Iron deficiency, Anemia & Folate Deficiency: National Micronutrient Survey 2011-12

Dr. Tahmeed AhmedDirector, Centre for Nutrition and

Food Security, icddr,b

Sampling

15000 Primary Sampling Units (MICS 2009)

1st stage: 150 Primary Sampling Units

2nd stage: 50 household segments

3rd stage: 20 households

50 Rural

50 Urban

50 Slum

Primary Sampling Units of the Survey

Iron Deficiency & Anemia

Preschool children (6-59 month)School age Children (6-14 years)Non Pregnant Non Lactating Women (15-49 years)

Folate Deficiency

Non Pregnant Non Lactating Women (15-49 years)

Study Population

Preschool School age NPNL Women

Total

Ferritin 600 1050 1500 3150

Hemoglobin 600 1050 1500 3150

Folate 1050 1050

Sample size

Adjusting for Infection

Ferritin is adjusted for infection by CORRECTION FACTORSDavid Thurnham 2010Reina Engle-Stone 2011

Results

Preschool age

NPNL women

School age (6-11 y)

School age (12-14 y)

0

5

10

15

20

25

30

10.7

7.1

3.9

9.5

National

Rural

Urban

Slums

Iron deficiency: S. ferritin <12ng/ml (Pre-school) S. ferritin <15ng/ml (NPNL and School age)

Prevalence Iron Deficiency(%)

RDA(mg/d) % of population

meeting RDA

Median intake of animal iron as % of RDA

PSAC 1-3 y 7 5.8 14.2

PSAC 4-5 y 10 2.8 7.1

SAC 6-8 y 10 10.4 9.2

SAC 9-14 y 9 16.6 10.0

NPNLW 15-18 y 15 0.0 6.6

NPNLW 19-49 y 18 0.0 5.2

Dietary Intake of Iron

Stratan %

National247 1.3

Rural78 0.7

Urban89 3.3

Slums80 0.0

MNP coverage in children 6-23 mo

Groundwater Iron Status in Bangladesh

NPNLW68 ng/ml vs.

44 ng/ml (p<0.001)

PSAC39 ng/ml vs.

23 ng/ml (p<0.001)

NPNLW57 ng/ml vs.

42 ng/ml (p<0.001)

Rural Urban Slums0

10

20

30

40

50

60

70

80

90

78

67

31

9.4 12.3

27.2

Tubewell water drinking(%)

Prevalence of iron deficiency(%)

Drinking of tube well water and iron deficiency

Multivariate Regressions showing association of ferritin

Independent Variables: Age, Education, Occupation, Residence, Morbidity, Dietary Intake, SES, Household Food Insecurity, Knowledge about iron related health issues, serum level of retinol, zinc, folate and hemoglobin and Groundwater iron level

Dependent Variable: Serum Ferritin

Variables t p Effect sizeHemoglobin 5.85 <0.001 0.25Agricultural profession (Ref: Non-agricultural) 1.67 0.09 0.08Age 7.11 <0.001 0.30Slum residence (Ref: Rural) -2.05 0.04 -0.08Wealth index (Ref: Poorest) Poorer 1.41 0.16 0.08Middle -0.62 0.53 -0.03Richer -1.39 0.16 -0.07Richest -1.01 0.31 -0.06“high” IRON area (Ref: “low” Iron area) 3.35 0.001 0.21Household food insecurity (Ref: food secure) Mild food insecure 0.76 0.45 0.03Moderate food insecure -1.21 0.22 -0.05Severe food insecure 0.63 0.52 0.03

Multivariate regression showing associations of serum ferritin in PSAC

Variables t p Effect sizeHemoglobin 3.25 0.001 0.14Household’s spending -0.94 0.35 -0.05Profession (Reference: non-agricultural profession) Agricultural profession 2.48 0.01 0.13Female (Ref: male) 1.15 0.25 0.05Diarrhea in last 2 weeks (Ref: history of diarrhea) No diarrhea in last 2 weeks 2.11 0.03 0.10Connection of electricity (Ref: electricity connected) No connection of electricity 0.19 0.85 0.01Groundwater iron (Ref: “low” GWI area) “High” IRON area (Ref: “Low” Iron area) 2.95 0.003 0.15Knowledge about eating iron rich foods Did not mention, iron rich food is “good for health” (Ref: Did mention) -2.87 0.004 -0.13Knowledge about eating iron rich foods

“Do not know” (Ref: Knows “which foods are rich source of iron”) 1.34 0.18 0.06

Serum retinol 3.37 0.001 0.15Household food insecurity (Ref: food secure) Mild food insecure -1.62 0.1 -0.07Moderate food insecure -0.99 0.32 -0.06Severe food insecure -1.01 0.31 -0.06

Multivariate regressions showing associations of serum ferritin in SAC

Variables t p Effect sizeHemoglobin 3.69 <0.001 0.16Household’s spending -2.15 0.03 -0.11Some institutional education (Ref: no institutional education) 0.54 0.59 0.025Wealth index (Ref: Poorest) Poorer 2.47 0.01 0.13Middle 1.03 0.30 0.05Richer 1.75 0.08 0.10Richest 2.76 0.006 0.19“High” IRON area (Ref: “Low” IRON area) 5.00 <0.001 0.257-day total iron intake -0.13 0.89 -0.005Knowledge about foods that are rich in iron (Ref: “knows”) “Do not know” -0.13 0.89 -0.006Location of residence (Ref: Rural) Urban -0.23 0.82 -0.01Slum -0.12 0.90 -0.005Serum retinol -0.53 0.60 -0.02No. of para -0.45 0.65 -0.02Serum zinc 0.48 0.63 0.02Household food insecurity (Ref: food secure) Mild food insecure 1.26 0.21 0.06Moderate food insecure 2.60 0.01 0.12Severe food insecure 1.00 0.32 0.05Serum B12 2.06 0.04 0.09Serum folate 3.19 0.002 0.13Possession of refrigerator (Ref: non possession) Possess a refrigerator 2.58 0.01 0.15

Multivariate Regressions showing associations serum ferritin in NPNLW

Summary of Positive Associations of FerritinPreschool childrenHemoglobinAge“High” Iron area

School age childrenHemoglobinAgricultural profession“High” iron areaAbsence of diarrheaSerum Retinol

NPNL WomenHemoglobin“High” iron area“Richest” quintile“Moderate” food insecuritySerum B12Serum FolatePossession of Refrigerator

S. Ferritin

Summary of negative associations of serum ferritin

Preschool children

Slum residence

School children

Mother’s lack of knowledge that iron rich food is healthy

NPNL women

Household expense

S. Ferritin

Anemia (%)

Preschool age children (6-59 mo) BDHS 2011

National 33.1 51.0%

Rural 36.6

Urban 22.8

Slum 22.0

NPNL women (15- 49 y)

National 26.0 42.0%

Rural 27.4

Urban 21.4

Slum 20.1

Anemia: Hemoglobin <11 gm/dl (Pre-school) Hemoglobin <12 gm/dl (NPNLW)

Prevalence of anemia (%)

School age children (6-11 yrs) Urban anemia survey 2001-3

National 19.1 24

Rural 21.7

Urban 11.8

Slum 13.2

School age children (12-14 year)

National 17.1

Rural 18.1

Urban 13.2

Slum 18.1

Anemia: Hemoglobin <11.5 gm/dl (School age, 6-11 y) Hemoglobin <12 gm/dl (School age, 12-14 y)

Prevalence of anemia (%)

Multivariate Regressions showing association of hemoglobin

Independent Variables: Age, Education, Occupation, Residence, Morbidity, SES, Household Food Insecurity, Possession of Assets, Serum level of Ferritin, Retinol, Zinc, Folate, and Groundwater Iron level

Dependent Variable: Hemoglobin

Variables t p Standardized BetaSerum ferritin 3.22 0.001 0.21Mother’s institutional education (Ref: none) 0.03 0.97 0.001Serum retinol 2.66 0.008 0.13Age 2.63 0.009 0.13No fever in last 2 weeks (Ref: fever) -0.63 0.52 -0.03No measles in last 6 mo (Ref: measles) 3.89 <0.001 0.20Urban location of residence (Ref: rural) 4.03 <0.001 0.22Agricultural profession (Ref: non-agricultural profession) 4.74 <0.001 0.25Wealth index (Ref: Poorest)      Poorer 0.67 0.50 0.04Middle 1.88 0.06 0.12Richer -0.33 0.74 -0.02Richest 0.01 0.99 0.001“High” Iron area (Ref: “Low” Iron area) 2.57 0.01 0.14Serum zinc 1.18 0.23 0.07Household food insecurity (Ref: food secure)      Mild food insecure -0.43 0.66 -0.02Moderate food insecure -3.73 <0.001 -0.21Severe food insecure -0.37 0.73 -0.02Possession of refrigerator (Ref: non possession) 1.38 0.16 0.12Do not possess a mobile phone (Ref: possession) -4.36 <0.001 -0.23

Multivariate regression showing associations of hemoglobin in PSAC

Variables t p Standardized BetaHousehold’s spending 2.17 0.03 0.07Serum ferritin 3.76 <0.001 0.11Wealth index (Ref: Poorest)      Poorer -3.16 0.002 -0.11Middle -2.29 0.02 -0.08Richer -1.44 0.15 -0.05Richest -1.20 0.23 -0.05Serum retinol 5.14 <0.001 0.14Agricultural profession (Ref: non-agricultural) -3.09 0.002 -0.09Age 6.97 <0.001 0.20Female (Ref: male) -3.68 <0.001 -0.10No fever in last 2 weeks (Ref: fever) -1.94 0.06 -0.05Do not possess a mobile phone (Ref: Possession) -1.28 0.20 -0.04Do not possess a refrigerator (Ref: possession) -1.99 0.04 -0.08Urban location of residence (Ref: Rural) 2.58 0.01 0.08

Multivariate regressions showing association of hemoglobin in SAC

Variables t p Standardized BetaHousehold’s spending -0.05 0.95 -0.003Serum ferritin 3.1 0.002 0.137-day animal source iron intake 2.46 0.01 0.127-day total iron intake -0.46 0.64 -0.02No. of para -1.42 0.15 -0.06Serum folate 2.13 0.03 0.09Serum retinol 2.93 0.004 0.13Location of residence (Ref: Rural      Urban 1.52 0.13 0.06Slum 1.34 0.18 0.05Wealth index (Ref: Poorest)      Poorer -1.04 0.30 -0.05Middle -1.67 0.10 -0.09Richer -1.59 0.11 -0.09Richest -0.35 0.72 -0.02Serum zinc 1.80 0.07 0.08Household food insecurity (Ref: food secure)      Mild food insecure -4.34 <0.001 -0.20Moderate food insecure -1.14 0.25 -0.05Severe food insecure -0.24 0.81 -0.01

Multivariate regressions showing associations of hemoglobin in NPNL

Summary of positive associations of hemoglobinPreschool childrenSerum ferritinSerum retinolAge“High” iron in waterAbsence of measles in last 6 moUrban residenceAgricultural profession

School childrenHousehold expenseSerum ferritinSerum retinolAgeUrban residence

NPNL women7-day animal iron intakeSerum ferritinSerum retinolSerum folateSerum zinc

Hemoglobin

Summary of negative associations of hemoglobin

Preschool children

“Moderate” household food insecurityNon possession of mobile phone

School children

Poor SESAgricultural professionBeing a girl childNon-possession of refrigerator

NPNL women

“Mild” household food insecurity

Hemoglobin

Prevalence of folate deficiency n % 95% CI

National849 9.1 5.3-12.9

Rural294 8.6 3.6-13.5

Urban288 11.4 6.6-16.3

Slum267 7.9 3.3-12.4

Prevalence of folate deficiency(%)

S. Folate level <6.8 nmol/l (Lindstorm et al 2011)

7-day plant folate intake

7-day animal folate intake

7-day folate intake

National 1031 87 1118

Rural 951 86 1037

Urban 1237 93 1330

Slum 1550 74 1624

Dietary intake of folate by strata

7d Plant source folate

(microgram)

7d Animal source folate

( microgram)

7d total folate ( microgram)

Food secure 1057.5 109.3 1166

Mild insecure 946.9 90.5 1037

Moderate insecure

935.5 62.6 998

Severe insecure 1153.1 39.6 1192

Dietary Intake of folate by household food security in women

RDA (%) Intake(%)0

102030405060708090

100100

40

RDA: 400 µg/d

Only 5.5% women meet the RDA

Dietary intake of folate in women

(400 µg/d)

160 µg/d

Multivariate regressions showing association of serum folate in women

Independent Variables: Household expense, Dietary folate intake, Residence, Assets, Serum level of ferritin, retinol, SES, Household food insecurity

Dependent Variable: Serum Folate

Variables Co-efficient p Effect sizeHousehold expense -0.11 0.82 -0.0097 day intake of plant source folate 0.81 0.005 0.107 day intake of animal source folate 0.22 0.36 0.036Non married (Ref: married) -0.65 0.28 -0.04Serum ferritin 0.86 0.005 0.10Serum retinol 1.85 0.006 0.10Non possession of refrigerator (Ref: possession)

-1.88 0.05 -0.096

Rural location of residence (Ref: slum) 2.11 0.09 0.13SES (Ref: Poorest) Poorer 0.12 0.84 0.009Middle 0.67 0.37 0.04Richer 1.44 0.14 0.07Richest 1.85 0.13 0.09Household food insecurity (Ref: Food secure) Moderate insecure -0.72 0.36 -0.03Moderate insecure -0.38 0.53 -0.02Severe insecure -0.83 0.28 -0.04

Multivariate regression showing associations of folate in NPNL women

Summary of positive associations of folate in women

Intake of plant source folateSerum ferritinSerum retinolRural residence

S. Folate

Summary of negative associations of folate in women

Non-possession of refrigerator

S. Folate