Introduction

· Over 800 million women are affected by anemia globally¹.

^·  The poorest nations of the world suffer 60% of the morbidity and 95% of the mortality due to iron deficiency¹.

· South Asia and sub-Saharan Africa bear about 70% of the global iron-deficiency anemia mortality burden¹.

^·  Anemia takes up 12.8% of maternal deaths during pregnancy and childbirth in Asia¹.

^·  In India, anemia stands as a major public health problem, since about 52% of nonpregnant women of reproductive age are anemic¹.

Causes of Anemia

· The primary cause of anemia remains iron deficiency but it is rarely found alone¹.

^·  It coexists with various other causes like malaria, parasitic infection, nutritional deficiencies, and hemoglobinopathies¹.

· The influence of iron deficiency as a cause of anemia differs with the region.

· Nearly 50% of anemia in sub-Saharan Africa is because of iron deficiency due to the high prevalence of HIV, hookworm, malaria, and other infectious diseases¹.

^·  Over 70% of premenopausal women in India suffer from anemia caused by iron deficiency¹.

Consequences of Anemia

^·  Iron deficiency anemia increases the risk for preterm labor, low birth weight, infant mortality, and predicts iron deficiency in infants after 4 months of age¹.

^·  It also causes cognitive deficits and reduced intellectual performance among school children¹.

^·  In regions with a high prevalence of iron deficiency, successful iron supplementation causes dissolution of anemia as a public health problem (except where malaria and HIV or hookworm infection rates are high)¹.

^·  Moderate-to-severe anemia (hemoglobin level below 10 g/dL) are related to significant public health implications¹.

Solicitudes

· Although there has been increased national and international awareness and recent governmental intervention programs, the prevalence of anemia among Indian women is constantly higher than 45% since 1990, and anemia trends remain strongly correlated with iron deficiency¹.

· The main causes of iron deficiency anemia in India are low dietary intake, poor availability of iron, chronic blood loss due to hookworm infestation and malaria¹.

Indian Dietary Pattern is a Concern for Anemia

^·  Vegetarianism, defined as the exclusive consumption of plant-based diets, is a common dietary pattern in India, for at least 2500 years. In India, vegetarianism is due to ethical teachings of “nonviolence” inherent in Hinduism, Buddhism, and Jainism¹.

^·  Indians constitute about 70% of the world’s population who adhere to vegetarian-style diets¹.

· Seventy-five percent of Indian vegetarians are lactovegetarians, who do not consume meat or eggs, with no prohibition for milk or other dairy products¹.

^·  Twenty-five percent of Indian vegetarians are lacto-ovo vegetarians, who do not eat meat, with no prohibition on eggs and dairy products¹.

^·  Further, the popular and affordable foodstuffs in India like wheat bread contain high levels of phytates. Also, tea a popular beverage in India is high in tannic acid content. Phytates and tannins further inhibit iron absorption¹.

· Less than 1% of Indians are vegans, who do not consume any animal products at all¹.

Dietary Recommendations

· Nutritionists recommend vegetarians to increase dietary iron by 80% to compensate for a lower iron availability of 10% from a vegetarian diet compared with 18% from an omnivorous diet ¹.

· This recommendation is challenging for Indians where the majority of vegetarians sustain on inade­quate quantities of iron - poor staples like lentils, wheat bread, green peppers, and rice¹.

· A modified food guide pyramid for vegetarians recommends including 32-36 mg of iron daily in a 2,000 calorie diet comprising 8 servings of grains, 3 of vegetables, 2.5 of green leafy vegetables, 1.5 of fruit, 2.5 of beans and protein foods, 3 of dairy or nonfortified dairy, 1.5 of nuts and seed, and 2.5 of oils¹.

Strategies to Prevent Anemia among Indian Women

Advocate

Consuming meat, fish, chicken, or egg daily or several times weekly can significantly lower the level of anemia¹.

Educate

Spreading knowledge about the importance of iron-rich foods in diet and iron fortification of vegetarian diets will help Indian women fight anemia¹.

Food-based Strategies

Food-based strategies to educate Indian women should include:

· Consumer education to promote diversification of the diet including iron-rich foods¹

· Popularizing and making accessible the foods and fruits containing vitamin C, which enhances iron absorption ¹

^·  Behavior modification should be done to encourage women to avoid consuming tea with meals since tea interferes with iron absorption¹.

Promote

Iron-rich food sources like millet (Ragi ganji), should be promoted to be consumed either as roti bread or as malt beverage. Ragi ganji is higher in iron and contains less iron-inhibiting phytates than rice, wheat and maize¹.

Regional Strategies

Mass food fortification with iron, iron supplementation programs for women and children, implementing effective programs for the prevention of malaria and hookworm, and effective public education about iron-rich sources of plant-based and animal-based foods will serve as effective strategies for reducing the incidence and prevalence of iron deficiency anemia among Indian women¹.

^a30-60 mg of elemental iron equals 150-300 mg of ferrous sulfate heptahydrate, 90-180 mg of ferrous fumarate or 250-500 mg of ferrous gluconate.

^bIn the absence of prevalence data in this group, consider proxies for high risk of anemia. For the most recent estimates, visit the WHO - hosted Vitamin and Mineral Nutrition Information System (VMNIS).

References

1.  Rammohan A, Awofeso N, Robitaille MC. Addressing female iron-deficiency anaemia in India: Is vegetarianism the major obstacle? ISRN Public Health. 2012;2012:765476.

2.  Guideline: Daily iron supplementation in adult women and adolescent girls. Geneva: World Health Organization; 2016. Available from: https://apps.who.int/iris/bitstream/handle/10665/204761/9789241510196_eng.pdf?sequence=1&isAllowed=y