Reduction of anaemia
Authors: John Mason, Reynaldo Martorell, Lisa Saldanha, Roger Shrimpton
Journal: The Lancet Global Health (2013)

In The Lancet Global Health, Gretchen Stevens and colleagues'1Stevens GA Finucane MM De-Regil LM et al.for the Nutrition Impact Model Study Group (Anaemia)Lancet Glob Health. 2013; 1: e16-e25Summary Full Text Full Text PDF Scopus (1072) Google Scholar update of global, regional, and national trends in haemoglobin concentration and levels of anaemia emphasises both the massive extent of the problem, and its very slow rate of improvement. About 30% or more of women and children younger than 5 years are affected by the disorder—nearly 800 million people. Anaemia has improved by only 0·2–0·3 percentage points per year in the past two decades. By comparison, child underweight, affecting nearly 20% of children, has declined at an average of almost 0·6 percentage points per year.2UN Standing Committee on NutritionSixth report on the world nutrition situation: progress in nutrition.http://www.unscn.org/files/Publications/RWNS6/html/index.htmlDate: 2010Google Scholar The trend rates are such that, globally, women's anaemia would take about 60 years or more before the prevalence rates of 15% noted in high-income regions are achieved; in south Asia, this rate would take more than a century to reach, and in for example central and west Africa, it would take more than 150 years. The global problem is not resolving as part of normal socioeconomic development. Assessment of the causes of anaemia suggests likely future trends, and needs for additional interventions. Gross national income and consumption of meat are significantly (and independently) associated2UN Standing Committee on NutritionSixth report on the world nutrition situation: progress in nutrition.http://www.unscn.org/files/Publications/RWNS6/html/index.htmlDate: 2010Google Scholar with anaemia prevalences, so that countries transitioning to higher income and more diversified diets that include more animal products and fruits and vegetables might decrease anaemia prevalence. The exception is when diets exclude meat, which notably includes many of the estimated 300 million women in India, of whom about 50% have anaemia. Indeed, rapid improvements have been documented at the national level (eg, 1–3 percentage points per year in Thailand and Vietnam3Mason J Deitchler M Mathys E Winichagoon P Tuazon MA Lessons from successful micronutrient programs. Part III: program impact.Food Nutr Bull. 2004; 25: 53-78PubMed Google Scholar and Nicaragua4Victora CG Barros FC Assunção MC et al.Scaling up maternal nutrition programs to improve birth outcomes: a review of implementation issues.Food Nutr Bull. 2012; 33: S6-26PubMed Google Scholar), ascribed more to improvements in diet and infectious disease than to direct supplementation, although supplementation was widely implemented. For the millions of poor individuals who live in stagnant conditions of poverty, which are exacerbated by high food prices and unemployment, not much will change unless deliberate measures are taken. Implementation of effective direct intervention programmes, such as supplementation with iron (as iron and folic acid or multiple micronutrients), fortification of staple foods or condiments, and disease control (notably malaria and deworming), is urgently needed. The effectiveness of these solutions is well established and the effects are large relative to the slow rate of anaemia's decline, showing a missed opportunity.5WHOGuideline: daily iron and folic acid supplementation in pregnant women.http://apps.who.int/iris/bitstream/10665/77770/1/9789241501996_eng.pdfDate: 2012Google Scholar The challenge is how to implement these programmes on a wide enough scale, with well-known methods (table).4Victora CG Barros FC Assunção MC et al.Scaling up maternal nutrition programs to improve birth outcomes: a review of implementation issues.Food Nutr Bull. 2012; 33: S6-26PubMed Google ScholarTableProcesses for implementation at scale of interventions to prevent or treat anaemiaTarget groupsHealthAgriculture extension servicesEducation (schools)Social protection (CCTs)Community health volunteers, mobilisation, and follow-upHealth servicesCampaigns and child health daysIFA supplementation*Multiple micronutrients containing iron are soon likely to replace iron-folate in many cases; however, formal guidance from WHO is yet to come.Pregnant women (daily), preconception (weekly)†When indicated., adolescent girls (menstruating; weekly)MobilisationThrough ANC, counselling, and suppliesCounselling and suppliesNAProvidePotential for condition in CCTsHelminth control (6-monthly)Pregnant women, children (6–59 months), adolescent girlsMobilisationThrough ANC, in routine careCounselling and suppliesNAProvide··Malaria prevention and controlHouseholdsMobilisation, bednetsProphylaxis, bednetsBednetsNAPromotion··Fortified supplementary foodsPregnant women, children (6–59 months)MobilisationSupplyScreening, and if needed, provisionNANAPotential for supply route for supplementary food distributionDelayed cord clampingBirthNAIn institutional delivery and with trained birth attendantsNANANANAEducation and counselling to increase iron intake through dietPreconception, pregnant women, children (6–59 months)MobilisationIn routine care, in ANC, and through growth monitoringNACounsellingHealth and nutrition education might be included in curriculaInclude topics in public education sessions when these are condition in CCTsPromotion of consumption of fortified complementary foodsHouseholdsMobilisationIn ANC, growth monitoringNACounselling····Home-based fortification‡Guidance not yet available on use of home-based fortification during pregnancy.Children (6–59 months), pregnant womenMobilisation plus suppliesIn routine care, growth monitoringNANA····Promote animal source foods through household productionHouseholdsMobilisation..NAAdvice, supplies····CCTs=conditional cash-transfer programmes. IFA=iron-folic acid. ANC=antenatal care. NA=not applicable.* Multiple micronutrients containing iron are soon likely to replace iron-folate in many cases; however, formal guidance from WHO is yet to come.† When indicated.‡ Guidance not yet available on use of home-based fortification during pregnancy. Open table in a new tab CCTs=conditional cash-transfer programmes. IFA=iron-folic acid. ANC=antenatal care. NA=not applicable. For supplementation, the key issues are how to develop and sustainably support the relevant systems and platforms. The table shows options for implementation of interventions.6Mason JB Saldanha L Martorell R Opportunities to improve women's nutrition and maternal, neonatal and child health outcomes.Food Nutr Bull. 2012; 33: S3-137PubMed Google Scholar Timely participation in antenatal care is restricted, and even for participating countries, supplies of supplement are rarely sufficient. Incentives are essential for use of antenatal care, including improvement of quality of services through conditional cash-transfer programmes and counselling, and overhaul of supply logistics, from central stores to health posts, is a prerequisite.6Mason JB Saldanha L Martorell R Opportunities to improve women's nutrition and maternal, neonatal and child health outcomes.Food Nutr Bull. 2012; 33: S3-137PubMed Google Scholar, 7Galloway R Dusch E Elder L et al.Women's perceptions of iron deficiency and anemia prevention and control in eight developing countries.Soc Sci Med. 2002; 55: 529-544Crossref PubMed Scopus (176) Google Scholar Community-based health and nutrition programmes are operational in many countries8Disease Control Priorities ProjectCommunity health and nutrition programs.http://www.dcp2.org/pubs/DCP/56/Date: 2006Google Scholar and are mainly aimed at children, but could readily include women. Other opportunities are through family planning, child health days, and cash-transfer programmes. To address child anaemia, provision of suitable iron sources as drops or in multiple micronutrient powders is needed. Interventions to combat child marriage and early pregnancy, and to increase birth intervals, will contribute to the reduction of anaemia. Iron fortification of staple foods (especially wheat) has contributed to the reductions in anaemia prevalence reported in high-income regions. Fortification in low-income countries has expanded: the Flour Fortification Initiative reports that 76 countries now have mandatory flour fortification, and 31% of the world's wheat flour is fortified.9Flour Fortification InitiativeGlobal progress.http://www.feedthefuture.gov/sites/default/files/resource/files/ftf_handbookindicators_apr2012.pdfDate: April, 2013Google Scholar Rice is the staple food in most of Asia, and thus for nearly half the world's population. Many such individuals are vegetarian and have high rates of anaemia. However, rice is not yet widely fortified, and substantial technical issues demand increased investment in research, both for added iron and biofortification. Fortification of widely used condiments, such as soy sauce and fish sauces, has also begun, notably in China. In countries where populations rely on wheat, additional benefit to anaemia can now be expected; populations that consume mainly rice might have to wait. Infectious and parasitic diseases cause about half the anaemia burden. Stevens and colleagues1Stevens GA Finucane MM De-Regil LM et al.for the Nutrition Impact Model Study Group (Anaemia)Lancet Glob Health. 2013; 1: e16-e25Summary Full Text Full Text PDF Scopus (1072) Google Scholar estimate that iron-amenable anaemia was about 50% in non-pregnant and pregnant women, and 42% in children in 2011. In addition to the contributions of malaria, schistosomiasis, hookworm infection, and HIV, which Stevens and colleagues list as causes of low haemoglobin concentrations, presence of Helicobacter species should perhaps be added as an emerging issue.10Ozkasap S Yarali N Isik P Bay A Kara A Tunc B The role of prohepcidin in anemia due to Helicobacter pylori infection.Pediatr Hematol Oncol. 2013; (published online Apr 5.)https://doi.org/10.3109/08880018.2013.783144Crossref PubMed Scopus (21) Google Scholar Improved sanitation and disease control can be expected to make a substantial contribution to anaemia reduction, again especially in transition countries in which diet and disease control are likely to improve in parallel. Direct interventions are needed, especially for the poorest populations, and these can improve health and nutrition even when underlying causes remain important. Moreover, these improvements enhance human capital, and can contribute to a virtuous cycle by fostering economic development, which in turn enhances the health and nutrition of women and children. A step in the right direction is the specific attention to maternal anaemia as a problem of importance in the US Global Health Initiative's Feed the Future programme.11Feed the Future the Future indicator handbook: definition sheets.http://www.feedthefuture.gov/sites/default/files/resource/files/ftf_handbookindicators_apr2012.pdfDate: 2012Google Scholar Now that the World Health Assembly has proposed a target of 50% reduction in anaemia in women by 2025, the necessary resources and policy priority will hopefully be directed towards this pervasive but under-recognised problem. We declare that we have no conflicts of interest. Global, regional, and national trends in haemoglobin concentration and prevalence of total and severe anaemia in children and pregnant and non-pregnant women for 1995–2011: a systematic analysis of population-representative dataChildren's and women's haemoglobin statuses improved in some regions where concentrations had been low in the 1990s, leading to a modest global increase in mean haemoglobin and a reduction in anaemia prevalence. Further improvements are needed in some regions, particularly south Asia and central and west Africa, to improve the health of women and children and achieve global targets for reducing anaemia. Full-Text PDF Open Access