Current scenario of iron deficiency in India

• Anemia – Major health problem

• Who are at risk? - Infants, young children, adolescents and pregnant women

• Why? Demand for iron, folic acid & other nutrients by this group is high

• Prevalence – 60 – 90% in different age groups & in 6 – 11years in Delhi 66.4% (Study conducted by Sethi et al – 2002)

• What is the effect in children?

Impaired cognitive performance, behavioral and language development, scholastic achievement, physical performance and increased morbidity and mortality from infectious diseases.

WHY?

• Inadequate intake of iron containing foods

• Inadequate absorption of iron from cereal based

diet

• Inadequate consumption of GLVs & citrus fruits

• High prevalence of infections & infestation.

• Lack of dietary diversification

Strategies to overcome

micronutrient deficiencies

Four main strategies recommended to

overcome micronutrient deficiencies:

• dietary diversification,

• food fortification,

• supplementation with vitamin

and minerals and

• global public health and disease

control measures.

Most effective

intervention

approaches

considering

cost : benefit

ratio

• Benefit:cost ratio ranges from 3:1 to 11:1for

physical productivity alone (median 6:1)

• Ratio ranges from 4:1 to 14:1 (median 9:1)when

including cognitive effects

• Therefore iron interventions are very high

priority

Benefit:cost of iron interventions

Sue Horton, 2008

Achieve Universal Primary education

Iron

improves

Cognitive

skillsSchool

participation

School

achievement

In one study in India, eliminating anemia was associated with a

5.8% point increase in school participation, and a 20% decrease

in absenteeism.

Eradicate extreme poverty and hunger

Iron

improves

Productivity

Manual

Labour

Income

of poor

Iron

improves

Cognitive

skill and

education

Future

income of

poor

children

Anemia is associated with 17% lower productivity in heavy manual

labour, 5% lower productivity in other manual labour, and an estimated

4% loss of earnings due to lower cognitive skills

Food vehicles for iron fortification –

advantages & disadvantages

• Fortification of foods

– Wheat flour

– Rice

– Dry milk

– Cocoa products

– Sauces

– Double fortified salt

– Juice

– Cereal based foods

– Breakfast cereals

Requires further

preparation

Hygiene & safety issue

Cost – unaffordable by

low income group

What is the advantage of biscuit?

• Ready to eat

• Convenient – can be carried anywhere

• Hygienic

• Tastier option

• Low cost / affordable

• Good vehicle of fortification

Impact of intervention with iron

fortified biscuits in anemic

children was assessed

• Study centre: Schools sponsored by Navjyoti India Foundation, Delhi

• Location: Bawana, a resettlement colony in Delhi

• Study protocol – approved by institutional ethical committee of Navjyoti India Foundation

• Parents were given a presentation on importance of iron for children to enable them to decide on their child’s participation in study.

• Informed consent form was obtained from the parents.

SUBJECTS AND STUDY

DETAIL• Age group: 7 – 9 years

• Socioeconomic status: Low

• Gender : Both male & female children; 300 children were

screened

• 3ml of blood was drawn from each child by an expert

clinician and analysed for Hb, TIBC & serum ferritin.

• Basis analysis results of Hb, selection of children was

done.

• Hemoglobin level: < 11g/dl (this level is described as

moderate anemia by ICMR & WHO Stds)

• Out of 300 children, 151 children met this criteria.

• Due to ethical reasons (as all the selected children were anemic), in this study there was no control group and all the selected children received iron fortified biscuits.

• Deworming (Albendazole – 400mg single dose at start and after 15days)

• Ensuring compliance

• Blood parameters & other data –– Hemoglobin – a direct indicator of anemia

– Total iron binding capacity - measures the extent to which iron-binding sites in the serum are saturated

– Serum ferritin – an indicator of iron stores in body

– Height & weight measurements

• These parameters were analysed at start & completion of study.

• Dietary intake record through 24 hour recall method

SUBJECTS AND STUDY

DETAIL - Contd

Distribution pattern of children – anemic

indices

Hemoglobin:

• 10 – 11g Hb 47.5%

• 9 – 10g Hb 25.0%

• 8 – 9g Hb 27.5%

49% of children had serum

ferritin <20ng/ml

95% of children had TIBC

>350mcg/dl

151 children

% distribution

0

5

10

15

20

25

30

35

40

45

50

8 - 9g 9 - 10g 10 - 11g

Hb level

Children dietary pattern & intake

300 children screened 151 (50.3%) met the

inclusion criteria12 children

dropped out –

parents moved

out

139 (92%) completed

the study

Diet intake

-Wheat more than rice

-Vegetables – once a day

-Non veg & Fruits – once a fortnight

-Milk – in the form of tea or coffee

only – literally therefore nil milk

consumption

-Protein & energy intake deficient by

50%

-Iron – through diet met 50% RDA

Four biscuits given to children was

able to meet >75% RDA for iron

Intake of dietary iron

0

5

10

15

20

25

30

35

40

<30% 30 - 50% 50-70% >70%<90%

% RDA

% o

f ch

ild

ren

PRODUCT & INTERVENTION

DETAILS•Britannia biscuit – low cost, mass

product

•Fortified with iron

•Source of iron – ferrous fumarate (an

iron salt recommended by World

Health Organization – after reviewing

various studies on toxicology,

absorption, bioavailability - for cereal

based products).

•Children received biscuits fortified

with Fe @ 5mg/biscuit ~ 20mg

elemental iron per child per day

•Intervention period – 90days

Parameters Nutritional

composi

tion per

100g

biscuit

Nutritional

compositio

n per 33g

biscuit (4

biscuits)

Energy (Kcal) 431.0 142.0

Carbohydrates (g) 76.0 25.0

Proteins (g) 7.0 2.30

Fat (g) 11.0 3.60

Calcium (mg) 15.0 4.95

Iron (mg) 102.0 20.0

Folic acid (mcg) 25.0 8.25

Impact of intervention on Hb status

Level of

Hb in

g/dl

Initial g/dl

(Mean+/

- SD)

Final g/dl

(Mean+/

-SD)

8 - 9g 8.57+/-0.38 12.6+/-1.52

9 - 10g 9.74+/-0.2 12.4+/-1.03

10 - 11g 10.7+/-0.22 12.7+/-0.96

Effect on Hb levels

0

2

4

6

8

10

12

14

8 - 9g 9 - 10g 10 - 11g

Hb

Initial

Final

Impact of intervention on serum

ferritin, TIBC and anthropometric

measurements

Initial Final

Serum ferritin(ng/ml)

<20

20 – 40

10.4±4.6

27.4±6.8

33.6±14

40.7±18

TIBC (mcg/dl) 421.8±5.15 405.1±4.8

Height (in cms) 131.7±4.24 134.4±2.47

Weight (in kgs) 26.0±0.21 27±0.64

No change in school attendance was observed pre and

during intervention time.

Conclusion

Prevalence of anemia in the study group was 52%

Dietary intake of iron was found to be less than RDA.

Intervention with iron fortified biscuits (at 20mg/day) for a period of 90days

showed:

- significant improvement in the status of hemoglobin

- significant improvement of storage iron

- Improvement of TIBC was less significant

- Change observed in anthropometric measurements was

insignificant

To assess the impact of iron fortified biscuits on growth and cognitive

functions a longer period of intervention along with control group is

required.

Thank you