Nutritional Anemia in Bangladesh: Problems and Solutions
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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
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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
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Definition of Anemia at Sea Level
Stoltzfus & Dreyfuss; INACG/UNICEF/WHO 1998
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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
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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
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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
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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
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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
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• 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
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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
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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
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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
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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
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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
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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
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Existing Programs on Iron Supplementation
Age group Department
Infants, children No national program
Adolescents DGFP
PLW DGFP, DGHS, NGOs
NPW DGFP
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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
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Iron-folic Acid Tablets
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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
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Iron Coverage among Pregnant Women
HFSNA 2009
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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
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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
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Multiple Micronutrient Powder
1 RDA of•Iron•Folic acid•Vitamin A•Vitamin C•Zinc
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No colorNo taste of its own
No odor
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Children with the following conditions are excluded:
•Any acute illness
•Severe cough
•Breathlessness
•Severe visible wasting
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What can we do to control anemia?
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• 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
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• 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