ANEMIA AND STUNTING

SCENARIO IN INDIA
POSSIBLE INTERVENTIONS

ANEMIA
This is a medical situation in which the concentration of haemoglobin in blood
drops down to abnormally low levels.
Causes
This happens due to deficiency of one or several of the following nutrients: iron,
folic acid and vitamin B12. When compared data wise the anemia cases due to
deficiency of iron is the most widespread in comparison to others. Folic acid
deficiency anemia cases are rare and even rarer are the anemia cases caused

due to deficiency of vitamin B 12. There are other causes like chronic infections,
such as malaria and hereditary hemoglobinopathies.
Out of the above, multiple reasons of anemia can coexist in an individual.
However considering the anemia caused due to nutritional deficiency the most
common case if due to deficiency of iron and hence the report would look at
those cases mainly in the children.
Classification Criteria
As per the criteria set by World Health Organization, the following table shows
the cut off of haemoglobin in blood used to classify people from different age
groups as anaemic.

IRON DEFICIENCY PROBLEM

At the time of birth haemoglobin concentrations are higher than at any other
point in life. Although no change in the total amount of iron till four months of
age, there is a continual decrease in the iron reserves with rapid growth
thereafter. There is a large increase in the volume of blood and hence an
increased demand for iron through diet. At this point children are vulnerable to
suffer from iron deficiency ad develop anemia. Other situations in which the
infant is provided with low or non- iron fortified food may result in causing
anemia.
To summarize, the three main reasons for IDA in children are:
a. Poor bioavailability of iron consumed, related to the low consumption of
absorption enhancers and a high consumption of absorption inhibitors in
the second year of life.
b. Insufficient intake of iron as compared to the need.
c. Increased requirement during the rapid growth stage of infancy and early
childhood, between six and twenty-three months.
ANEMIA IN INDIA

Overall, girls and boys are about equally likely to be undernourished. Undernutrition is higher in rural areas and is strongly correlated with the level of
maternal education showing a two-fold difference between non-educated
mothers and 10-year and above educated mothers. This may be linked to a
stark difference in access to a nutritious diet and complementary feeding at
6-9 months.
Most children under age three are anemic (79.2%). The prevalence is slightly
higher in rural areas and among non-educated mothers. High prevalence of
anemia may be linked to poor variety of diet, poor hygienic conditions and
limited access to iron supplementation.

PROGRAMMES UNDERTAKEN TO COUNTER ANEMIA

There are many instances of anemia improving in many parts of the world. Some
examples can be cited as Burundi (64.4% to 28% in 20 years); China (50.0% to
19.9% in 19 years); Nepal (65% to 34% in 8 years); Nicaragua (36.3% to 16.0%
in 10 years); Sri Lanka (59.8% to 31.9% in 13 years); and Viet Nam (40.0% to
24.3% in 14 years).
Prevention of Anemia in Vietnam
In 2006, a pilot project distributing weekly iron-folic acid, together with deworming for all women of reproductive age, was implemented in two districts of
Yen Bai province, covering approximately 50000 women aged 15 to 45 years.
Following an evaluation survey after 12 months, the programme was expanded
to target all women of reproductive age in the province (250 000 women), with
management of the programme led by provincial health authorities. The
prevalence of anemia fell from 38% at baseline to 19% after 12 months and 18%
after 54 months of intervention; the prevalence of iron deficiency anemia fell
from 18% at baseline to 3% at 12 months and remained at 4% at 54 months,
confirming that this condition had essentially been eliminated in this population.
Prevention of Anemia in Venezuela
In 1992, Venezuelan health authorities began a programme to fortify precooked
maize and wheat flours with iron and other vitamins. The authorities achieved
success by selecting an effective and well-absorbed iron compound, choosing
food vehicles that are consumed daily, and maintaining quality control over the
process. Precooked maize was fortified to 50 mg/kg and white wheat to 20
mg/kg. The prevalence of anemia in children aged 7, 11 and 15 years fell by 50%
within 12 months of introduction of this programme, and average ferritin
concentrations had almost doubled in the first 6 years since implementation.

Prevention of Anemia in India

A programme of weekly ironfolic acid supplementation for adolescent girls was

piloted in 52 districts in 13 states. The programme reached both schoolattending and non-attending girls aged 1019 years. Evaluation of the pilot
programmes indicated a 24% reduction in the prevalence of anemia after 1 year
of implementation.
For example, in Gujarat, implementation of intermittent (weekly) ironfolic acid
supplementation to over 1.2 million adolescent girls led to a reduction in the
prevalence of anemia, from 74.2% to 53.5% within 1 year, with estimated
compliance of over 90%. The cost of the programme was estimated at US$ 0.58
per adolescent per year. The project was expanded to cover 11 entire states by
the end of 2011. In 2013, the Government of India introduced national
implementation of weekly ironfolic acid supplementation to approximately 120
million adolescent girls.
Prevention of Anemia in Ghana
Micronutrients and Health (MICAH) program was launched by world vision
Canada in 1995 with funding from Canada International Development Agency
(CIDA) with a goal to reduce micronutrient deficiency in women and children.
This program was implemented in 5 countries Ethiopia, Ghana, Malawi, Senegal
and Tanzania.
The key strategy implemented by Micah for anaemic control in Ghana was
iron/folic acid (IFA) supplementation to vulnerable groups. Dietary diversification
activities were also implemented including promotion of household gardens and
raising small animals for meat consumption. Household gardening included the
promotion of citrus fruits as a source of vitamin C to enhance iron absorption. His
program achieved excellent coverage for IFA supplementation and monitoring
activities showed high compliance rates. Women realized benefits of
haemoglobin levels, older women and men began to request for IFA for
themselves. This is an example of compliance and increased demand for IFA
supplements.
The Iron Intensification Program in Nepal
Similar to most poor countries and based on WHOs global guidance, Nepal for a
long while had a policy of universal, daily iron-folic acid (IFA) supplementation of
pregnant women starting at the beginning of the second trimester of pregnancy
and continuing through 45 days postpartum. The policy stipulated that the IFA be
distributed through health facilities and outreach clinics (ORCs) that were run by
health workers. Beginning in the 1990s, it became apparent that this policy was
not being implemented effectively, and alternative delivery mechanisms were
explored.
Small-scale efforts were then launched in the mid-1990s to explore how access
might be increased through expanding the role of FCHVs in distributing IFA to
pregnant women. The introduction of outreach clinics in 1997 contributed to this

effort to expand access to IFA. Three to five ORCs were established in each
Village Development Committee (VDC) depending on the population, leading to a
total of 15,000 ORCs throughout the country. These were run once a month by
maternal and child health workers (MCHWs) and village health workers (VHWs)
from the sub-health post (SHP) and were supplied a kit with basic medications.
Nepal adopted a community-based delivery platform improved supply and
logistics. After careful monitoring it found out the following things:

Much of the problem of low compliance was due not to lack of supplies,
but rather to the limited understanding on the part of health workers
about the importance of iron deficiency.
There had been little attention paid to increasing the awareness of the
target groups about iron deficiency and its prevention, and this resulted in
little or no demand for IFA and other anemia reduction interventions.
A major constraint to success of anemia programs to date had been that
anemia control was considered synonymous with iron supplementation
and did not address other preventable causes of anemia. To be effective
and sustainable, a more comprehensive and integrated approach was
required, with interventions such as de-worming treatment and malaria
prevention included in the overall strategy.

STUNTING
Stunting is a condition of reduced growth rate among human beings. To talk of
figures, more than 62 million children suffer from this condition in India. It exists
when either the height or the weight of a child corresponding to an age is below
the 5th percentile on the reference growth curve, and is mostly prevalent in the
children aged below 5 years. Not only does it restricts physical growth, but also
causes a deficiency in cognitive abilities such as IQ level, and increases the
chances of illnesses like Diabetes and heart strokes at a later stage in life. The
suffering children tend to stay away from social groups and become lethargic.
Almost 48% of Indian children (61 million) with age lesser than five are suffering
from stunting, which translates into the serious fact that 3 out of 10 stunted
children in the World belong from India.
Causes
Initial research suggested that it is mainly caused due to malnutrition since many
families, being poor and large in size, are not able to earn money enough to
nourish their children after birth or during prenatal stage. The lack in nutritional
intake limits the amount of energy available for work and hence children arent
able to perform satisfactorily.
Nutritional interventions have been made in the past to tackle the nourishment
problem but as it turned out, it cant be the sole solution. Off late it has been
found that stunting can even affect well fed children, poor sanitation and hygiene
levels being the causal agents. From studies, it emerged that open defecation,

which is a shabby practice, still exists in most parts of the country and is more
prevalent than any other country in the World. Though construction of public
toilets and awareness campaigns have happened in the past and is further
picking pace, growth in population is negating any such positive effort. Another
reason that affects child nutritional level is the education level of their mothers.
For example, the proportion of underweight children is 63% in case of mothers
who cant read or write in contrast with 43% children with mothers having 10 or
more years of education.
PROGRAMMES UNDERTAKEN TO COUNTER STUNTING
Despite an overall decrease in developing countries, stunting remains a major
public health problem in many of them. Childhood stunting is one of the most
significant impediments to human development, globally affecting approximately
162 million children under the age of 5 years. First, improving optimal
breastfeeding practices is key to ensuring a childs healthy growth and
development.
Program in Brazil
Stunting among children aged under 5 years also dropped from 37.1% in 1974 to
7.1% in 2007. Five key factors have contributed to Brazils successes in
combating malnutrition:

Improvements in the purchasing power of families through increases in the

minimum wage and expansion of cash-transfer programs.
A rise in the rates of female education.
Improvements and expansion of maternal and child health services.
Expansion of water and sanitation systems; and
Improvements in the quality and quantity of food produced by small family
farms.

Brazils success was also driven by political leadership, effective decentralization,

active civil society involvement and conditional and targeted funding. Not only
has the Government of Brazil demonstrated strong political will to combat
malnutrition, it has also invested strategically in policies and programmes to
improve access to social services.
Program in Peru
An associated programme, JUNTOS (together), is a conditional cash-transfer
programme targeting the poorest municipalities, with the aim of improving
resources at the household level, educational opportunities and the utilization of
health and nutrition services. Stunting among children aged below 5 years
dropped from 22.9% in 2005 to 17.9% in 2010
Program in India

Maharashtra: Maharashtra, a state in western India, was able to successfully

reduce stunting rates in children under 2 years, from 44% in 2005 to 22.8% in
2012
To provide information on the coverage of the Integrated Child Development
Scheme (ICDS) programme, NFHS-3 collected data on the existence of
Anganwadi Centres (AWC) and on the utilization of selected nutrition, health, and
education services provided through AWCs. The coverage of enumeration areas
by an AWC ranges from 100 percent in Tripura to only 27 percent in Meghalaya.
1. Only 81% of children could be covered by Anganwadi Centres.
2. Only 28 percent of the children have received any service from an AWC in
the year preceding the survey.
3. Only about one in five mothers in areas covered by an Anganwadi Centre
received any service from an AWC during pregnancy or during the
lactation period.
4. Only one-quarter of last-born children who were ever breastfed started
breastfeeding within half an hour of birth, as is recommended.
5. Overall only 21 percent of breastfeeding and non-breastfeeding children
are fed according to the infant and young child feeding recommendations.
Conclusion
Studies of the metabolism of stunted children can coincide with studies of water
access, sanitation, and intestinal flora. Such interdisciplinary research would
provide solid evidence of interactions between key factors contributing to
stunting. Living in an environment where many people defecate in the open due
to lack of sanitation has emerged as yet another important cause of stunted
growth in children.