idiopathic haemochromatosis has a

homozygote frequency estimated to be between 100 and 500 per 100 000 in

some northern European populations. Persons with idiopathic

haemochromatosis have reduced protective inhibition of iron absorption and

may develop iron overload, especially if taking frequent iron tablets for long

periods. For this reason some have suggested that, because of the increased

risk to such individuals, iron fortification should be withheld, even from irondeficient populations.

94
 IRON DEFICIENCY ANAEMIA

The objection is the same as that used earlier to resist iodization of salt

because of the occasional individual susceptible to iodine-induced

hyperthyroidism. Relatively rare diseases should be dealt with medically

and not serve to prevent a needed public health measure that benefits or is

benign for the population as a whole. The same is true for diet in relation to

several other metabolic diseases and for foods to which some individuals are

commonly allergic.

In developed countries, where the iron content of the diet is higher and the

iron status is better than in developing countries, screening of individuals

at risk for iron overload can be done by measuring transferrin saturation or

serum ferritin. In most developing countries, where dietary iron content and

availability are low, the additional iron to improve iron nutriture is unlikely to

pose a risk even for those genetically susceptible to iron overload.

It has also been suggested that there is the possibility of a relationship

between high iron intakes and the risk of coronary heart disease (10) and some

kinds of cancer (11-14) on the basis of the notion that increased body iron

stores, as judged from serum ferritin levels, are associated with increased

risk. Although these studies are inconclusive and contradictory (15), they have

raised concern because these chronic diseases are now the leading causes

of mortality in many countries. It is possible that rather than high iron levels

acting causally, chronic disease processes themselves alter iron metabolism

giving rise to an apparent association. It is noteworthy that neither morbidity

nor mortality from coronary heart disease is increased among subjects with

hereditary haemochromatosis (Hallberg, personal communication).

References

1. Bullem JJ, Rogers HJ. Bacterial iron metabolism and resistance

to infection. Journal of Medical Microbiology, 1970, 3:8-9.

2. Sussman M. Iron and infection. In: Iron in biochemistry and medicine.

New York, Academic Press, 1974:649-679.

3. Weinberg ED. Infection and iron metabolism. American Journal

of Clinical Nutrition, 1977, 30:1485-1490.

4. Baggs RB, Miller SA. Nutritional iron deficiency as a determinant

of host resistance in the rat. Journal of Nutrition, 1973, 103:1554-1560.

95
IRON DEFICIENCY ANAEMIA

5. Murray MJ et al. Diet and cerebral malaria: the effect of famine and

refeeding. American Journal of Clinical Nutrition, 1978, 31:57-61.

6. Murray MJ et al. The adverse effect of iron repletion on the course

of certain infections. British Medical Journal, 1978, 2:1113-1115.

7. McFarlane H et al. Immunity, transferrin and survival in kwashiorkor.

British Medical Journal, 1970, 4:268-270.

8. Husaini MA. The use of fortified salt to control vitamin A deficiency.

Bogor, Indonesia, Bogor Agricultural University, 1982.

9. Hussein MA et al. Effect of iron supplements on the occurrence of

diarrhoea among children in rural Egypt. Food & Nutrition Bulletin, 1989,

10(2):35.

10. Edwards CQ et al. Hereditary hemochromatosis. Clinical Hematology,

1982, 11:411-435.

11. Stevens RG, Beasley RP, Blumberg BS. Iron-binding problems and

risk of cancer in Taiwan. Journal of the National Cancer Institute, 1986,

76:605-610.

12. Stevens RG et al. Body iron stores and the risk of cancer.

New England Journal of Medicine, 1988, 319:1047-1052.

13. Selby JV, Freidman GD. Epidemiologic evidence of an association

between body iron stores and risk of cancer. International Journal of Cancer,

1988, 41:677-682.

14. Weinberg ED. Iron withholding: a defence against infection and

neoplasia. Physiological Reviews, 1984, 64:65-101.

15. Edwards CQ et al. Prevalence of hemochromatosis among

11,065 presumably healthy blood donors. New England Journal of Medicine,

1988, 318:1355-1362.

96
 IRON DEFICIENCY ANAEMIA

Variations in haemoglobin 3 and haematocrit levels

annex

97

This annex presents tabled data which describe in quantitative terms

variations in haemoglobin and haematocrit levels according to age, gender,

stage of gestation, smoking, and altitude. Described in Tables A1 through A5,

respectively, are:

A1 Normal age- and gender-related changes of haemoglobin

and haematocrit values for children and adults

A2 Normal gestation-related changes of haemoglobin

and haematocrit values

A3 Normal increases of haemoglobin and haematocrit values

related to long-term altitude exposure

A4 Adjustments for haemoglobin and haematocrit values

for smokers

A5 Normal age- and gender-related red cell indices

for children and adults
IRON DEFICIENCY ANAEMIA

98

Table A1. Normal age- and gender-related changes of haemoglobin and haematocrit values for children and adultsa

 Females

0.50–0.99 1.00–1.99 2.00–4.99 5.00–7.99 8.00–11.99 12.00–14.99 15.00–17.99 18.00-44.99

years years years years years years years years

Haemoglobin (g/l)

Mean 122 123 124 125 128 134 135 135

-2SD 105 107 107 109 110 115 117 117

 Haematocrit (l/l)

Mean 0.357 0.359 0.363 0.372 0.384 0.390 0.395 0.400

-2SD 0.310 0.320 0.320 0.330 0.340 0.340 0.340 0.340

 Males

0.50–0.99 1.00–1.99 2.00–4.99 5.00–7.99 8.00–11.99 12.00–14.99 15.00–17.99 18.00-44.99

years years years years years years years years

Haemoglobin (g/l)

Mean 122 123 124 125 128 140 148 153

-2SD 105 107 107 109 110 120 123 132

 Haematocrit (l/l)

Mean 0.357 0.359 0.363 0.372 0.384 0.405 0.430 0.445

-2SD 0.310 0.320 0.320 0.330 0.340 0.350 0.370 0.390

a Based on the US second National Health and Nutrition Examination Survey (NHANES II), after excluding those with abnormal tests related to iron.

 (Centers for Disease Control. CDC Criteria for anemia in children and childbearing age women. MMWR, 1989, 38: 400-404; Yip R, Johnson C, Dallman PR.

Age-related changes in laboratory values used in the diagnosis of anemia and iron deficiency. American Journal of Clinical Nutrition, 1984, 39:427-436).
 IRON DEFICIENCY ANAEMIA

99

Table A2. Normal gestation-related changes

of haemoglobin and haematocrit valuesa

Gestation (weeks)

12 16 20 24 28 32 36 40

Haemoglobin (g/l)

Mean 122 118 116 116 118 121 125 129

-2SD 108 104 103 103 105 108 112 116

Haematocrit (l/l)

Mean 0.367 0.354 0.348 0.348 0.355 0.364 0.375 0.387

-2SD 0.325 0.315 0.310 0.310 0.315 0.325 0.335 0.350

aAdapted from Centers for Disease Control. CDC Criteria for anemia in children and childbearing age

women. MMWR, 1989, 38:400-404.

Table A3. Normal increases of haemoglobin and haematocrit

values related to long-term altitude exposurea

Altitude Increase in Increase in

(metres) haemoglobin (g/l) haematocrit (l/l)

0

+0.005

+0.015

+0.025

+0.040

+0.060

+0.085

+0.110

+0.140

<1000

1000

1500

2000

2500

3000

3500

4000

4500

 0

+ 2

+ 5

+ 8

+13

+19

+27

+35

+45

a

Adapted from Hurtado A , Merino C, Delgado E. Influence of anoxemia on haematopoietic activities.

Archives of Internal Medicine, 1945, 75:284-323. Centers for Disease Control. CDC Criteria for

anemia in children and childbearing age women. MMWR, 1989, 38:400-404.
IRON DEFICIENCY ANAEMIA

Table A4. Adjustments for haemoglobin and haematocrit values

for smokers

 Haemoglobin Haematocrit

 (g/l) (l/l)

Non-smoker 0 0

Smoker (all) +0.3 +0.010

1/2 - 1 packet/day +0.3 +0.010

1-2 packets/day +0.5 +0.015

⊕ 2 packets/day +0.7 +0.020

100
 IRON DEFICIENCY ANAEMIA

Table A5. Normal age- and gender-related red cell indices

for children and adultsa

Female and male

1–1.9 2–4.9 5–7.9 8–11.9

years years years years

RBC count

Mean 4.34 4.34 4.41 4.52

-2SD 3.8 3.7 3.1 3.8

MCV (fl)

Mean 79 81 82 84

-2SD 67 73 74 76

MCH (pg)

Mean 27.4 28.1 28.6 28.7

-2SD 22 25 25 26

MCHC (g/l)

Mean 34.4 34.5 34.5 34.5

-2SD 32 32 32 32

Female Male

12-14.9 15-17.9 >18 12-14.9 15-17.9 >18

years years years years years years

RBC count

Mean 4.47 4.48 4.42 4.71 4.92 4.99

-2SD 3.9 3.9 3.8 4.1 4.2 4.3

MCV (fl)

Mean 86 88 90 85 87 89

-2SD 77 78 81 77 79 80

MCH (pg)

Mean 29.4 30.0 30.6 29.1 29.9 30.5

-2SD 26 26 26 26 27 27

MCHC (g/l)

Mean 34.1 33.9 33.9 34.4 34.4 34.5

-2SD 32 32 32 32 32 32

a Based on the US second National Health and Nutrition Examination Survey (NHANES II)

after excluding those with abnormal tests related to iron; Yip R, Johnson C, Dallman PR.

Age-related changes in laboratory values used in the diagnosis of anemia and iron deficiency.

American Journal of Clinical Nutrition, 1984, 39:427-436.

101
IRON DEFICIENCY ANAEMIA
 IRON DEFICIENCY ANAEMIA

Approaches for

obtaining information

annex

103

Information on local dietary patterns and on the availability and consumption of

iron-containing foods is essential in establishing a food-based intervention

programme to improve iron status. Information is needed on availability in

an area or a population at the market and household levels; on general meal

patterns of vulnerable groups; and on semi-quantitative and qualitative intakes

of iron-containing foods and foods that inhibit or enhance iron absorption.

A.4.1 Market and household food availability

Surveys, conducted in markets, households, or both, are useful in establishing

the availability of iron-containing foods and those that contain the major

enhancers and inhibitors of iron absorption. At the market level, information

can be collected by interviewing vendors to obtain a list of the important foods

acquired by communities of concern, and a rough estimate of quantities

available by season and their unit costs for the size of the population served by

the market.

Vendors may also provide information on quantities usually purchased by

families. The focus should be on animal products (meat, poultry, and fish and

other seafood), cereals, legumes, nuts and seeds, green leafy and yellow

vegetables, and fruits (especially citrus). Foods should be identified in the local

language and, when possible, by their scientific name.

Surveys at the household level should first use focus groups of women

and elders to generate a list of important foods available in households from

the market, home production, hunting and gathering, and imported foods.

Information collected should include seasonal availability of foods, the usual

quantity acquired and prepared for the family, and how frequently the foods are

consumed. A random selection of households should be visited at various

seasons to ascertain which iron sources are available. Questions should be

asked to ascertain whether the household consumes those sources present,

and especially the frequency of their consumption by young children and women.

Generally, there are no major feasibility obstacles in conducting market and

household food availability surveys. Such surveys require participation of

a local assistant, guided by a nutritionist and with back-up by an in-country

botanist who can provide botanical sampling for identification if required.

4
IRON DEFICIENCY ANAEMIA

Adequate training is critical to prepare staff to be good facilitators and

recorders at focus group discussions. The facilitator must speak the local

language. In urban areas, consideration should be given to the specific

shopping districts frequented by the sampled communities.

A4.2 Dietary patterns of vulnerable groups

Information on dietary patterns of vulnerable groups can be obtained through

general focus group discussions. Emphasis should be on regular food use

practices during pregnancy and lactation, complementary feeding of infants,

and post-weaning diets of young children. Information is needed on food

preparation, frequency of consumption of iron-rich foods in season, and usual

portion sizes, and should include an estimate of the proportion of community

members that ascribe to each practice. Special attention should be given

to the use of tea, coffee, herbal teas, spices, and fermented foods.

This information is most useful when obtained from the community or region

and stratified by ethnic group, ecological zone, socioeconomic status, and by

specifically vulnerable groups, in particular pregnant women, infants, and

preschool children. Obtaining the information requires the cooperation and

goodwill of local leaders, and skilled focus group leaders who have nutrition

experience and are familiar with the local language and customs.

A4.3 Food beliefs and attitudes

Information on food beliefs and attitudes is best collected in focus group

discussions with women and elders in the communities surveyed, and also

health personnel and teachers. The accumulated facts should be stratified by

ethnic group, socioeconomic status, and ecological zone, and should be based

on separate sessions for each vulnerable group (pregnant or lactating women,

infants, and preschool children), depending on the quantity of information and

discussion time needed. Focus group discussions should include beliefs and

attitudes towards iron-rich foods and the relationships between iron-rich foods

and health in general. It should seek ideas from the community about how

best to improve use of iron-containing foods and foods having the auxiliary

nutrients and factors that modulate iron bioavailability.

This approach is particularly dependent on interest and support from the

local leadership and the skill of focus group leaders. The information gathered,

which should include the percentage of community members who hold specific

food-related beliefs, will greatly assist in developing dietary intervention

programmes.

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 IRON DEFICIENCY ANAEMIA

A4.4. Semi-quantitative and qualitative food

consumption levels

There are a number of qualitative and semi-quantitative methods for making

rapid assessments of the consumption of iron-containing foods for use both

on a household basis and for specific at-risk groups. Rapid survey procedures

are also designed to assess the usual frequency with which specific foods are

consumed within households or by individuals over a defined period, e.g. days,

weeks, or months. Even though this is not a quantitative survey of food

consumption, with trained interviewers the estimates can be made

semi-quantitative.

The primary purpose, however, is to determine whether the consumption of

iron-rich foods, and those containing enhancers or inhibitors of absorption,

is frequent enough in households as a whole, or in at-risk individuals within

households, to meet their probable needs. This determination can serve to

rank the risk of a diet inadequate in iron sources and absorption promoters or

excessive in inhibitors of absorption. This information is useful, together with

other indicators of anaemia and iron deficiency, for understanding the underlying

causes of the problem and designing appropriate food-based interventions to

prevent and control iron deficiency.

One example of this approach is the “recall method” summarized here.

The “population” to be surveyed may be an entire community (i.e. all households

in a community) or a selected sample of households representing a whole

area (e.g. a district). In the latter case the cluster sample approach is

appropriate. At least 30 children in each of the age groups of interest is

suggested, in order to achieve a minimum sample of 150-200 children under

3 years of age (less than or equal to 35 months). These children, who constitute

about 10% of the population, should be from separate households.

The initial universe, therefore, should be a population of at least 3 000

( i.e. 3 000 households). Thirty clusters of seven households each should

provide the number of children needed, and the clusters could be selected

to represent a district. A multistage random cluster sampling of villages, and

of households within villages, is then undertaken. After a preliminary visit to

each of the communities concerned, an interview is conducted with the

mother (or the caregiver) of each child under 3 years of age in the randomly

selected households.

The interviews should be conducted at home or in a neutral public place,

not in a health facility. They should not be conducted by a regular health worker.

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IRON DEFICIENCY ANAEMIA

106

 Short-term intake can be atypical of the usual diet, especially

in times of illness or during festive occasions.

 If there is a special market in the village on a particular day,

the timing of the visit in relation to that of the market may

influence results.

 Analysis should be according to broad food groups

and ranges of iron content within food groups from food

composition tables.

 Such an approach does not directly provide information

on why certain foods are or are not given before a certain age.

The latter circumstances are likely to produce biased answers in an attempt to

please the interviewer. The interviewer should be fluent in the language of the

person being interviewed and questions should be asked in the local language.

Care must be taken to avoid asking leading questions or prompting replies.

The recall method gives quick and useful information, because it can be

conducted overnight in a village. However, the following limitations should

be carefully borne in mind:

 The method represents consumption patterns over only

a limited period, usually 1 week or less. If there are important

seasonal variations, the procedure should be repeated at

3- to 4-month intervals.

 Unless surveyors are trained to collect the data in a

semi-quantitative manner, the data concern frequency

of consumption only.

 Bias should be avoided in selecting villages and households

interviewed (e.g. village notables tend to want to be included

in the sample); random sampling is essential.
 IRON DEFICIENCY ANAEMIA

 Strategies and guidelines for

national IDA control programmes

annex

5

107

Although the treatment of iron deficiency anaemia is technically simple,

its prevention through interventions is more demanding and depends on

concerted strategies and multisectoral involvement. A focused, effective,

and affordable national strategy is needed. The experience of several

countries has been used in formulating the following general guidelines.

A5.1 Situation analysis

The first step in developing a national strategy is to prepare a situation analysis

to establish justification for a programme and to support decision-making.

Components of needed information include as much of the following as possible:

Epidemiology of IDA

Magnitude and severity; age and gender distribution; regional differences;

causes (e.g. iron deficiency, combined micronutrient deficiency, infection,

parasitic infestation); dietary patterns; information on bioavailability of iron;

related micronutrients (e.g. vitamin C, vitamin A, zinc); enhancers and inhibitors

of iron absorption (e.g. phytates, inositol phosphate, iron-binding phenolic

compounds).

Health infrastructure and delivery system

Distribution of health facilities, transport and storage capacity, management,

and access of the population to health services.

Technical feasibility

Logistics (equipment, protocols); training and supervision; people (current

technical ability of the personnel involved), considering current and past

experience in IDA control.

Economic feasibility

Government health budget and financing; private sector and community

contributions.
IRON DEFICIENCY ANAEMIA

108

Community and individual concerns about iron fortification,

supplementation or therapy

Perception, attitude, cultural issues, and what people recognize as undesirable

symptoms or patterns of distress related to anaemia; possibility for community

action or involvement, or both.

Political concern and commitment

Inter- and intra-ministerial collaboration in efforts to control IDA.

A5.2 Goals and objectives

Based on the situation analysis, achievable and realistic goals and specific

and quantifiable objectives can be formulated. The overall objective is unlikely

to be the complete elimination of IDA, because this is certainly not achievable

in most countries in the near future. However, the objectives should set

attainable achievement targets for the most vulnerable groups in definite time

periods in terms of both prevalence and processes (actions).

A5.3 Components of a strategy for IDA control

Programmes to control iron deficiency are usually based on several major

strategies. Each country, according to its stage of development and the results

of its own situation analysis, should formulate an appropriate short- and

long-term strategy, incorporating some or all of the following elements.

A5.3.1 Dietary modification

Dietary modification activities require not only information on real food

availability by groups at risk but also on dietary patterns, the bioavailability

of iron in local diets, and cultural aspects and local preferences. Information,

education, and communication at all levels play key roles in promoting a

healthy diet. Evidence to date indicates that well-conducted education and

communication campaigns can indeed change knowledge, attitudes, and

behaviour, and can thereby improve nutritional status.
 IRON DEFICIENCY ANAEMIA

109

Local dietary factors

Local dietary factors influencing the bioavailability of dietary iron,

including both enhancers and inhibitors, should be identified. Common

practices in food selection and preparation (including meal composition and

preparation with respect to these factors), iron-rich foods available throughout

the year and staples - and their interaction - should be assessed.

Appropriate dietary modification activities should seek to:

 increase, where possible, intakes of locally available

haem-iron food products, e.g. meat, liver, blood curd, etc;

 increase intake of vitamin C-rich foods and other foods

that promote iron absorption (e.g. fermented food products); and

 reduce as much as possible consumption of iron absorption

inhibitors (e.g. phytates and iron-binding phenolic compounds).

Behavioural aspects

Modifying dietary patterns that are usually culturally ingrained and may have

existed for hundreds of years is not so easily achievable. Beliefs, preferences,

restrictions, taboos, and cultural issues governing food consumption should

be understood and appreciated. An approach is needed that is solidly based

on formative research, messages that are targeted to specific groups, and a

good understanding of the possibilities and limits of behavioural objectives.

Intersectoral action

This component should include, in particular, agricultural extension to promote

the production and consumption of iron- and other micronutrient-rich foods;

school garden and lunch programmes; community development programmes;

and community involvement. Meal preparation demonstrations are needed.

These should include homemade complementary foods and school menus

rich in micronutrients, based on local foods. School lunch programmes should

include community participation, so that their impact will be carried over

into the household. Governments should invest not only in terms of money

for the school to run the programme, but also in well-thought-out guidelines

and suggestions. The latter should include many alternatives, among which

managers can select in order to conform to their specific situations.
110

Promoting breastfeeding and use of iron-rich complementary foods

Breast milk usually supplies adequate iron during the first 6 months of life.

Accordingly, emphasis on preventing iron deficiency in infants and preschool

children should include promotion of both breastfeeding and the preparation in

the home of iron-rich complementary foods.

Nutrition communication to promote consumption of animal products (e.g. meat,

liver, blood curd) and vegetables rich in iron, vitamin C, and vitamin A

in home-based weaning food should be encouraged. Fermentation or

germination of some foods might also be helpful.

A5.3.2 Fortification

Iron fortification can be an effective way of preventing iron deficiency, and does

not necessarily require cooperation of the individual. Recent technical

developments to overcome undesirable changes in fortified food and

success with salt iodization make it more realistic for countries to consider

and adopt this strategy. This development is especially significant in reaching

urban populations.

Prerequisites for successful fortification include a suitable food vehicle;

a bioavailable iron source compatible with the vehicle; careful market research;

preparation of appropriate standards and regulations; and long-term

commitment.

A5.3.3 Iron supplementation

Targeting (in descending order of priority)

 Pregnant and lactating women, and low-birth-weight infants.

 Infants 6-12 months of age.

 Women of childbearing age, starting from adolescence.

 School-aged children.

IRON DEFICIENCY ANAEMIA
111

 Creating awareness, linking iron deficiency anaemia

to conditions which people recognize as undesirable

symptoms or patterns of distress.

 Stressing undesirable consequences of IDA during pregnancy

and delivery for infants.

 Encouraging positive expectations as a result of supplements.

 Motivating and training personnel for IDA prevention.

Approach

 Universal supplements for pregnant and lactating women

and low-birth-weight infants.

 Supplementation for women of childbearing age

including adolescent girls and school-aged children,

if anaemia prevalence exceeds 40%.

 Screening - only if anaemia prevalence is mild or moderate

(<20%) and protocols and guidelines for action are available.

Delivery system

 Integration with the activities of primary health care

and maternal and child health clinics.

 Using channels outside the health system,

building on existing programmes in the communities.

 Sharing facilities, training and supervision.

 Providing adequate supplies and logistics.

 Ensuring shelf-life under prevailing climatic conditions.

 Identifying and addressing factors leading to low adherence.

 Forewarning on side-effects (black faeces and dyspepsia)

by providers.

IRON DEFICIENCY ANAEMIA
IRON DEFICIENCY ANAEMIA

A5.3.4 Other public health measures

 Reduction of the prevalence of infectious diseases in general

(e.g. diarrhoeal and respiratory diseases, measles).

 Reduction in the prevalence of hookworms, trichuriasis,

and schistosomiasis infestations. Ideally, parasite control

should be complemented with primary preventive measures

to break the transmission cycle and environmental health

measures to reduce parasitism (especially hookworms).

This is particularly important for pregnant women, who

should receive an appropriate anti-helminthic after the

third month of pregnancy

·

 Reduction in the prevalence of malaria, which is a major

cause of anaemia, particularly in Africa.

A5.3.5 Support measures

Advocacy and social communications

At all levels, from that of the community to that of national policy-makers,

it is necessary to identify the target and communication objective for each,

the main messages, the methods and media to be used, and the materials

required. A strong political will at the highest level is mandatory; without it,

the programme cannot hope for national coverage, adequate budgeting,

or intersectoral collaboration.

A strong advocacy effort is therefore essential, starting from the highest levels

down to local political leaders and communities. Advocacy statements should

be devised; examples include:

and

112

“Iron deficiency anaemia is compromising physical and cognitive

development and performance, especially in the coming generation .”

“Iron deficiency anaemia in adults contributes to low work productivity

and has a negative impact on the economy.”
 IRON DEFICIENCY ANAEMIA

Training of personnel

It is important to train personnel from various sectors (e.g. health, agriculture,

commerce, and industry), as well as community leaders, to motivate

the participation of households, communities, the private sector, and

nongovernmental organizations.

Infrastructure

The minimum necessary infrastructure (e.g. haemoglobinometry down to

district or sub-district levels) should be provided.

Management mechanisms

A task force for preventing iron deficiency anaemia - or, better still, for

preventing micronutrient malnutrition in general - could be created. This task

force would lead the advocacy effort, as well as plan and oversee

implementation of action programmes.

The task force should be multisectoral, with members from government

departments, academic and research institutes, the private sector (including

professional groups and industry), nongovernmental organizations, and others.

Expert groups may be formed to provide technical guidance to the task force.

A5.3.6 Monitoring and evaluation

Monitoring and evaluation is best incorporated into, or conducted partly by, the

existing built-in supervisory and reporting system. However, a complementary

independent sentinel surveillance system, linked with monitoring of other

micronutrient deficiencies, should be encouraged. Monitoring and evaluation

should encompass both programme implementation and epidemiological

information.

Haemoglobin or haematocrit determinations on a public health basis are,

in any case, important for monitoring trends in anaemia prevalence and

assessing the effectiveness of interventions. Serum ferritin measurements,

which provide a more sensitive and specific measure of tissue iron

deprivation, should be taken systematically - on the basis of a limited

subsample - for evaluation purposes. If feasible, serum transferrin receptor

levels should also be determined as another indicator.

113
IRON DEFICIENCY ANAEMIA

Data to be collected by the routine reporting system include:

 supply and logistics;

 coverage;

 process indicators, especially provider

and client compliance; and

 impact indicators.

If possible, coverage indicators should also take into consideration the size

of floating populations and underprivileged groups. Determining compliance

can assist in deciding whether sustaining a programme or approach will be

cost-effective, or whether programme modifications have improved or

detracted from performance.

For supply and logistics in supplementation programmes, special emphasis

should be placed upon:

 monthly monitoring of stocks at each level of distribution;

 scheduling of orders to ensure regular supply; and

 quality control measures by periodic sample checking,

including a check on the condition and authenticity of

supplies of supplements.

Data on food beliefs and preferences, and semi-quantitative and qualitative

food-consumption data, should be obtained from time to time using rapid

assessment methods.

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 IRON DEFICIENCY ANAEMIA
IRON DEFICIENCY ANAEMIA