Why Is Anemia Not Reducing In India?

In our last article, we discussed the why and how of prevention of iron deficiency anemia in women and children. We saw the consequences of anemia in women and how neglecting it can impact the physical as well as mental health of their child. A variety of efforts and guidelines have been made over the years to combat anemia efficiently and effectively. In this article, we discuss the role that the government has played in implementing these guidelines and the programs that were successful and those that weren’t. 

Currently, daily folic acid supplementation till the end of the first trimester and iron and folic acid supplementation thereafter is recommended by WHO and the government of India as part of antenatal care. This helps in strengthening the existing iron and folic acid stores. This reduces the risk of low birth weight, anemia, and birth defects in the child.

The government has introduced several programs and schemes throughout the years to improve anemia in our country like the National Iron Plus Initiative, Integrated Child Development Services Scheme, and National Nutrition Mission. These programs, however, have not been very successful in decreasing the prevalence of anemia in women and children.  The coverage of iron and folic acid supplementation has been limited. According to the NFHS-5 report only around 54% and 40% of pregnant women in urban areas and rural areas, respectively, consumed iron-folic acid supplementation for 100 days during their pregnancy.

The Anemia Mukt Bharat strategy, started in 2018, under the POSHAN Abhiyaan, with its structured interventions has shown some promise in reducing anemia. It focuses on six key interventions. 

• Giving IFA to children, adolescents, and women of reproductive age and pregnant women irrespective of anemia. 
• Carrying out a bi-annual mass deworming for children in the age groups between 1-19 years. 
• Conducting behavior change communication activities addressing key behaviors - improving compliance to iron folic supplements, deworming, appropriate infant and young child feeding with age-appropriate complementary foods, increased intake of iron-rich, protein-rich, and vitamin C-rich foods, and delayed cord clamping in health facility deliveries. 
• Screening and testing of anemia in all age groups so that appropriate treatment may be initiated as per the hemoglobin level of the individual. 
• Making the provision of iron and folic acid-fortified foods mandatory in government-funded health programmes. 
• Improving awareness, screening, and treatment of non nutritional causes of anemia in endemic pockets, with a special focus on malaria, hemoglobin defects, and excessive fluorine intake.

There has been an increase in the number of beneficiaries across all groups including pregnant and lactating women and adolescent girls. However, the coverage for children between 6 months and 5 years is still lagging. Despite the reported increase in coverage, according to the NFHS 5 report, in 2019-21 53.4% of women were anemic as opposed to 52.9% of women in 2015-16.

The shortfalls of the programs

A possible reason for the worsening status of anemia in the country could be a lack of compliance with the supplements. Iron tablets are known to cause severe gastritis and diarrhea and thus have shown poor long-term compliance. Lack of awareness regarding the timing and method of consumption of the tablet could also be a barrier to its proper utilization. 

Iron tablets should ideally be taken 1-2 hours before food on an empty stomach. Milk, eggs, tea, and calcium tablets (also prescribed in pregnancy) decrease iron absorption whereas Vitamin C-containing food items increase it. The impact of the stringent lockdown on the supply chain too would have affected the availability and access to these supplements, thus, explaining the worsening of anemia in the recent reports. 

Anemia Mukt Bharat program mainly focuses on iron supplementation and deworming. Anemia occurs due to other causes apart from iron deficiency - deficiency of vitamin B12 and folic acid, impaired production, like in thalassemia, or excessive destruction of the red cells, like in sickle cell anemia, in our blood, or infections like malaria. Anemia also occurs because of chronic blood loss due to gynecological disturbances, conditions like piles, or due to intestinal worm infections. Hence sole supplementation of iron cannot be used to treat all anemias. 

Nutritious food- the new unaffordable vaccine

A vegetarian diet is also linked with iron and vitamin B12 deficiency anemia. Even though a vegetarian diet contains as much dietary iron as a non-vegetarian diet, research has shown that animal-based iron is better absorbed (15-40%) than plant-based iron (1-15%). To make up for the low absorption, large quantities of green leafy vegetables, pulses, and nuts need to be consumed. But these are unaffordable for the majority. 

In today’s time, a non-vegetarian diet also doesn't assure adequate iron consumption as most people cannot afford to eat enough animal products either. The surge in prices of food has considerably shrunk the size of the Indian food basket. The declaration of the year 2023 as the Year of Millet by the United Nations, is a beneficial step in the direction of providing the average Indian adequate nutrition in a cost efficient manner. 

The Way Forward

Improved testing and cause-specific treatment of anemic patients are essential instead of using the one-size-fits-all approach. Just focusing on distribution of iron tablets leads to unncessary iron supplementation in those who do not need it and also leaves people with other causes of anemia untreated. It is therefore essential to educate health providers at all the levels in the health system on the symptoms, causes and treatment of anemia.

Besides providing oral supplementations, the program should also focus on improving the nutritional content of mid-day meals in schools. Collaboration with other programs, like Swachh Bharat Mission, is also important as poor hygiene also plays a significant role in anemia.

The increased coverage across all beneficiary groups with the Anemia Mukt Bharat strategy is encouraging, but the pace of improvement has to be sustained to make a substantial impact on anemia in India. Decentralized decision-making is the need of the hour with region-specific interventions to tackle anemia. Finally, prioritizing women’s health since birth and not just during the period of pregnancy could go a long way in substantially reducing the burden of anemia in our country. 

Edited by Parth Sharma.