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. 2022 Aug 26;59(11):837–840. doi: 10.1007/s13312-022-2639-6

Childhood and Adolescent Anemia Burden in India: The Way Forward

Anura Viswanath Kurpad 1, Harshpal Singh Sachdev 2,✉
PMCID: PMC9748895  PMID: 36036186

Abstract

The burden of anemia in Indian children, based on capillary blood sampling, is believed to be profound and worsening (67.1%) according to the successive National Family Health Surveys (NFHS). This might be an overestimate. The recent Comprehensive National Nutrition Survey of Indian children, that used venous blood sampling, found only less than half (30.7%) the NFHS prevalence, of which only one third was due to iron deficiency (ID). Unfortunately, the apparently worsening NFHS anemia burden estimate has been interpreted as an inadequacy of the present iron supplementation policy. This has led to additional iron supply through mandatory rice fortification. However, the lack of efficacy of iron supplementation appears inevitable, if the true prevalence of iron deficiency anemia is only about 10%. Thus, etiology is a critical consideration when devising appropriate and effective prevention policies. Future policies must focus on precision, thoughtfulness, restraint, and community engagement.

Keywords: Fortification, Hemoglobin, Prevalence, Iron deficiency

Acknowledgements

AVK and HSS are recipients of the Wellcome Trust/Department of Biotechnology India Alliance Clinical/Public Health Research Centre Grant (IA/CRC/19/1/610006). AVK is also supported by the India Alliance through their Margdarshi Fellowship.

Contributors: Conceptualized, drafted and finalized by both authors, who will be equally accountable for the content.

Funding: None

Competing interests: HSS is a member of the WHO Guideline Development Group on Anemia: Use and interpretation of haemoglobin concentrations for assessing anemia status in individuals and populations. AVK and HSS are members of the National Technical Board on Nutrition and of Task Forces and Expert Groups on anemia constituted by the Department of Biotechnology, Ministry of Health and Family Welfare and the Indian Council of Medical Research.

References

  • 1.National Family Health Survey, India. NFHS-4. Accessed July 15, 2022. Available from: http://rchiips.org/nfhs/nfhs4.shtml
  • 2.National Family Health Survey, India. NFHS-5. Accessed July 15, 2022. Available from: http://rchiips.org/nfhs/nfhs5.shtml
  • 3.Ministry of Health and Family Welfare (MoHFW), Government of India, UNICEF and Population Council. 2019. Comprehensive National Nutrition Survey (CNNS) National Report. Accessed July 15, 2022. Available from: https://nhm.gov.in/WriteReadData/1892s/1405796031571201348.pdf
  • 4.Sarna A, Porwal A, Ramesh S, et al. Characterisation of the types of anemia prevalent among children and adolescents aged 1–19 years in India: A population-based study. Lancet Child Adolesc Health. 2020;4:515–25. doi: 10.1016/S2352-4642(20)30094-8. [DOI] [PubMed] [Google Scholar]
  • 5.Neufeld LM, Larson LM, Kurpad A, et al. Hemoglobin concentration and anemia diagnosis in venous and capillary blood: biological basis and policy implications. Ann N Y Acad Sci. 2019;1450:172–89. doi: 10.1111/nyas.14139. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Varghese JS, Thomas T, Kurpad AV. Evaluation of haemoglobin cut-off for mild anemia in Asians — analysis of multiple rounds of two national nutrition surveys. Indian J Med Res. 2019;150:385–89. doi: 10.4103/ijmr.IJMR_334_18. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.World Health Organization. Haemoglobin concentrations for the diagnosis of anemia and assessment of severity. 2011. Accessed July 15, 2022. Available from: https://apps.who.int/iris/bitstream/handle/10665/85839/WHO_NMH_NHD_MNM_11.1_eng.pdf?ua=1
  • 8.Johnson-Spear MA, Yip R. Hemoglobin difference between black and white women with comparable iron status: justification for race-specific anemia criteria. Am J Clin Nutr. 1994;60:117–21. doi: 10.1093/ajcn/60.1.117. [DOI] [PubMed] [Google Scholar]
  • 9.Sachdev HS, Porwal A, Acharya R, et al. Haemoglobin thresholds to define anemia in a national sample of healthy children and adolescents aged 1–19 years in India: A population-based study. Lancet Glob Health. 2021;9:e822–e831. doi: 10.1016/S2214-109X(21)00077-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Addo OY, Yu EX, Williams AM, et al. Evaluation of hemoglobin cut-off levels to define anemia among healthy individuals. JAMA Netw Open. 2021;4:e2119123. doi: 10.1001/jamanetworkopen.2021.19123. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Indian Council of Medical Research. Nutrient Requirements and Recommended Dietary Allowance for Indians. A Report of the Expert Group of the Indian Council of Medical Research. ICMR-National Institute of Nutrition, 2010.
  • 12.Ghosh S, Sinha S, Thomas T, Sachdev HS, Kurpad AV. Revisiting Dietary Iron Requirement and Deficiency in Indian Women: Implications for Food Iron Fortification and Supplementation. J Nutr. 2019;149:366–71. doi: 10.1093/jn/nxy283. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Indian Council of Medical Research. Nutrient Requirements for Indians. A Report of the Expert Group. ICMR-National Institute of Nutrition, 2020. Accessed July 15, 2022. Available from: https://www.nin.res.in/RDA_Full_Report_2020.html
  • 14.Kulkarni B, Peter R, Ghosh S, et al. Prevalence of iron deficiency and its sociodemographic patterning in Indian children and adolescents: findings from the Comprehensive National Nutrition Survey 2016–18. J Nutr. 2021;151:2422–434. doi: 10.1093/jn/nxab145. [DOI] [PubMed] [Google Scholar]
  • 15.Coffey D, Geruso M, Spears D. Sanitation, disease externalities and anemia: Evidence From Nepal. Econ J (London) 2018;128:1395–432. doi: 10.1111/ecoj.12491. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Mehta U, Dey S, Chowdhury S, et al. The association between ambient PM2.5 exposure and anemia outcomes among children under five years of age in India. Environ Epidemiol. 2021;5:e125. doi: 10.1097/EE9.0000000000000125. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Kurpad AV, Ghosh S, Thomas T, et al. Perspective: When the cure might become the malady: the layering of multiple interventions with mandatory micronutrient fortification of foods in India. Am J Clin Nutr. 2021;114:1261–266. doi: 10.1093/ajcn/nqab245. [DOI] [PubMed] [Google Scholar]
  • 18.Ghosh S, Thomas T, Kurpad AV, Sachdev HS. Is iron status associated with markers of non- communicable disease in Indian children? Preprint, Research Square; December 3, 2021. [preprint] [DOI] [PubMed]
  • 19.Walter PB, Fung EB, Killilea DW, et al. Oxidative stress and inflammation in iron-overloaded patients with beta-thalas-saemia or sickle cell disease. Br J Haematol. 2006;135:254–63. doi: 10.1111/j.1365-2141.2006.06277.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Zimmermann MB, Fucharoen S, Winichagoon P, et al. Iron metabolism in heterozygotes for hemoglobin E (HbE), alpha-thalassemia 1, or beta-thalassemia and in compound heterozygotes for HbE/beta-thalassemia. Am J Clin Nutr. 2008;88:1026–31. doi: 10.1093/ajcn/88.4.1026. [DOI] [PubMed] [Google Scholar]
  • 21.Paganini D, Zimmermann MB. The effects of iron fortification and supplementation on the gut microbiome and diarrhea in infants and children: A review. Am J Clin Nutr. 2017;106:1688S–1693S. doi: 10.3945/ajcn.117.156067. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Peña Rosas JP, Mithra P, Unnikrishnan B, et al. Fortification of rice with vitamins and minerals for addressing micronutrient malnutrition. Cochrane Database of Systematic Reviews. 2019;2019:CD009902. doi: 10.1002/14651858.CD009902.pub2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.Thankachan P, Selvam S, Narendra AR, et al. There should always be a free lunch: the impact of COVID-19 lockdown suspension of the mid-day meal on nutriture of primary school children in Karnataka, India. BMJ Nutrition Prevention and Health. 2022;e000358. [DOI] [PMC free article] [PubMed]
  • 24.Nemeth E, Ganz T. Anemia of inflammation. Hematol Oncol Clin North Am. 2014;28:671–81. doi: 10.1016/j.hoc.2014.04.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Yu EX, Addo OY, Williams AM, et al. Association between anemia and household water source or sanitation in preschool children: the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project. Am J Clin Nutr. 2019;112:488S–97S. doi: 10.1093/ajcn/nqaa148. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 26.Kulkarni B, Augustine LF, Pullakhandam R, et al. ‘Screen and treat for anemia reduction (STAR)’ strategy: Study protocol of a cluster randomised trial in rural Telangana, India. BMJ Open. 2021;11:e052238. [Google Scholar]
  • 27.Kurpad AV, Sachdev HS. Commentary: Time for precision in iron supplementation in children. Int J Epidemiol. 2022; dyac102. [Online ahead of print version]. [DOI] [PubMed]

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