Anaemia Burden — Iron Alone Is No Solution

UPSC Syllabus: Gs Paper 2- Health Sector

Introduction

India faces a high burden of anaemia, especially among women and children. Although iron deficiency is an important cause, it explains only about half of anaemia cases globally. Double-Fortified Salt (DFS), which combines iron and iodine, is proposed as a convenient intervention. However, its dependence on salt consumption, uncertain effectiveness and possible risks raise concerns. Tackling anaemia requires more than adding iron to food through one intervention.

Understanding Anaemia and Iron Deficiency

1. Meaning of Anaemia: Anaemia is a condition in which haemoglobin levels fall below normal, reducing the blood’s ability to carry oxygen.
2. Iron Deficiency Anaemia: It occurs when the body lacks sufficient iron to produce haemoglobin, making iron deficiency an important cause of anaemia.
3. Iron Deficiency and Anaemia Are Different: Globally, roughly half of anaemia cases are attributed to iron deficiency, showing that iron deficiency does not explain every case.
4. Evidence from India: The Comprehensive National Nutrition Survey (CNNS, 2016–18) found that iron deficiency explained only part of anaemia among Indian children and adolescents.

Status of Anaemia in India

1. High Prevalence: The fifth National Family Health Survey (NFHS-5) found that more than half of Indian women and about two-thirds of young children are anaemic.
2. Iron Deficiency Burden: Around 31% of children under five, 36% of women and 28% of the general population have some degree of iron deficiency.
3. Vulnerable Groups: Adolescent girls, pregnant women and young children face greater risks due to menstruation, pregnancy and increased iron requirements during growth.
4. Socioeconomic Vulnerability: Low-income rural households face greater risks because access to iron-rich foods, fortified foods and supplements is often limited.
5. Maternal and Child Health: Anaemia increases the risk of maternal and child deaths during pregnancy and childbirth, affecting overall health outcomes.
6. Cognitive and Educational Impact: Iron deficiency during early childhood can permanently affect brain development, physical growth, energy levels and learning outcomes.
7. Economic and Psychological Effects: Anaemia reduces work capacity and productivity, while iron deficiency has also been linked to heart problems and depressive symptoms.

Government Initiatives and Other Interventions to Address Anaemia

1. Anaemia Mukt Bharat (AMB): The Government distributes iron and folic acid (IFA) tablets through this programme, although coverage and compliance remain challenges.
2. 7x7x7 Strategy: India’s revised anaemia strategy includes additional measures beyond existing interventions, recognising the need for a broader approach to anaemia control.
3. Fortified Rice Distribution: Iron-fortified rice is distributed through the Public Distribution System (PDS), Pradhan Mantri Poshan Shakti Nirman (PM POSHAN) and Integrated Child Development Services (ICDS) to reach vulnerable groups.
4. Wheat Flour Fortification: Fortify Health partners with mills to add iron, folic acid and vitamin B12 to wheat flour, improving access to fortified foods without major behavioural changes.
5. Double-Fortified Salt (DFS): DFS contains iron and iodine and is proposed as a convenient way to improve iron intake through a commonly consumed household food item.

Limitations and Concerns Associated with Double-Fortified Salt

1. Conflict with Salt Reduction Goals: Indians consume roughly twice the World Health Organization (WHO)-recommended five grams of salt daily, while DFS relies on regular salt consumption to deliver iron.
2. Risk to Cardiovascular Health: About one in three Indian adults has hypertension, while India’s non-communicable disease (NCD) action plan targets a 30% relative reduction in salt intake.
3. Unequal Iron Consumption: Adult men generally consume the most salt, while women and young children consume the least, potentially giving the groups with greatest iron needs smaller doses.
4. Risk of Iron Overload: The body has no regulated mechanism to excrete excess iron, which can accumulate, promote oxidative stress and has been linked to metabolic disease.
5. Risks in Haemoglobinopathies: People with beta-thalassaemia, particularly those receiving blood transfusions, face greater risks of iron overload; sickle cell disease is concentrated in tribal areas.
6. Limited Screening Capacity: The PDS reaches around 800 million people, making individual screening for iron-related risks before nationwide DFS consumption impractical.
7. Cumulative Iron Exposure: Fortified rice, IFA tablets and DFS could expose children and adolescents to iron through three or four government programmes simultaneously, without adequate assessment of total intake.
8. Poor Iron Absorption: Phytates in cereals and pulses, polyphenols in tea and coffee, and calcium in milk reduce the absorption of non-haem iron from meals.
9. Uncertain Household Effectiveness: Cooking losses, uneven dosing and variable diets may reduce actual iron intake, while supervised trials cannot fully reflect household conditions.
10. Infection-Related Limitations: Infections and inflammation increase hepcidin levels, which block iron absorption and reduce the effectiveness of fortification in populations with higher infection burdens.
11. Evidence of Potential Health Risks: The 2006 Pemba trial in Tanzania associated iron and folic acid supplementation with increased hospitalisations and deaths among children in a malaria-endemic setting; a 2015 Kenyan trial found increased pathogenic gut bacteria and diarrhoea among infants receiving iron-fortified foods.

Why Iron Alone Cannot Address Anaemia

1. Other Nutritional Deficiencies: Folate and vitamin B12 deficiencies also cause anaemia and are common concerns among vegetarian populations.
2. Infectious and Parasitic Diseases: Chronic inflammation, recurrent infections, malaria and hookworm contribute to anaemia through pathways beyond insufficient dietary iron.
3. Haemoglobin Disorders: Beta-thalassaemia and sickle cell disease contribute to anaemia and require attention beyond routine iron supplementation or food fortification.
4. Other Contributing Factors: Early marriage, pregnancy, adolescent undernutrition and menstrual blood losses increase anaemia risks, while low protein and vitamin A intake add to nutritional deficiencies.
5. Dietary Limitations: The Indian diet is often monotonous and low in haem iron, while poor affordability limits access to diverse and nutritious foods.
6. Diagnostic Gaps: Haemoglobin testing alone cannot identify the cause of anaemia, while routine testing for ferritin, vitamin B12 and inflammation markers remains limited.
7. Weak Programme Monitoring: Digital tracking often counts tests and tablets rather than health outcomes, making it difficult to assess actual improvements in anaemia.
8. Neglected Public Health Measures: Deworming, malaria control and water, sanitation and hygiene require greater attention alongside nutritional interventions to address the wider causes of anaemia.

Way Forward

1. Monitored District-Level Pilots: India should conduct district-level DFS pilots before national expansion, measuring haemoglobin, ferritin and inflammation while monitoring potential harm in malaria-endemic and haemoglobinopathy-prone areas.
2. Assess Cumulative Iron Intake: The government should examine iron exposure across existing food fortification and supplementation programmes before introducing additional sources of iron.
3. Targeted Food Fortification: Fortification should be targeted rather than universal and use better-absorbed iron forms suited to local dietary patterns.
4. Strengthen Diagnostic Facilities: Testing should identify different causes of anaemia through ferritin, vitamin B12 and inflammation markers instead of relying only on haemoglobin measurements.
5. Improve Dietary Diversity: Affordable access to eggs, dairy, green leafy vegetables, pulses and millets should improve nutritional intake among vulnerable households.
6. Strengthen Infection Control: Greater investment in deworming, malaria control, clean water, sanitation and hygiene can address important non-dietary causes of anaemia.
7. Learn from Global Experiences: Peru combined iron supplements, micronutrient powders, cash transfers and regional accountability, while Vietnam used weekly supplementation, deworming and iron-fortified fish sauce alongside dietary improvements.

Conclusion

India should address anaemia through accurate diagnosis, targeted supplementation and fortification, diverse diets, infection control and stronger public health services. DFS should not be expanded nationally without monitored pilots, assessment of cumulative iron exposure and evidence of safety and effectiveness. The priority must be better health outcomes, not simply wider distribution of iron.

Question for practice:

Examine the causes of anaemia in India and discuss why iron fortification alone cannot effectively address the problem.

Source: The Hindu