Iron Deficiency in Pregnancy and the Rationality of Iron Supplements Prescribed During Pregnancy

Abstract

Iron deficiency with its resultant anemia is probably the most widespread micronutrient deficiency in the world. Women who are pregnant or lactating and young children are the most affected, especially in the developing world. Despite that only 1 to 3 mg of absorbed iron is required daily at different stages of life, most diets remain deficient. Failure to include iron-rich foods in the diet and inappropriate dietary intake coupled with wide variation in bioavailability (based on the presence of iron absorption inhibitors in the diet) are some of the important factors responsible for iron deficiency. Iron supplementation can be targeted to high-risk groups (eg, pregnant women) and can be cost-effective. Iron fortification of food can prevent iron deficiency in at-risk populations. Selective plant breeding and genetic engineering are promising new approaches to improve dietary iron nutrition quality.

Introduction

Iron deficiency continues to be the leading single nutritional deficiency in the world, despite considerable efforts over the past 3 decades to decrease its prevalence. Many of the affected individuals live in the developing world. Interventional approaches that appear quite feasible in the United States or Europe are impractical in settings where resources are scarce.

The World Health Organization (WHO) estimates that 39% of children younger than 5 years, 48% of children between 5 and 14 years, 42% of all women, and 52% of pregnant women in developing countries are anemic.[1] In India, the second National Family Health Survey in 1998–1999 (NFHS-11) showed that 54% of rural women of childbearing age were anemic compared with 46% of women in urban areas. Kerala has only a 23% prevalence of anemia compared with 62% in many northeastern states of India.[2]

The high frequency of iron-deficiency anemia in the developing world has substantial health and economic costs. In an analysis of 10 developing countries, the median value of physical productivity losses per year resulting from iron deficiency was about US $0.32 per head, or 0.57% of the gross domestic product.[3]

Women in developing countries are always in a state of precarious iron balance during their reproductive years. Their iron stores are not well developed because of poor nutritional intake, recurrent infections, menstrual blood loss, and repeated pregnancies. Gender discrimination in a country like India results in girls lacking access to a balanced diet, adequate healthcare, and proper education. Thus the average Indian woman enters her reproductive years, and particularly pregnancy, with iron and folate deficiency.[4]

During the first 2 trimesters of pregnancy, iron-deficiency anemia increases the risk for preterm labor, low-birth-weight babies, and infant mortality and predicts iron deficiency in infants after 4 months of age.[5,6] It is estimated that anemia accounts for 3.7% and 12.8% of maternal deaths during pregnancy and childbirth in Africa and Asia, respectively.[7] Therefore it is important to diagnose and treat anemia to ensure the optimal health of the mother and the newborn.[7]

Iron Requirements During Pregnancy

The high incidence of iron deficiency underscores the need for iron supplementation in pregnancy. Iron supplementation is especially important because the demand for iron by the mother and the fetus increases during pregnancy. This increased demand cannot be met without iron supplementation. During pregnancy the total maternal need for extra iron averages close to 800 mg (elemental iron), of which about 300 mg is for the fetus and the placenta and the rest is for maternal hemoglobin mass expansion.[4] The placental and fetal requirement is obligatory and dietary intake will be diverted to this end even if the mother is iron-deficient. Approximately 200 mg more is shed via the gut, urine, and skin. This total amount of 1000 mg quite exceeds the iron stores of most women, even in Western countries. Practically all of this iron is used during the later half of pregnancy. Therefore, the iron requirement increases from a 0.8 mg/day in the first trimester to 6 to 7 mg/day in the second half of pregnancy.[4] Overall, a pregnant woman needs about 2 to 4.8 mg of iron per day.[4] The woman must consume 20 to 48 mg of dietary iron to absorb this quantity of iron daily. An average vegetarian diet does not provide more than 10 to 15 mg of iron per day. Thus, the amount of iron absorbed from diet, coupled with that mobilized from body iron stores, is usually insufficient to meet the demands imposed by pregnancy. This is true even though the bioavailability of iron from the gastrointestinal (GI) tract is moderately increased during pregnancy and menstrual iron loss ceases. Therefore, iron supplementation during pregnancy is recommended universally even in nonanemic women.[4]

The usual diet of a population strongly affects iron bioavailability[8]; thus recommended intakes for iron depend on diet characteristics (Table 1). In developing countries, where average meals may be poor in iron, iron supplementation may be considered in prepregnant woman and adolescent girls as well. Women might then enter pregnancy with adequate iron reserves.

Table 1.

Selected Recommended Daily Intakes for Iron, by Estimated Dietary Iron Bioavailability[8]

	Children (1–3 years)	Children (4–6 years)	Women (19–50 years)	Women during pregnancy (second trimester)	Women during breastfeeding (0–3 months lactation)	Men (19–50 years)
15%	3.9	4.2	19.6	> 50.0	10.0	9.1
10%	5.8	6.3	29.4	> 50.0	15.0	13.7
5%	11.6	12.6	58.8	> 50.0	30.0	27.4

Numbers are mg per day.

Recommended daily intake for iron depends on the bioavailability of the diet: diet rich in vitamin C and animal protein = 15%; diet rich in cereals, low in animal protein, but rich in vitamin C = 10%; diet poor in vitamin C and animal protein = 5%.[9]

Strategies

There are 3 main strategies for correcting iron deficiency in populations, which can be used alone or in combination: (1) education combined with dietary modification or diversification to improve iron intake and bioavailability; (2) iron supplementation (provision of iron, usually in higher doses, without food); and (3) iron fortification of foods. A new approach is biofortification by plant breeding or genetic engineering. Although dietary modification and diversification has been traditionally thought of as the most sustainable approach, change of dietary practices and preferences is difficult, and foods that provide highly bioavailable iron (such as meat) are expensive.[9]

Iron Supplementation

Iron supplementation is the most common strategy currently used to address iron deficiency in developing countries. Iron supplementation can be targeted to high-risk groups (eg, pregnant women) and can be cost-effective,[10] but the logistics of distribution and compliance issues are major limitations. For oral supplementation, ferrous iron salts (ferrous sulphate and ferrous gluconate) are preferred because of their low cost and high bioavailability. Standard therapy for iron-deficiency anemia in adults is a 300-mg tablet of ferrous sulphate (60 mg of iron) 3 or 4 times per day. Although absorption is enhanced when given on an empty stomach, nausea and epigastric pain sometimes results. If these side effects occur, lower doses between meals should be attempted or iron should be provided with meals, although food reduces the absorption of medicinal iron by about two thirds.[11] Alternatively, oral iron supplements can be supplied every few days; this regimen might increase fractional iron absorption.[12] In studies supported by WHO in southeast Asia, iron and folic acid supplementation every week to women of childbearing age improved iron nutrition and reduced iron-deficiency anemia.[12] Iron supplementation during pregnancy is advisable in developing countries, where women often enter pregnancy with low iron stores.[13]

Food-Based Approaches

Food-based approaches can broadly be categorized into 2 interventions: dietary improvement and food fortification. Dietary improvement includes strategies to[14]:

• Improve the year-round availability of micronutrient-rich foods;

• Ensure the access of households, especially those at risk, to such foods; and

• Improve dietary habits with respect to these foods.

Efforts to reduce iron deficiency should be directed toward promoting the availability of and access to iron-rich foods. Examples include liver, meat, fish, poultry, and nonanimal foods such as legumes, green leafy vegetables, nuts, oilseeds, jaggery, and dried fruits. In general, animal foods tend to have higher iron content than nonanimal foods.[14]

Bioavailability of iron-containing foods is strongly influenced by enhancers in the diet (eg, ascorbic acid present in citrus fruits, fruit juices, green leafy vegetables, cabbage, cauliflower, tubers, and some germinated or fermented foods such as soya sauce) and inhibitors (eg, phytates present in cereal bran, cereal grains, high-extraction flour, legumes, nut and seeds; calcium, particularly in milk and milk products; tannins present in tea, coffee, and cocoa; phosphates in egg yolk; and oxalates in vegetables). Iron absorption can vary from 1% to 40% depending on the mix of such elements in the meal. Typical vegetarian Indian diets can contain large quantities of inhibitors.[14] Therefore, focus should also be on foods that enhance the absorption or utilization of iron. Examples of simple alterations in food habits that may improve iron bioavailability include:

• Including fresh fruits or fruit juices and other sources of vitamin C such as tomatoes, spinach, cabbage, cauliflower, potatoes, and other green leafy vegetables and tubers in the meal;

• Consuming milk, cheese, and other dairy products as between-meal snacks rather than at mealtimes;

• Separating tea drinking from mealtime by at least 2 hours; and

• Consuming foods that contain inhibitors of iron absorption with tea or milk at those meals that are inherently low in iron such as a breakfast of a low-iron cereal (eg, bread, cornflakes).[4]

Fortification

Iron fortification is probably the most practical sustainable and cost-effective long-term solution to control iron deficiency at the national level.[10,14,15] Fortification of foods with iron is more difficult than it is with other nutrients, such as iodine in salt and vitamin A in cooking oil. The most bioavailable iron compounds are soluble in water or diluted acid, but these compounds often react with other food components to cause off flavors and color changes or fat oxidation or both.[16] Thus, less-soluble forms of iron, although less well absorbed, are often chosen for fortification to avoid unwanted sensory changes. Fortification with low iron doses is more similar to the physiologic environment than is supplementation and might be the safest intervention.[14,17]

Food Fortification in Developing Countries

Universal iron fortification is generally recommended for countries where the risk for iron deficiency is high for all groups other than adult men and postmenopausal women.[14] Food fortification is increasingly being recognized as an effective long-term approach to improving the iron status of populations. An effective fortification program will require the cooperative efforts of governments, the food industry (producers, distributors, and retailers) and consumers. Recent studies have convincingly shown that iron fortification can be effective.[18–20] The iron compound and type of fortification should be chosen on the basis of the fortification vehicle, iron requirements of the target population, and iron bioavailability of the local diet (Table 2).

Table 2.

Iron Compounds That Can Be Used for Iron Fortification of Food in Order of Preference

Most foods (eg, cereal flours)

Ferrous sulfate

Ferrous fumarate

Encapsulated ferrous sulfate or fumarate

Electrolytic iron (at twice the amount vs ferrous sulfate

Ferric pyrophosphate (at twice the amount vs ferrous sulfate)

NaFeEDTA

For high-phytate cereal flours and high-peptide sauces (eg, fish and soy sauce)

NaFeEDTA

For liquid milk products

Ferrous biglycinate

Micronized dispersible ferric pyrophosphate

Ferric ammonium citrate

NaFeEDTA = sodium iron ethylenediaminetetraacetic acid

The foods most often used for mass fortification are staple cereal flours. Iron is only poorly absorbed from high-extraction flours because of the presence of phytate and other inhibitory factors.[21,22] Dried ferrous sulphate can be used in wheat flour that is consumed shortly after it is milled, but in most developing countries flour is stored for longer periods. Thus, elemental iron powders, which are less reactive, are widely used despite their lower bioavailability.[20,22] Findings from an efficacy trial in Thailand suggest that 2 forms of elemental iron, electrolytic iron and hydrogen-reduced iron, might be useful for fortification, but they have only 50% to 79% of the bioavailability of ferrous sulphate.[20] Two other forms of reduced iron, carbon monoxide-reduced and atomized iron, are poorly absorbed and unlikely to be useful for food fortification.

Sodium iron ethylenediaminetetraacetic acid (NaFeEDTA) has shown effectiveness as a fortificant in sugar in Guatemala,[23] in curry powder in South Africa,[24] in soy sauce in China,[25] in fish sauce in Vietnam,[26] and in maize flour in Kenya.[27] NaFeEDTA is absorbed 2 to 3 times better than ferrous sulphate from diets high in phytic acid.[28] NaFeEDTA does not promote fat oxidation in stored cereals and is the only soluble iron compound that does not precipitate peptides in fish and soy sauces. Use of micronized ground ferric pyrophosphate, a white-colored iron compound with good bioavailability, has allowed successful fortification of color-sensitive food vehicles such as low-grade salt in Africa[18,29] and rice in India.[19]

Biofortification

Variation in the iron content of cultivars of wheat, bean, cassava, maize, rice, and yam[9] suggests that selective breeding might increase the iron content of staple foods. However, although there are variations in the iron content of wheat (25–56 mg/kg) and rice (7–23 mg/kg), most of the iron is removed during the milling process. Iron absorption from other cereals and legumes (many of which have high native iron content) is low because of the high phytate and polyphenole content of these foods.[30] It might be necessary to decrease the content of these inhibitors in high-iron cultivars to have a positive effect on human nutrition. Phytic acid content may need to be lowered by more than 90% to increase iron absorption from the monotonous cereal-based diets seen in many developing countries.[31] Because of these limitations, genetic engineering might prove to be the most effective way to ensure a useful amount of absorbable iron in plant foods.[10] Iron content in rice can be increased twofold to threefold by introducing the ferritin gene from soy bean.[32] Iron uptake from soils might be increased by the introduction of a ferric reductase gene into plant root systems.[33] To lower the phytic acid content of rice, Lucca and colleagues[34] introduced a phytase from Aspergillus fumigatus that was developed to withstand food processing.

Iron Preparations Available in the Indian Market and Their Rationale for Use as Supplements

A number of iron preparations are currently available in the Indian market – ferrous, ferric, as well as various iron complexes – for the prevention and treatment of iron-deficiency anemia. The elemental iron dose required for the treatment of iron-deficiency anemia is 120 mg/day according to WHO estimates.[4] Table 3 lists some of the iron preparations available in the Indian market and their compositions and costs. It may be noted that the WHO model list of essential medicines recommends a ferrous salt. For oral supplementation, any preparation can be used provided it has sufficient oral bioavailability considering average Indian meal habits. The choice, therefore, depends to a large extent on cost and subjective adverse effects. Some experimentation may be necessary by the individual to find the most suitable preparation.

Table 3.

Examples of Some Iron Preparations Available in the Indian Market, Their Compositions, and Costs

Brand Name	Compositions	Preparations	Cost (Rs*)
Festo-TR® (DWD Pharma)	Dried ferrous sulfate 60 mg, folic acid 1.5 mg, vitamin C 75 mg, vitamin B6 1.5 mg, vitamin B12 15 mcg	10 tablets	30.00
		1 tablet	3.0
Conviron-TR® (Ranbaxy)	Dried ferrous sulfate (timed release) 60 mg, folic acid 1.5 mg, vitamin B12 15 mcg, vitamin B6 1.5 mg, vitamin C 75 mg	15 capsules	51.00
		1 capsule	3.4
Fesovit® (Glaxo Smith Kline) spansule	Dried ferrous sulfate (timed release) 150 mg, folic acid 1 mg, nicotinamide 50 mg, vitamin B6 2 mg, vitamin B12 15 mcg	30 spansules	73.34
		1 spansule	2.44
Iberol® (Pfizer)	ferrous sulfate 525 mg, vitamin B12 12.5 mcg, liver desiccated 100 mg, vitamin C 75 mg, folic acid 1 mg, vitamin B1 4.5 mg, vitamin B2 5 mg, nicotinamide 45 mg, vitamin B6 1.5 mg, calcium pantothenate 5 mg	30 tablets	49.00
		1 tablet	1.63
Fefol (GlaxoSmithKline) spansule	ferrous sulphate 150 mg, folic acid 0.5 mg	15 spansules	31.05
		1 spansule	2.07
Fefol-Z (GlaxoSmithKline) spansule	ferrous sulphate 150 mg, zinc sulphate monohydrate 6.18 mg, folic acid 0.5 mg	15 spansules	65.90
		1 spansule	4.39
Ironate capsule (Chemo)	Ferrous fumarate 350 mg, L-lysine monohydrate 150 mg, folic acid 1.5 mg, vitamin B12 15 mcg, zinc sulphate 6 mg, copper sulfate 0.2 mg, manganese sulphate 1 mg	10 capsules	19.00
		1 capsule	1.9
Softeron (Aristo)	Folic acid 750 mcg, ferrous fumarate 165 mg, docusate sodium 50 mg, vitamin C 75 mg	15 capsules	17.20
		1 capsule	1.14
Astyfer® (ITL)	Ferrous fumarate 150 mg, L-histidine 4 mg, L-lysine 25 mg, glycine 10 mg, vitamin B1, 1.5 mg, vitamin B 2 5 mg, vitamin C 75 mg, zinc sulphate 41.2 mg, vitamin E 20 mg	10 tablets	13.60
		1 tablets	1.36
Safiron (Khandelwal)	Carbonyl iron 100 mg, folic acid 1.5 mg, vitamin B12 10 mcg, selenium 60 mcg, vitamin E 15 mg, zinc 11.5 mg	30 capsules	400.00
		1 capsule	13.33
Feroluv capsules (Neu Foreva)	Carbonyl iron 100 mg, folic acid 1.5 mg, vitamin B12 15 mcg, vitamin C 75 mg, zinc sulfate 61.8 mg	30 capsules	55.00
		1 capsule	3.66
Fered (Wallace)	iron polymaltose complex 100 mg, folic acid 350 mcg	10 tablets	45.00
		1 tablet	4.5
Fevorit chewable tab (Indoco Remedies)	iron polymaltose complex 100 mg, folic acid 350 mcg	10 tablets	45.00
		1 tablet	4.5
Fecotin-F continus (Modi-Mundi Pharma)	Controlled-release ferrous iron (as glycine sulphate) 100 mg, folic acid 0.5 mg	30 tablets	133.05
		1 tablet	4.43
Fecotin-Z continus (Modi-Mundi Pharma)	Controlled-release ferrous iron (as glycine sulphate) 100 mg, controlled release zinc sulphate monohydrate 61.8 mg, folic acid 0.5 mg	30 tablets	141.90
		1 tablet	4.73

^*Cost is shown in rupees.

mcg = micrograms

Source: Mims India, 2005; 25(8): 230–237.

Much of the reported poor compliance with oral iron therapy is because of the associated side effects. GI side effects are particularly common. Increasing the number of tablets that are required daily is also likely to invite noncompliance. Therefore, a single daily dose of a preparation containing sufficient iron may be preferred in subjects prone to noncompliance and is best given at bedtime.

Many oral preparations of iron available in the Indian market contain ascorbic acid (Table 3) to aid absorption or are in the form of a chelate, which has been shown experimentally to produce a modest increase in iron absorption. However, the clinical advantage is minimal and the cost can be substantially increased. For instance, the currently popular iron (III) hydroxide polymaltose complex is a chelate that has a pleasant chocolate-like taste and does not cause prominent GI irritation. Unfortunately, most rigorous clinical studies have shown that it has variable and generally poor bioavailability.[4] The cost of this preparation, therefore, does not justify its use.

The Indian market is flooded with preparations containing a cocktail of iron, vitamins, minerals, and other micronutrients (Table 3). The iron content of most of these preparations is too low to be of any use in supplementation, even for prophylactic purposes. There are only limited data from well-controlled intervention studies of dietary supplements, and with few exceptions (iron during pregnancy and folate during the periconceptional period), the evidence is not strong that nutrient supplements confer measurable benefit.[35]

Modified-release preparations, often in spansule formulation, are designed to release iron gradually as the preparation traverses the GI tract so that at any given time, only a small amount of iron is present in the lumen. The advantages claimed are less GI irritation and a long duration of action, permitting once- or twice-daily dosage. However, these preparations may carry the iron beyond the first part of the duodenum where the conditions for iron absorption are optimal, and the lower incidence of intolerance may be because a smaller quantity of iron is actually released and absorbed. Furthermore, technical failure of the preparation can lead to dose-dumping and even to entire tablets being passed out in stool.[4]

Many of the preparations available in the Indian market contain minerals (like zinc sulphate, copper sulfate, selenium, and manganese), vitamins, amino acids, and other substances along with iron salt (Table 3). The beneficial effect of such ingredients in pregnancy or to the fetus is still not established and they may not be safe during pregnancy.

It is pertinent to mention here that the newer iron preparations may not be more effective and beneficial in pregnancy. Iron preparations containing iron polymaltose complex and carbonyl iron as a source of elemental iron are much more costly than preparations containing ferrous iron (Table 3). The older preparations are cost-effective for treating iron-deficiency anemia compared with newer iron preparations. Studies have shown that iron polymaltose complex is equally or less effective in improving blood hemoglobin, mean corpuscular hemoglobin, mean corpuscular volume, and mean corpuscular hemoglobin concentration compared with ferrous and ferric iron.[36,37] Higher cost does not mean the preparation will be more effective and the higher cost of newer iron preparations without clear evidential efficacy may result in drug noncompliance.

National Nutritional Anemia Control Programme in India

The National Nutritional Anemia Control Programme (NNACP) aims at significantly decreasing the prevalence and incidence of anemia in women of reproductive age, especially women who are pregnant or lactating, and preschool-age children. The program focuses on the following strategies[38]:

• Promotion of regular consumption of foods rich in iron;

• Provision of iron and folate supplements in the form of tablets to high-risk groups; and

• Identification and treatment of patients who are severely anemic.

The program is implemented through the primary health centers and subcenters. Multipurpose workers (female) and other paramedicals working in the primary health centers are responsible for the distribution of iron tablets (adult and pediatric doses) to women who are pregnant or lactating, women with intrauterine devices, and children aged 1 to 5 years.

The NNACP solicits the support of various departments in implementing dietary modification and supplementation measures:

• The Department of Women and Child Development (Ministry of Human Resource Development) facilitates the distribution of folifer tablets and the education of women in the reproductive age group;

• The Department of Food (Ministry of Food and Civil Supplies) promotes the consumption of iron-rich foods; and

• The Department of Horticulture (Ministry of Agriculture) promotes the production of iron-rich foods.

The program also makes use of a formal and nonformal education system; the media; voluntary, private, and nongovernment organizations; and Panchayats and community members.

Recommended Doses of Folic Acid and Iron Supplementations

Pregnant women should receive 1 adult tablet per day for 100 days. Each tablet contains 100 mg of elemental iron and 500 mcg of folic acid. These tablets should be provided to women after the first trimester of pregnancy.

Women who are lactating or who are using an intrauterine device should receive 1 adult tablet per day for 100 days. Each tablet contains 100 mg of elemental iron and 500 mcg of folic acid.

Preschool-aged children (1 to < 5 years) should receive 1 pediatric (small) tablet containing 20 mg of elemental iron and 100 mcg of folic acid daily for 100 days every year.

The NNACP in India was launched in 1970. However, anemia continues to be a major public health problem. The evaluation of the NNACP in various states of India reveals that the program has not achieved its objective. The main weaknesses of the program were short supplies, poor coverage of the population, inadequate dose of the iron supplement, defective absorption because of intestinal infestations, problems with formulation, inadequate consumption by the beneficiaries, failure to replenish the stocks at the beneficiary level, and lack of effective health education and supervision.[39]

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.

Proposed Initiatives in the Ninth 5-Year Plan (1997–2002)

Under the nationwide Reproductive and Child Health program launched in October 1997, efforts are being made to improve the coverage and quality as well as the efficiency of the NNACP in the ninth plan period. There is increased emphasis on participatory planning in implementing the program at all stages from the grass root to the district levels. These initiatives include the following:

• Ensuring early registration of antenatal mothers;

• Focusing more on regular hemoglobin estimation at each antenatal check-up;

• Promoting blister packaging of iron-folate tablets to ensure better presentation, delivery, acceptance, safe-keeping, and compliance;

• Improving logistics management and the education component and monitoring system for the NNACP;

• Ensuring iron therapy for the required period;

• Including adolescents in the national program; and

• Focusing more on intersectoral coordination, operations research, and concurrent evaluation of the program.

National Consultation

In October 1997, the Ministry of Health and Family Welfare of India organized a National Consultation on Control of Nutritional Anemia with the following objectives:

• To review the epidemiology of nutritional anemia among women who are pregnant or lactating, adolescent girls, and children;

• To review the existing policy on control of nutritional anemia and its implementation to identify gaps and constraints;

• To recommend measures for strengthening the NNACP with reference to its policy and implementation; and

• To identify areas of research required for nutritional anemia control.

Conclusions

Nutritional iron deficiency is still common in young women and children in developing countries, where monotonous plant-based diets provide low amounts of bioavailable iron. The high prevalence of iron deficiency in the developing world has substantial health and economic costs. The NNACP in India was launched in 1970 with the aims of significantly decreasing the prevalence and incidence of anemia in women in the reproductive age group, especially women who are pregnant or lactating, and preschool-aged children. However, anemia continues to be a major public health problem. Partial coverage of the population, inadequate dosing of the iron supplement, short supplies, defective absorption because of intestinal infestations, problems with formulation, inadequate consumption by the beneficiaries, failure to replenish the stocks at the beneficiary level, and lack of effective health education and supervision have been recognized as factors responsible for the program's failure.

Continuing rapid advances in understanding the molecular mechanisms of iron absorption and metabolism might enable the development of new strategies to combat iron deficiency. Although technical challenges limit the amount of bioavailable iron that can be added to many foods, evidence from controlled trials has shown that iron fortification can effectively control iron deficiency. Whether iron fortification can be successful in tropical areas without concurrent control of malaria and hookworm infections remains to be seen. Selective plant breeding and genetic engineering are promising new approaches to improve dietary iron bioavailability; however, a major challenge is to show that they can increase iron content to nutritionally useful levels and that the additional iron is bioavailable.

In medical science, the morbidity and mortality are high in diseases where the cause is unknown or where there is no specific treatment. In nutritional anemia, the cause is not only known, but there are also simple interventions to both prevent and treat the problem. The cost is also well within our means. The continuing prevalence of nutritional anemia in India is thus a neglected tragedy and continues to exact a heavy toll of suffering and death. We know what is needed. The challenge lies in using this knowledge accurately and effectively implementing a solution. Unfortunately, those who require supplementation cannot afford it, and those who can afford it generally do not require it. So, what is actually required is nutritional education and an active role for dieticians in antenatal Outpatient Departments.

Dieticians should educate pregnant mothers about careful selection of food and meal planning and preparation during their routine antenatal checkups. Even simple alterations in food habits like separating tea drinking from mealtime can increase iron absorption.

There is an urgent need to improve the implementation of the NNACP in all its aspects. Policymakers and administrators should encourage implementation of the program. In view of the widespread prevalence of anemia, particularly among pregnant women, the program needs to be strengthened adequately and should be reinforced with alternate measures.