sec 1 IDA

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Iron deficiency itself, and anemia as one of the major consequences, is probably the most widespread nutritional deficiency in the world.

Iron deficiency anemia is endemic in all developing countries, with more than 50% of reproductive women typically affected.

Causes

General-

Quantity- low dietary consumption
Quality- iron is not from heme (animal) sources (more readily absorbed in the intestines)
Dietary factors such as consumption of inhibitors (phytates and phosphates in cereals and grains, egg yolks, and tannins in tea and coffee) and lack of enhancers (ascorbic acid, esp. mixed with salt)
Individual needs are higher and less likely to be met, especially for women and infants

Infants and children-

Premature infants have fewer red blood cells at birth and less iron store, therefore they are prone to anemia
Babies born to anemic mothers have lower iron stores during months of breastfeeding (breastmilk is not a rich source of iron)
Babies breastfed past 6 months or not introduced to iron rich weaning foods
Children with low dietary iron consumption, especially those with hookworm or bilharzia infection

Women-

Pre-menopausal women have increased bodily requirements from blood loss (loss of iron is about double that of men) which are often not met, especially considering low absorption of iron from food (~10% of iron is absorbed)
Pregnant women have increased needs to requirements the fetal as well as her own needs for iron
Lactating women have increased requirements to supply iron in the breastmilk

Manifestations

Children-

Impaired motor development and coordination
Impaired cognitive development (poorer scholastic achievement)
Fatigue and attention deficiency
Lowered resistance to infection

Adults, usually women of reproductive age-

Fatigue, therefore decreased working and earnings
Lowered resistance to infection

Pregnant Women -

Increased maternal morbidity and mortality
Increased risk of low birth weight and miscarriage

Indicators

Process and Outcome Indicators of Iron Deficiency Anemia

Indicator type Indicator

Process and Other Non-Outcome Indicators

Dietary intake - especially for children 6- 71 months, pregnant women, and lactating women; food frequency questionnaire (FFQ) and dietary recall (include measurement of iron absorption enhancing and inhibiting foods)

Iron Supplementation – especially in women of child bearing age and children 3 to 7 years at risk of IDA *

Availability of iron rich foods (both market and home, influenced by seasonality in certain areas)

Disease Prevalence –hookworm, schistosomiasis, malaria, diarrheal disease

Birth weight - children born <2500 grams

Umbilical Cord Ligation – delayed umbilical cord ligation improves iron status

Duration of Exclusive breastfeeding in the first 4-6 months

Poor general nutrition status - stunting and wasting

Birth spac ing – rapid sequence of pregnancies, esp. in teenagers is a risk for IDA

Use of IUDs – intrauterine devices increase menstrual blood losses

Low Maternal education and literacy

Low Family income level

Poor Water supply and sanitation

Inadequate Access to health care

Poor Access to land

Inadequate caring capacity for the child – use of ORT in illness

Outcome

Clinical (not often used and not reliable)

Pallor of the skin and tongue

Tiredness/ Fatigue

Breathlessness and increased heart rate

Sub-clinical
Blood -

Serum Ferritin

Transferrin Saturation

Red Blood Cell protoporphyrin

Mean Corpuscular Volume (MCV)

Hemoglobin

Hematocrit

Sources: Process indicators- John’s notes p6 11, p 3B 18 and 9 4 Main causes of IDA and Prevention of Micronutrient Deficiencies Ch 3 by Fernando Viteri, p56 Table 3-3, 1998. * WHO/ UNICEF/UNU emphasize supplementation of children at risk in 3-7 year old group. Outcome Indicators- Nutrition in Developing Countries, Burgess and King, 199?, Bothwell et. al 1979; Present Knowledge in Nutrition Ch20, 1997.

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Outcome Indicators for Iron Deficiency (Anemia)
Cut-offs at the individual and population level

Indicator
Individual Level
Population Level (%)

(to be defined as a public health problem)

Mild/ Moderate

Severe

Mild

Moderate

Severe

Pallor
(vulnerable groups; e.g pregnant and infants)

Present

Present

--

>5%

--

Serum Ferritin
(vulnerable groups)

10 ug/l
(iron deficient erythropoeisis)

<10 ug/l
(iron deficiency anemia)

--

--

--

Transferrin Saturation
(vulnerable groups)

<15%
(iron deficient erythropoeisis)

<10 %
(iron deficiency anemia)

--

--

--

RBC Protoporphyrin
(vulnerable groups)

100 ug/dl RBC
(iron deficient erythropoeisis)

200 ug/dl RBC
(iron deficiency anemia)

--

--

--

Hemoglobin-
6 mo – <5 years
ł 5 years – 11 years
ł 12 years – 14 years
Women (not pregnant)
Pregnant women

<11.0 to >=7 g/l
<11.5 to >=7 g/l
<12.0 to >=7 g/l <12.0 to >=7 g/l
<11.0 to >=7 g/l

<7g/dl
<7g/dl
<7g/dl
<7g/dl
<7g/dl

ł 5 - <12 % (for all groups)

ł 12 - <19 %
(for all groups)

>20%
(for all groups)

Hematocrit-
6 mo – <5 years
ł 5 years – 11 years
ł 12 years – 14 years
Women (not pregnant)
Pregnant women

33%
34%
36%
36%
33%

--
--
--
--
--

ł 5 - <12 %

(for all groups)

ł 12 - <19 %

(for all groups)

>20%

(for all groups)

Sources: Pallor- Prevention of Micronutrient Deficiencies Ch 3 Prevention of Iron Deficiency, F. Viteri, 1998; SF, TS, Protoporphyrin Bothwell et. al 1979, Hemoglobin at individual level from ACC/SCN 1991 (except 5 yr to 11 year is a new WHO cut-off from www.who.int/chd/pub/newlet/dialog/9/anaemia_in_children.htm; Population level cut-offs for hemoglobin/hematocrit levels is taken from Prevention of Micronutrient Deficiencies Ch 3 Prevention of Iron Deficiency by F. Viteri, Box 3-1, 1998.

The following is a preview to the suggested assessments and action taken when IDA is detected.

…Assessment

Assessment usually involves either a rough prevalence of pale tongue or conjunctiva (pallor), although this is often difficult to determine and not very clinically accurate. As mentioned, it is for ROUGH estimates. If blood is collected, then a hemoglobin or hematocrit (packed cell volume) may be measured by a simple finger prick.

…Action

Distribute ferrous sulphate tablets (200 mg, preferably with folate) at least to pregnant women, but preferably to all women.

Supplement probably required daily, but weekly may suffice—research is currently underway.

Counseling for those receiving supplement to improve adherence.

Try to supply meat, and/or encourage consumption of meat (if economically feasible)

Encourage consumption of fruits and vegetables to provide vitamin C

If possible, begin advocating fortification of the staple cereal.

Indicator type		Indicator
Process and Other Non-Outcome Indicators		Dietary intake - especially for children 6- 71 months, pregnant women, and lactating women; food frequency questionnaire (FFQ) and dietary recall (include measurement of iron absorption enhancing and inhibiting foods) Iron Supplementation – especially in women of child bearing age and children 3 to 7 years at risk of IDA * Availability of iron rich foods (both market and home, influenced by seasonality in certain areas) Disease Prevalence –hookworm, schistosomiasis, malaria, diarrheal disease Birth weight - children born <2500 grams Umbilical Cord Ligation – delayed umbilical cord ligation improves iron status Duration of Exclusive breastfeeding in the first 4-6 months Poor general nutrition status - stunting and wasting Birth spac ing – rapid sequence of pregnancies, esp. in teenagers is a risk for IDA Use of IUDs – intrauterine devices increase menstrual blood losses Low Maternal education and literacy Low Family income level Poor Water supply and sanitation Inadequate Access to health care Poor Access to land Inadequate caring capacity for the child – use of ORT in illness
Outcome	Clinical	(not often used and not reliable) Pallor of the skin and tongue Tiredness/ Fatigue Breathlessness and increased heart rate
	Sub-clinical	Blood - Serum Ferritin Transferrin Saturation Red Blood Cell protoporphyrin Mean Corpuscular Volume (MCV) Hemoglobin Hematocrit

Indicator	Individual Level		Population Level (%) (to be defined as a public health problem)
Indicator	Mild/ Moderate	Severe	Mild	Moderate	Severe
Pallor (vulnerable groups; e.g pregnant and infants)	Present	Present	--	>5%	--
Serum Ferritin (vulnerable groups)	10 ug/l (iron deficient erythropoeisis)	<10 ug/l (iron deficiency anemia)	--	--	--
Transferrin Saturation (vulnerable groups)	<15% (iron deficient erythropoeisis)	<10 % (iron deficiency anemia)	--	--	--
RBC Protoporphyrin (vulnerable groups)	100 ug/dl RBC (iron deficient erythropoeisis)	200 ug/dl RBC (iron deficiency anemia)	--	--	--
Hemoglobin- 6 mo – <5 years ł 5 years – 11 years ł 12 years – 14 years Women (not pregnant) Pregnant women	<11.0 to >=7 g/l <11.5 to >=7 g/l <12.0 to >=7 g/l <12.0 to >=7 g/l <11.0 to >=7 g/l	<7g/dl <7g/dl <7g/dl <7g/dl <7g/dl	ł 5 - <12 % (for all groups)	ł 12 - <19 % (for all groups)	>20% (for all groups)
Hematocrit- 6 mo – <5 years ł 5 years – 11 years ł 12 years – 14 years Women (not pregnant) Pregnant women	33% 34% 36% 36% 33%	-- -- -- -- --	ł 5 - <12 % (for all groups)	ł 12 - <19 % (for all groups)	>20% (for all groups)