Nutritional Anemia in Bangladesh: Problems and Solutions

Dr Tahmeed Ahmed

Director Centre for Nutrition & Food Security ICDDR,B

Professor, Public Health NutritionJames P. Grant School of Public Health, BRAC University

Anemia

A condition in which the Hb

concentration in the blood is below

a defined level, resulting in a

reduced oxygen-carrying capacity

of red blood cells

Definition of Anemia at Sea Level

Stoltzfus & Dreyfuss; INACG/UNICEF/WHO 1998

Consequences of Anemia

• Poor immune function and increased morbidity

from infection

• Fatigue and lower physical work capacity

• Poor physical growth

• Impaired learning and school achievement

Brabin BJ 2001Grantham-McGregor S 2001

Consequences of Anemia in Pregnancy

• Increased risk of complications during delivery, including prolonged labor, preterm delivery, LBW and maternal and neonatal deaths

• Infants of mothers with iron deficiency anemia are more likely to have low iron stores and to become anemic

Brabin BJ 2001Grantham-McGregor S 2001

Christian P 2005UN/SCN 2004

Anemia causes huge economic loss

• Results in productivity loss

• Economic cost of anemia in Bangladesh is

estimated to be 7.9% of GDP

What are the causes of anemia?

• Iron deficiency – dietary deficiency, loss of iron • Hookworm • Vitamin deficiencies, eg vitamin B12, folic acid • Malaria• Hemoglobinopathies, eg thalassemia• Chronic infections, such as TB, HIV

Iron Deficiency Anemia

• Iron deficiency is the most important cause of

anemia

• 60% of all anemia is due to iron deficiency

Stoltzfus R 1998, Black RE 2008

• Review of literature, survey reports

• Meta analyses

• Communication with stake holders from public, private and research sectors

• 22 interviews - NNP, DGFP, IPHN, IEDCR, CMSD, NIPORT, EDCL, UNICEF, MI, BRAC, ICDDR,B

• Informal round table discussion at ICDDR,B

Review of Anemia Control Program

Age Year Settings Sample Size %

Infants

(6-11 mo)

20041

20032

20032

20013

19994

Rural

Urban

CHT

Rural

Urban

1227 U-5

93

51

1148 U-5

183

92

83.9

90

74.1

92.3

NSP 20041 , Anemia prevalence survey UNICEF/BBS 20032, NSP 20023 , NSP 20004

Prevalence of Anemia in Bangladesh

Age Year Settings Sample Size %

Infants

(6-11 mo)

20041

20032

20032

20013

19994

Rural

Urban

CHT

Rural

Urban

1227 U-5

93

51

1148 U-5

183

92

83.9

90

74.1

92.3

NSP 20041 , Anemia prevalence survey UNICEF/BBS 20032, NSP 20023 , NSP 20004

Prevalence of Anemia in Bangladesh

•Demand for iron is high•Complementary feeding is inappropriate•No program for anemia control in infants

Complementary Foods Provide little Micronutrients to Bangladeshi Infants

Kimmons J, 2006

Breast milk contributes to 75% of total energy intake

Small amounts of CF offered

Vitamin B6 50% of RNI

Vitamin A 48% of RNI

Zinc 45% of RNI

Iron 9% of RNI

Increase in CF will not substantially increase MN

intake

Age Year Settings Sample Size %

Pre-school

(6-59 mo)

20041

20032

20013

Rural

Urban

Rural

1227

861

1148

68

55.7

48.3

Adolescent

(13-19 yr)

20041

20032

20013

Rural

Urban

Rural

661

1341

237

39.7

23.4

30

NSP 20041 , Anemia prevalence survey UNICEF/BBS 20032, NSP 20023

Pre-school Children and Adolescent Girls

0

10

20

30

40

50

60

70

80

90

100

Perc

en

t

Infant Pre school

Adolescent NPNL women

Pregnant Women Lactating Women

200420032001

74.1

92

67.9

48.3

39.7

30

46

33 38.8

46.735

46

NSP 2004, Anemia prevalence survey UNICEF/BBS 2003, NSP 2002, WHO global database on anemia

Anemia Prevalence Trends in Bangladesh

Strategies for Anemia Prevention and Control

• Micronutrient supplementation

• Dietary improvement

• Parasitic disease control

• Food fortification

• Family planning and safe motherhood

National Strategy for Anemia Prevention and Control in Bangladesh, MOHFW 2007

Existing Programs on Iron Supplementation

Age group Department

Infants, children No national program

Adolescents DGFP

PLW DGFP, DGHS, NGOs

NPW DGFP

Dose of Iron-folic Acid Tablets

Target group Doses

Adolescent girls 2 tablets/week

Newly wed women 2 tablets/week

Pregnant women 2 tablets daily up to delivery(NGOs 1 tab daily)

Lactating mother 1 tablet daily for 90-120 d

Iron-folic Acid Tablets

DGFP Given in a polythene bag Spoilage ?

DGHS Wrapped in paper Spoilage ?

BRAC Now giving tablets in blister pack

Tk 14 for 100 tab vs

Tk 12 for 100 open tabs

Dispensing IFA Tablets

Iron Coverage among Pregnant Women

HFSNA 2009

IFA Tablet Coverage during Pregnancy in BINP Areas

NNP Baseline Survey 2004

Indicator Survey Area

BINP (%) Comparison (%) All (%)

IFA intake Regular Irregular None

25.49.9

64.7

169.5

74.5

19.59.6

70.9

Total (n) 2193 3785 5979

Reasons for Not Taking IFA Tablets Regularly

Reasons N=1741 pregnant women, %

Side effects (diarrhea, etc)Forget to takeDid not consider necessaryLack of supplyDo not receive enough tabletsEconomic constrainsObjection of family membersLost tabletsOthers

25.519.516.312.06.14.51.90.27.8

NNP Baseline Survey 2004

Multiple Micronutrient Powder

1 RDA of•Iron•Folic acid•Vitamin A•Vitamin C•Zinc

No colorNo taste of its own

No odor

Children with the following conditions are excluded:

•Any acute illness

•Severe cough

•Breathlessness

•Severe visible wasting

What can we do to control anemia?

• Increase exclusive breastfeeding rates

• Improve complementary feeding practices by

using various foods rich in iron

• Consider home-based fortification of CF using

multiple micronutrient powder

• Coordination of efforts of different agencies and

the private sector in control of anemia

Comprehensive Nutrition Actions Required

• Promote factors that will increase coverage of

IFA supplementation among adolescent girls,

pregnant & lactating women– Effective counseling– Sustained supply – Appropriate packaging– Mass media coverage– Trained workforce