Lessons learned from implementation of a demonstration program to reduce the burden of anemia and hookworm in women in Yen Bai Province, Viet Nam

Background  

Iron deficiency, anemia and hookworm disease are important public health problems for women of reproductive age living in developing countries and affect the health of newborns and infants. Iron supplementation and deworming treatment are effective in addressing these problems in both pregnant and non-pregnant women. Daily iron supplementation and deworming after the first trimester is recommended for pregnant women although these programs usually do not operate efficiently or effectively. Weekly iron-folic acid supplementation and regular deworming for non-pregnant women may be a viable approach for improving iron status and preventing anemia during the reproductive years. Addressing these diseases at a population level before women become pregnant could significantly improve women's health before and during pregnancy, as well as their infants' growth and development.     

Community Mobilization and Social Marketing to Promote Weekly Iron-Folic Acid Supplementation in Women of Reproductive Age in Vietnam: Impact on Anemia and Iron Status

The community mobilization and social marketing program promoting a preventive approach of weekly iron-folic acid supplementation in women of reproductive age improved iron status of non-pregnant women in Vietnam. Three to six months of weekly pre-pregnancy supplementation and regular weekly intake of supplements during pregnancy allowed women to achieve good iron and hemoglobin status during the two first trimesters of pregnancy. In the third trimester, iron deficiency and anemia were notably present but low birth weight prevalence was low. This demonstrates the effectiveness and safety of the preventive approach as implemented here to prevent and control iron deficiency and anemia in women of reproductive age before and during pregnancy.     

Effect of daily iron supplementation on iron status, cell-mediated immunity, and incidence of infections in 6-36 month old Togolese children

OBJECTIVE: To assess the impact of a daily oral iron supplementation on hematological status, cell-mediated immunity and susceptibility to infections in children living in an environment where iron deficiency, malaria and other infections are frequent. DESIGN: Randomized, double-blind iron supplementation including a placebo group. SETTING: A village in Togo, West Africa. SUBJECTS: Of the 229 6-36-month-old children of both sexes recruited, 197 with hemoglobin concentration >/=80 g/l were included and 163 completed the study. INTERVENTION: Children received daily a placebo (n=79) or a dose of 2-3 mg of elemental iron per kg of body weight (n=84) for 3 months. Hematological, nutritional and immune status were assessed at the beginning and at the end of the supplementation period, and 6 months later. Morbidity was recorded throughout the study. RESULTS: Iron supplementation had a significant and positive effect on iron status of children and no impact on the incidence of infections, especially malaria. Its probable effect on immune status was masked by interference of infections and their treatment, which contributed to improve hematological and immune status in both groups. CONCLUSION: According to the negative consequences of anemia and iron deficiency on global child development, control of iron deficiency by oral iron supplementation in young children has to be conducted, associated with prophylaxis and treatment of malaria and repeated deworming. SPONSORSHIP: Program supported by IRD. European Journal of Clinical Nutrition (2000) 54, 29-35     

Prevention and control of iron deficiency in developing countries

Iron deficiency is a global nutritional problem which mainly affects infants, children, and women of childbearing age. Using anemia as an indicator of iron deficiency, an estimated 30-60% of women and children in developing countries are iron deficient. Even in developed countries, iron deficiency warrants significant public health concern. This paper examines iron deficiency and strategies for its control, with an emphasis upon situations commonly found in developing countries. Sections address anemia and mortality, the effect of iron deficit upon child development and behavior, reduced work performance and productivity, meeting the nutritional requirements for iron in young children and women, general issues in the prevention and control of iron deficiency, nutrition promotion and an education-based approach, iron supplementation programs, the elimination of intestinal helminth infections, food fortification-based interventions for infants and younger children as well as adults, concerns about iron overload related to iron fortification, and an agriculture-based approach.     

National nutritional anaemia control programme in India

This article presents the strategies of the National Nutritional Anemia Control Program (NNACP) in India. The program, implemented through the Primary Health Centers and its subcenters, aims at decreasing the prevalence and incidence of anemia in women of reproductive age. It focuses on three vital strategies: promotion of regular consumption of foods rich in iron, provisions of iron and folate supplements in the form of tablets to the high risk groups, and identification and treatment of severely anemic cases. The program solicits the support of various departments in implementing the dietary modification and supplementation measures. Pregnant women are recommended to have one big tablet per day for 100 days after the first trimester of pregnancy; a similar dose applies to lactating women and IUD acceptors. Preschool children (ages 1-5 years) are recommended to take one small tablet per day for 100 days every year. Adult tablets contain 100 mg iron and 500 mg folic acid, while pediatric tablets contain 20 mg iron and 100 mg folic acid. For treatment of severe anemia, women in the reproductive age group are recommended to take three adult tablets per day for a minimum of 100 days. Drinking tea is discouraged, as it may inhibit the absorption of iron in the stomach. There are proposed initiatives to improve coverage, quality, and efficiency of the NNACP in the Ninth Plan period. In October 1997, the Ministry of Health and Family Welfare in India organized a National Consultation on Control of Nutritional Anemia to review the epidemiology of nutritional anemia and the existing policy on nutritional anemia control.     

Implications of malaria on iron deficiency control strategies

The populations in greatest need of iron supplementation are also those at greatest risk of malaria: pregnant women and young children. Iron supplementation has been shown to increase malaria risk in these groups in numerous studies, although this effect is likely diminished by factors such as host immunity, host iron status, and effective malaria surveillance and control. Conversely, the risk of anemia is increased by malaria infections and preventive measures against malaria decrease anemia prevalence in susceptible populations without iron supplementation. Studies have shown that subjects with malaria experience diminished absorption of orally administered iron, so that as a consequence, iron supplementation may have generally reduced efficacy in malarious populations. A possible mechanistic link between malaria, poor absorption of iron, and anemia is provided by recent research on hepcidin, the human iron control hormone. Our improved understanding of iron metabolism may contribute to the control of malaria and the treatment of anemia. Malaria surveillance and control are necessary components of programs to control iron deficiency and may enhance the efficacy of iron supplementation.     

Effects of iron supplementation on maternal hematologic status in pregnancy

OBJECTIVES: Prenatal iron supplementation has been the standard recommendation for reducing maternal anemia in developing countries for the past 30 years. This article reviews the efficacy of iron supplementation on hemoglobin levels in pregnant women in developing countries. METHODS: Data from randomized controlled trials published between 1966 and 1998 were pooled. Meta-analyses of the relative change in maternal hemoglobin associated with iron supplementation were stratified by initial hemoglobin levels, duration of supplementation, and daily gestational supplement dose and supplementation with other nutrients. RESULTS: Iron supplementation raises hemoglobin levels. Its effects are dose dependent and are related to initial hematologic status. The extent to which iron supplementation can reduce maternal anemia is unclear. CONCLUSIONS: The extent to which maternal hemoglobin levels can be increased by recommended prenatal supplementation is limited and has uncertain physiological benefits. Other approaches, including food fortification and prevention and treatment of other causes of anemia, require methodologically rigorous evaluation to find effective answers to this global problem.     

Iron deficiency anemia: Pregnancy outcomes with or without iron supplementation

Objective

To estimate the efficacy of iron supplementation in anemic pregnant women on the basis of occurrence of pregnancy complications and birth outcomes.

Methods

Comparison of the occurrence of medically recorded pregnancy complications and birth outcomes in pregnant women affected with medically recorded iron deficiency anemia and iron supplementation who had malformed fetuses/newborns (cases) and who delivered healthy babies (controls) in the population-based Hungarian Case-Control Surveillance System of Congenital Abnormalities.

Results

Of 22 843 cases with congenital abnormalities, 3242 (14.2%), while of 38 151 controls, 6358 (16.7%) had mothers with anemia. There was no higher rate of preterm births and low birth weight in the newborns of anemic pregnant women supplemented by iron. However, anemic pregnant women without iron treatment had a significantly shorter gestational age at delivery with a somewhat higher rate of preterm births but these adverse birth outcomes were prevented with iron supplementation. The rate of total and some congenital abnormalities was lower than expected and explained mainly by the healthier lifestyle and folic acid supplements. The secondary findings of the study showed a higher risk of constipation-related hemorrhoids and hypotension in anemic pregnant women with iron supplementation.

Conclusion

A higher rate of preterm birth was found in anemic pregnant women without iron treatment but this adverse birth outcome was prevented with iron supplementation. There was no higher rate of congenital abnormalities in the offspring of anemic pregnant women supplemented with iron and/or folic acid supplements.     

Effects of iron and zinc supplementation in Indonesian infants on micronutrient status and growth.

In this study the effects of supplementation of iron and zinc, alone or combined, on iron status, zinc status and growth in Indonesian infants is investigated. Micronutrient deficiencies are prevalent in infants in developing countries, and deficiencies often coexist; thus, combined supplementation is an attractive strategy. However, little is known about interactions between micronutrients. In a randomized, double-blind, placebo-controlled supplementation trial, 478 infants, 4 mo of age, were supplemented for 6 mo with iron (10 mg/d), zinc (10 mg/d), iron + zinc (10 mg of each/d) or placebo. Anthropometry was assessed monthly, and micronutrient status was assessed at the end of supplementation. Supplementation significantly reduced the prevalence of anemia, iron deficiency anemia and zinc deficiency. Iron supplementation did not negatively affect plasma zinc concentrations, and zinc supplementation did not increase the prevalence of anemia or iron deficiency anemia. However, iron supplementation combined with zinc was less effective than iron supplementation alone in reducing the prevalence of anemia (20% vs. 38% reduction) and in increasing hemoglobin and plasma ferritin concentrations. There were no differences among the groups in growth. The growth of all groups was insufficient to maintain the same Z-scores for height for age and weight for height. There is a high prevalence of deficiencies of iron and zinc in these infants, which can be overcome safely and effectively by supplementation of iron and zinc combined. However, overcoming these deficiencies is not sufficient to improve growth performance in these infants.     

Nutrition intervention program for the management of iron‐deficiency anemia in a group of pregnant women in Jordan

The impact of a nutrition education intervention program on the prevention of iron deficiency anemia in a group of pregnant Jordanian women was evaluated. The program was based on planned meals from local food sources in combination with nutritional counseling as an alternative approach to more costly iron supplementation.

Data on dietary intake, anthropometric measures, iron status indices and nutrition knowledge were used in evaluation of program effectiveness.

The treatment group showed increased nutrition knowledge, more adequate nutrient intake, normal weight gain and better iron status than the control group, which received only usual care including limited nutrition counseling.

Results of the study indicate the feasibility of the nutrition intervention program in the management of iron‐deficiency and prevention of anemia in women from communities of low socio‐economic status.     

Efficacy of iron supplementation with or without vitamin A for anemia control

This study aimed to evaluate the efficacy of weekly iron supplementation with or without vitamin A in the treatment of iron deficiency anemia, using an experimental, randomized, non-placebo-controlled design in 1999. 267 schoolchildren 6 to 14 years of age were randomized to two treatment groups: one group (144) received 200mg iron sulfate alone, with 40 mg of elemental iron, while the other (123) received the same iron supplementation dose plus 10,000 IU of vitamin A (both groups for 30 weeks). Final anemia prevalence was reduced from 48.4% to 17.7% (p < 0.001) in the group receiving iron supplementation alone and 58.1% to 14.3% (p < 0.001) in the group receiving iron plus vitamin A. There was no significant difference between the groups at the end of the study according to mean Hb (p = 0.355) and anemia (p = 0.479). There was a significant correction for iron deficiency anemia with weekly iron-alone supplementation, but with no additional advantage of vitamin A. New studies on the synergism between these two micronutrients are recommended.     

Hookworms, malaria and vitamin A deficiency contribute to anemia and iron deficiency among pregnant women in the plains of Nepal

Anemia and iron deficiency during pregnancy are prevalent in developing countries, but their causes are not always known. We assessed the prevalence and severity of anemia and iron deficiency and their association with helminths, malaria and vitamin A deficiency in a community-based sample of 336 pregnant women in the plains of Nepal. Hemoglobin, erythrocyte protoporphyrin (EP) and serum ferritin were assessed in venous blood samples. Overall, 72.6% of women were anemic (hemoglobin < 110 g/L), 19.9% had moderate to severe anemia (hemoglobin < 90 g/L) and 80.6% had iron deficiency (EP > 70 micromol/mol heme or serum ferritin < 10 microg/L). Eighty-eight percent of cases of anemia were associated with iron deficiency. More than half of the women (54.2%) had a low serum retinol concentration (<1.05 micromol/L), 74.2% were infected with hookworms and 19.8% had Plasmodium vivax malaria parasitemia. Hemoglobin, EP and serum ferritin concentrations were significantly worse and the prevalence of anemia, elevated EP and low serum ferritin was increased with increasing intensity of hookworm infection. Hookworm infection intensity was the strongest predictor of iron status, especially of depleted iron stores. Low serum retinol was most strongly associated with mild anemia, whereas P. vivax malaria and hookworm infection intensity were stronger predictors of moderate to severe anemia. These findings reinforce the need for programs to consider reducing the prevalence of hookworm, malaria infection and vitamin A deficiency where indicated, in addition to providing iron supplements to effectively control anemia.     

2 325例学龄期儿童缺铁性贫血患病状况及影响因素分析

目的探究2 325例学龄前儿童缺铁性贫血患病情况并分析其影响因素。方法选取2016年6月—2018年6月在河西学院附属张掖人民医院进行体检的2 325例儿童为研究对象,筛选出其中缺铁性贫血患儿,患儿及家属接受问卷调查,分析接受体检学龄前儿童缺铁性贫血患病情况,影响学龄前儿童缺铁性贫血患病单因素以及多因素logistic回归分析。结果接受体检2 325例儿童中检出缺铁性贫血儿童198例,其中轻度、中度以及重度贫血分别60例、81例和57例,缺铁性贫血儿童患病率为8.52%;单因素分析结果显示,影响学龄前儿童缺铁性贫血因素有年龄、出生时体质量指数、母亲妊娠期是否有贫血、是否早产、患儿肠胃消化能力是否正常、喂养形式、进辅食时间、父母学历、是否正常补充铁元素、家庭饮食习惯以及父母月收入(P0.05);多因素logistic回归分析结果显示,年龄小、母亲妊娠期贫血、早产、患儿肠胃消化能力不佳、进辅食时间晚、未补充铁元素以及家庭饮食习惯不佳等为导致患儿缺铁性贫血发生的危险因素(P0.05)。结论预防学龄期儿童缺铁性贫血工作关键在于关注孕妇以及胎儿营养情况,调整儿童饮食结构,养成合适饮食习惯。     

Concomitant supplemental vitamin A enhances the response to weekly supplemental iron and folic acid in anemic teenagers in urban Bangladesh.

BACKGROUND: Iron deficiency is the most common micronutrient deficiency and affects >2 billion persons worldwide, leading to anemia in >40% of women of reproductive age in the developing world. OBJECTIVE: The objective was to determine whether weekly supplementation with iron and folate would reduce the frequency of anemia in teenage women in urban Bangladesh before they became pregnant. DESIGN: Participants with a hemoglobin concentration of 80-120 g/L were entered into a randomized, double-blind, placebo-controlled trial and received supplements of placebo, vitamin A, iron + folic acid, or iron + folic acid + vitamin A weekly for 12 wk. The supplements contained 2.42 mg vitamin A (retinol) as retinyl palmitate, 120 mg elemental Fe as ferrous sulfate, and 3.5 mg folic acid. RESULTS: Hemoglobin concentrations increased significantly more after supplementation with iron + folic acid or iron + folic acid + vitamin A than after either the placebo or vitamin A alone. There was a significantly greater increase in hemoglobin after iron + folic acid + vitamin A than after iron + folic acid, but the additional effect disappeared after adjustment for baseline hemoglobin, serum vitamin A, and ferritin and the number of supplements taken. Those with the lowest baseline hemoglobin had the greatest increase in hemoglobin. Compared with the placebo, iron + folic acid + vitamin A reduced anemia by 92%, iron deficiency by 90%, and vitamin A deficiency by 76%. CONCLUSION: There may be significant health benefits from a program that enhances the nutritional status of iron, folate, and vitamin A in poor urban young women before they become pregnant.     

Effect of iron supplementation among pregnant women at mother-and-baby clinic of Sidi Bel Abbès, West Algeria

Iron deficiency is the most prevalent nutritional disorder worldwide, especially in developing countries. It occurs when iron absorption does not equal iron requirements plus iron loss. Because iron requirements are especially high in pregnant women, infants, young children, and adolescents, these groups run a high risk of iron-deficiency anemia. In this controlled prospective and longitudinal study of 83 pregnant women, we explored the correlations between various epidemiological characteristics and the onset of anemia. We also looked at the effect of iron supplementation on the hematological parameters among pregnant women with anemia. Blood counts during the first trimester of pregnancy (3 months +/- 2 weeks' gestation) revealed that 31 of the 83 subjects (37.3%) women had anemia (Hb < 11 g/100 ml): 16 moderate (7 g/dl < or = Hb < 10 g/dl) and 15 mild (10 g/dl < or = Hb < 11 g/dl). We detected no cases of severe anemia in our study. Nor did we find a clear correlation between anemia and such factors as age (r = 0.09), number of pregnancies (r = - 0.30), interval between pregnancies (r = 0.03), or number of abortions (r = - 0.18). Nonetheless, iron supplementation of 30 mg/day, prescribed for four months for all the women with anemia (n = 31), improved some of these hematological parameters, increasing hemoglobin and serum iron levels in particular. These two parameters were strongly positively correlated (r = 0.89). We also noted that the red blood cell count (RBC) and the mean corpuscular hemoglobin concentration (MCHC) both increased significantly (p < 0.05) among the anemic women receiving iron supplements. The prevalence of anemia fell from 34.1% in the first trimester, before supplementation, to 6.3% in the third trimester. This finding suggests that the supplementation prevented the fall in hemoglobin and serum iron that occurred among the women without anemia. We think that iron supplementation is a good strategy for treating and preventing anemia during pregnancy.     

Effect on longitudinal growth and anemia of zinc or multiple micronutrients added to vitamin A: a randomized controlled trial in children aged 6-24 months

Background  

The benefits of zinc or multiple micronutrient supplementations in African children are uncertain. African children may differ from other populations of children in developing countries because of differences in the prevalence of zinc deficiency, low birth weight and preterm delivery, recurrent or chronic infections such as HIV, or the quality of complementary diets and genetic polymorphisms affecting iron metabolism.     

Iron deficiency and anemia: a common problem in female elite soccer players

The objective of the study was to determine the prevalence of iron deficiency and iron deficiency anemia among elite women soccer players. Hemoglobin, serum iron, serum total iron binding capacity, and ferritin were determined in 28 female soccer players called up for the national team. Of the investigated female soccer players, 57% had iron deficiency and 29% iron deficiency anemia 6 months before the FIFA Women's World Cup. It is concluded that iron deficiency and iron deficiency anemia is common in female soccer players at the top international level. Some might suffer from relative anemia and measurement of hemoglobin alone is not sufficient to reveal relative anemia. Regular monitoring of hemoglobin concentration and iron status is necessary to institute iron supplementation when indicated.     

Iron Compounds for Food Fortification: Guidelines for Latin America and the Caribbean 2002

Iron deficiency is the most prevalent micronutrient deficiency in the world today. It affects millions of individuals throughout the life cycle, particularly infants and pregnant women, but also older children, adolescents, and women of reproductive age. Living organisms require iron for their cells to function normally. Iron is needed for the development of vital tissues - including the brain - and for transporting and storing oxygen in hemoglobin and muscle myoglobin. Iron deficiency anemia is the severe form of iron deficiency. It can result in low resistance to infection, impaired psychomotor development, and cognitive function in children, poor academic performance, as well as fatigue and poor physical/work endurance. In addition to the above, iron deficiency anemia in pregnancy can result in a low-birth-weight infant. Three intervention strategies are available to prevent iron deficiency and, therefore, iron deficiency anemia. These are supplementation, dietary diversification, and both targeted and untargeted food fortification. Nineteen countries in the Americas have a national food fortification program, in which iron and other micronutrients are added to at least one widely consumed food that is often wheat and/or corn flour. Table 1 shows the iron compounds added to the flours. Each iron compound has different properties and characteristics, which influence its bioavailability, as is discussed later. A number of countries also currently implement fortification programs targeted to specific groups of the population, primarily infants and young children age 6 to 24 months and school-age children.     

Iron interventions for women and children in low-income countries

The WHO estimates that 41% of women and 27% of children suffer from anemia due to iron deficiency. The consequences of iron deficiency anemia include suboptimal mental and motor development in young children, increased risk of maternal mortality, and decreased economic productivity of adults. Recent research also provides evidence that maternal iron deficiency in pregnancy increases neonatal morbidity and mortality. This short review briefly highlights how iron interventions might be positioned within 4 global health initiatives: making pregnancy safer, saving newborn lives, infant and young child feeding, and fortification. The importance of iron nutrition is recognized in the context of child nutrition, fortification, and biofortification, and it is likely that meaningful advances will be made through these initiatives in the coming decade. However, iron nutrition is not yet well integrated into the programmatic agendas for reducing morbidity and mortality of pregnant women and neonates. Iron supplementation in pregnancy has been advocated for decades as a means of controlling anemia, but this outcome has not been sufficient to motivate strong programs and policies, and the evidence base is still sparse for high-priority clinical outcomes. To act on the current evidence for maternal and neonatal health will require stronger advocacy within circles that have not traditionally included nutritionists. Successful implementation will require greater attention to antenatal care for pregnancy women and prioritization of iron-promoting actions (including iron supplementation and deworming) within that platform.