Anaemia in India- Understanding the Causes Beyond Iron Deficiency

Anaemia is a major public health challenge in India. The NFHS-5 found that more than half of women and about two-thirds of young children are anaemic. Although iron deficiency is an important cause, anaemia can result from several nutritional, infectious, and genetic factors. Therefore, a single solution such as iron fortification may not be sufficient to address the problem.

Why in the News?

The debate over Double-Fortified Salt (DFS) has gained attention as a possible solution to India's anaemia burden. DFS is fortified with iodine and iron and is proposed as a way to deliver iron through regular salt consumption. However, concerns have been raised about its effectiveness, excessive iron intake, health risks, and compatibility with India's salt-reduction targets.

What is Double-Fortified Salt (DFS)?

Double-Fortified Salt is ordinary salt fortified with two essential micronutrients:

Iodine: Helps prevent iodine deficiency disorders.

Iron: Helps address iron deficiency.

It is proposed as a convenient way to improve iron intake because salt is commonly consumed by households. However, its effectiveness depends on actual salt consumption, iron absorption, and the nutritional needs of different population groups.

Concerns Associated with Double-Fortified Salt

1. Conflict with Salt Reduction Targets

• Indians consume roughly twice the 5 grams of salt per day recommended by the World Health Organization (WHO).
• About one in three adults has hypertension.
• India's Non-Communicable Disease (NCD) action plan aims for a 30% relative reduction in salt intake.
• DFS depends on regular salt consumption, which may conflict with efforts to reduce sodium intake.
• Households that reduce salt consumption may also receive less iron through DFS.

2. Unequal Iron Intake

• Salt consumption varies according to age, sex and region.
• Adult men generally consume the highest amount of salt.
• Young children and women consume less salt.
• As a result, groups with greater iron requirements may receive smaller doses, while groups with lower anaemia risk may receive more iron.

Iron is Not a Harmless Nutrient

Excessive iron intake can create health risks because the human body has no regulated mechanism to excrete excess iron.

• Iron can accumulate in the body and promote oxidative stress.
• Excess iron has been linked to metabolic diseases.
• People with certain genetic blood disorders may be particularly vulnerable to iron overload.

Evidence from International Studies:

These findings raise concerns about iron supplementation and fortification in areas with high malaria prevalence and poor sanitation.

• Pemba Trial (2006), Tanzania: Iron and folic acid supplementation among children in a malaria-endemic setting was associated with increased hospitalisations and deaths.
• Kenyan Trial (2015): Iron-fortified foods shifted infants' gut flora towards pathogenic bacteria and increased diarrhoea.

Concerns Related to Haemoglobinopathies

Haemoglobinopathies are inherited disorders affecting haemoglobin production or structure.

Millions of Indians carry beta-thalassaemia.

• Sickle cell disease is concentrated in tribal regions.
• People with thalassaemia, particularly those receiving regular blood transfusions, are at risk of iron overload.
• Large-scale screening before distributing DFS is difficult.

For example, the Public Distribution System (PDS) reaches around 800 million people. Screening such a large population before salt consumption is not practical.

Problem of Cumulative Iron Intake

India already distributes iron through several government programmes.

Fortified Rice: Distributed through the PDS, PM POSHAN and Integrated Child Development Services (ICDS).

Iron-Folic Acid Tablets: Provided to several population groups through government programmes.

Double-Fortified Salt: Its additional introduction may increase total iron exposure.

A child or adolescent could receive iron through three or four government programmes simultaneously. However, there is no published analysis of cumulative iron intake across these programmes. Therefore, introducing DFS as a major national programme without assessing total iron exposure may be premature.

Factors Affecting Iron Absorption

The effectiveness of DFS also depends on the type of iron used and the food consumed with it.

• DFS contains non-haem iron, whose absorption depends heavily on the composition of the meal.
• Indian meals commonly include cereals, millets and pulses, which contain phytates that bind iron and reduce its absorption.
• Polyphenols in tea and coffee and calcium in milk can further reduce iron absorption.
• Salt is generally added during cooking or at the table. Therefore, iron from DFS is consumed along with food.
• A significant amount of unabsorbed iron may reach the colon and affect gut microbes.

Role of Infection and Inflammation:

• The hormone hepcidin regulates iron absorption.
• During infection or inflammation, hepcidin levels increase and block iron uptake.
• Therefore, iron fortification may be less effective in populations with a high burden of infections.

Anaemia is Not the Same as Iron Deficiency

Anaemia is a condition in which the haemoglobin level in the blood is below the normal range. Iron deficiency is only one of its possible causes.

• Globally, roughly half of anaemia cases are attributed to iron deficiency.
• India's Comprehensive National Nutrition Survey (2016–18) found that iron deficiency explained only part of the anaemia among children and adolescents.

Major Causes of Anaemia:

Other factors include poor sanitation, adolescent undernutrition and inadequate dietary diversity.

Measurement-related Concerns:

• Capillary haemoglobin readings and the cut-off values used can affect reported anaemia prevalence.
• The methods used to measure haemoglobin and define anaemia are also debated.

Challenges in India's Existing Anaemia Control Strategy

India's revised 7x7x7 approach recognises that anaemia requires multiple interventions. However, some important gaps remain.

• Dependence on Iron-Folic Acid Tablets: Compliance remains a challenge due to gastrointestinal side effects.
• Limited Diagnostic Testing: Haemoglobin testing alone cannot identify the exact cause of anaemia.
• Lack of Biomarker Testing: Routine testing for ferritin, Vitamin B12 and inflammation markers remains limited.
• Dietary Diversity: Awareness campaigns such as Eat Right need to address the affordability of nutritious foods, including eggs, dairy products, green vegetables and millets.
• Weak Outcome Monitoring: Digital tracking often focuses on the number of tests and tablets distributed rather than actual health improvements.
• Limited Focus on Other Interventions: Deworming, malaria control, safe drinking water, sanitation and hygiene need greater attention.

International Experiences in Tackling Anaemia

1. Peru

Peru reduced child anaemia by double digits in the early 2010s. It made anaemia reduction a political priority.

• Children were tracked individually through health contacts.
• Iron supplements and micronutrient powders were combined with cash transfers.
• Regional authorities were held accountable for progress.
• Progress reversed when the COVID-19 pandemic disrupted service delivery.

Lesson: Sustained public health services and accountability are essential for reducing anaemia.

2. Vietnam

Vietnam recorded a sharp decline in anaemia among women. Its strategy included:

• Weekly iron-folic acid supplementation.
• Deworming.
• Fortification of fish sauce with Sodium Iron Ethylenediaminetetraacetate (NaFeEDTA).
• NaFeEDTA is a form of iron that is better absorbed in phytate-rich diets. These measures were accompanied by rising incomes and greater dietary diversity.

Lesson: Fortification works better when it is suited to local diets and combined with other nutrition and public health interventions.

Way Forward

1. Conduct District-Level Pilot Studies

• India should avoid immediate nationwide expansion of DFS.
• Monitored district-level pilots should be conducted first.
• These pilots should assess haemoglobin, ferritin and inflammation markers.
• They should also examine cumulative iron exposure through different government programmes.

2. Targeted Fortification

• Fortification should be targeted rather than universal.
• Better-absorbed forms of iron should be considered.
• Special attention should be given to malaria-endemic and haemoglobinopathy-prone areas.

3. Strengthen Diagnostic Facilities

• Anaemia control should go beyond haemoglobin testing.
• Testing for ferritin, Vitamin B12, and inflammation markers should be improved.
• This will help identify the actual causes of anaemia.

4. Improve Nutrition and Dietary Diversity

• Ensure affordable access to nutritious foods such as eggs, dairy products, green vegetables and millets.
• Address the nutritional needs of women, children and adolescents.

5. Strengthen Public Health Measures

• Improve deworming and malaria control programmes.
• Increase investment in safe drinking water, sanitation and hygiene.
• Strengthen the delivery of existing nutrition programmes.

Conclusion

India's anaemia burden requires a multi-dimensional approach rather than dependence on a single nutrient. Iron fortification may help address iron deficiency, but it cannot solve anaemia caused by infections, nutritional deficiencies and genetic disorders. India should strengthen diagnosis, improve dietary diversity, and invest in sanitation and public health services. Double-fortified salt should be introduced only after careful assessment of its effectiveness and possible health risks.