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Current scenario of iron deficiency in India
• Anemia – Major health problem
• Who are at risk? - Infants, young children, adolescents and pregnant women
• Why? Demand for iron, folic acid & other nutrients by this group is high
• Prevalence – 60 – 90% in different age groups & in 6 – 11years in Delhi 66.4% (Study conducted by Sethi et al – 2002)
• What is the effect in children?
Impaired cognitive performance, behavioral and language development, scholastic achievement, physical performance and increased morbidity and mortality from infectious diseases.
WHY?
• Inadequate intake of iron containing foods
• Inadequate absorption of iron from cereal based
diet
• Inadequate consumption of GLVs & citrus fruits
• High prevalence of infections & infestation.
• Lack of dietary diversification
Strategies to overcome
micronutrient deficiencies
Four main strategies recommended to
overcome micronutrient deficiencies:
• dietary diversification,
• food fortification,
• supplementation with vitamin
and minerals and
• global public health and disease
control measures.
Most effective
intervention
approaches
considering
cost : benefit
ratio
• Benefit:cost ratio ranges from 3:1 to 11:1for
physical productivity alone (median 6:1)
• Ratio ranges from 4:1 to 14:1 (median 9:1)when
including cognitive effects
• Therefore iron interventions are very high
priority
Benefit:cost of iron interventions
Sue Horton, 2008
Achieve Universal Primary education
Iron
improves
Cognitive
skillsSchool
participation
School
achievement
In one study in India, eliminating anemia was associated with a
5.8% point increase in school participation, and a 20% decrease
in absenteeism.
Eradicate extreme poverty and hunger
Iron
improves
Productivity
Manual
Labour
Income
of poor
Iron
improves
Cognitive
skill and
education
Future
income of
poor
children
Anemia is associated with 17% lower productivity in heavy manual
labour, 5% lower productivity in other manual labour, and an estimated
4% loss of earnings due to lower cognitive skills
Food vehicles for iron fortification –
advantages & disadvantages
• Fortification of foods
– Wheat flour
– Rice
– Dry milk
– Cocoa products
– Sauces
– Double fortified salt
– Juice
– Cereal based foods
– Breakfast cereals
Requires further
preparation
Hygiene & safety issue
Cost – unaffordable by
low income group
What is the advantage of biscuit?
• Ready to eat
• Convenient – can be carried anywhere
• Hygienic
• Tastier option
• Low cost / affordable
• Good vehicle of fortification
Impact of intervention with iron
fortified biscuits in anemic
children was assessed
• Study centre: Schools sponsored by Navjyoti India Foundation, Delhi
• Location: Bawana, a resettlement colony in Delhi
• Study protocol – approved by institutional ethical committee of Navjyoti India Foundation
• Parents were given a presentation on importance of iron for children to enable them to decide on their child’s participation in study.
• Informed consent form was obtained from the parents.
SUBJECTS AND STUDY
DETAIL• Age group: 7 – 9 years
• Socioeconomic status: Low
• Gender : Both male & female children; 300 children were
screened
• 3ml of blood was drawn from each child by an expert
clinician and analysed for Hb, TIBC & serum ferritin.
• Basis analysis results of Hb, selection of children was
done.
• Hemoglobin level: < 11g/dl (this level is described as
moderate anemia by ICMR & WHO Stds)
• Out of 300 children, 151 children met this criteria.
• Due to ethical reasons (as all the selected children were anemic), in this study there was no control group and all the selected children received iron fortified biscuits.
• Deworming (Albendazole – 400mg single dose at start and after 15days)
• Ensuring compliance
• Blood parameters & other data –– Hemoglobin – a direct indicator of anemia
– Total iron binding capacity - measures the extent to which iron-binding sites in the serum are saturated
– Serum ferritin – an indicator of iron stores in body
– Height & weight measurements
• These parameters were analysed at start & completion of study.
• Dietary intake record through 24 hour recall method
SUBJECTS AND STUDY
DETAIL - Contd
Distribution pattern of children – anemic
indices
Hemoglobin:
• 10 – 11g Hb 47.5%
• 9 – 10g Hb 25.0%
• 8 – 9g Hb 27.5%
49% of children had serum
ferritin <20ng/ml
95% of children had TIBC
>350mcg/dl
151 children
% distribution
0
5
10
15
20
25
30
35
40
45
50
8 - 9g 9 - 10g 10 - 11g
Hb level
Children dietary pattern & intake
300 children screened 151 (50.3%) met the
inclusion criteria12 children
dropped out –
parents moved
out
139 (92%) completed
the study
Diet intake
-Wheat more than rice
-Vegetables – once a day
-Non veg & Fruits – once a fortnight
-Milk – in the form of tea or coffee
only – literally therefore nil milk
consumption
-Protein & energy intake deficient by
50%
-Iron – through diet met 50% RDA
Four biscuits given to children was
able to meet >75% RDA for iron
Intake of dietary iron
0
5
10
15
20
25
30
35
40
<30% 30 - 50% 50-70% >70%<90%
% RDA
% o
f ch
ild
ren
PRODUCT & INTERVENTION
DETAILS•Britannia biscuit – low cost, mass
product
•Fortified with iron
•Source of iron – ferrous fumarate (an
iron salt recommended by World
Health Organization – after reviewing
various studies on toxicology,
absorption, bioavailability - for cereal
based products).
•Children received biscuits fortified
with Fe @ 5mg/biscuit ~ 20mg
elemental iron per child per day
•Intervention period – 90days
Parameters Nutritional
composi
tion per
100g
biscuit
Nutritional
compositio
n per 33g
biscuit (4
biscuits)
Energy (Kcal) 431.0 142.0
Carbohydrates (g) 76.0 25.0
Proteins (g) 7.0 2.30
Fat (g) 11.0 3.60
Calcium (mg) 15.0 4.95
Iron (mg) 102.0 20.0
Folic acid (mcg) 25.0 8.25
Impact of intervention on Hb status
Level of
Hb in
g/dl
Initial g/dl
(Mean+/
- SD)
Final g/dl
(Mean+/
-SD)
8 - 9g 8.57+/-0.38 12.6+/-1.52
9 - 10g 9.74+/-0.2 12.4+/-1.03
10 - 11g 10.7+/-0.22 12.7+/-0.96
Effect on Hb levels
0
2
4
6
8
10
12
14
8 - 9g 9 - 10g 10 - 11g
Hb
Initial
Final
Impact of intervention on serum
ferritin, TIBC and anthropometric
measurements
Initial Final
Serum ferritin(ng/ml)
<20
20 – 40
10.4±4.6
27.4±6.8
33.6±14
40.7±18
TIBC (mcg/dl) 421.8±5.15 405.1±4.8
Height (in cms) 131.7±4.24 134.4±2.47
Weight (in kgs) 26.0±0.21 27±0.64
No change in school attendance was observed pre and
during intervention time.
Conclusion
Prevalence of anemia in the study group was 52%
Dietary intake of iron was found to be less than RDA.
Intervention with iron fortified biscuits (at 20mg/day) for a period of 90days
showed:
- significant improvement in the status of hemoglobin
- significant improvement of storage iron
- Improvement of TIBC was less significant
- Change observed in anthropometric measurements was
insignificant
To assess the impact of iron fortified biscuits on growth and cognitive
functions a longer period of intervention along with control group is
required.
Thank you