Iron deficiency, Anemia & Folate Deficiency: National Micronutrient Survey Dr. Tahmeed Ahmed Director, Centre for Nutrition and Food Security, icddr,b

Sampling Primary Sampling Units (MICS 2009) 1 st stage: 150 Primary Sampling Units 2 nd stage: 50 household segments 3 rd stage: 20 households 50 Rural 50 Urban 50 Slum

Primary Sampling Units of the Survey

Iron Deficiency & Anemia Preschool children (6-59 month) School age Children (6-14 years) Non Pregnant Non Lactating Women (15-49 years) Folate Deficiency Non Pregnant Non Lactating Women (15-49 years) Study Population

PreschoolSchool age NPNL Women Total Ferritin Hemoglobin Folate 1050 Sample size Adjusting for Infection Ferritin is adjusted for infection by CORRECTION FACTORS David Thurnham 2010 Reina Engle-Stone 2011

Results

Iron deficiency: S. ferritin <12ng/ml (Pre-school) S. ferritin <15ng/ml (NPNL and School age) Prevalence Iron Deficiency(%)

RDA(mg/d) % of population meeting RDA Median intake of animal iron as % of RDA PSAC 1-3 y PSAC 4-5 y SAC 6-8 y SAC 9-14 y NPNLW y NPNLW y Dietary Intake of Iron

Strata n% National Rural Urban Slums MNP coverage in children 6-23 mo

Groundwater Iron Status in Bangladesh NPNLW 68 ng/ml vs. 44 ng/ml (p<0.001) PSAC 39 ng/ml vs. 23 ng/ml (p<0.001) NPNLW 57 ng/ml vs. 42 ng/ml (p<0.001)

Drinking of tube well water and iron deficiency

Multivariate Regressions showing association of ferritin Independent Variables: Age, Education, Occupation, Residence, Morbidity, Dietary Intake, SES, Household Food Insecurity, Knowledge about iron related health issues, serum level of retinol, zinc, folate and hemoglobin and Groundwater iron level Dependent Variable: Serum Ferritin

VariablestpEffect size Hemoglobin5.85< Agricultural profession (Ref: Non-agricultural) Age7.11< Slum residence (Ref: Rural) Wealth index (Ref: Poorest) Poorer Middle Richer Richest “high” IRON area (Ref: “low” Iron area) Household food insecurity (Ref: food secure) Mild food insecure Moderate food insecure Severe food insecure Multivariate regression showing associations of serum ferritin in PSAC

VariablestpEffect size Hemoglobin Household’s spending Profession (Reference: non-agricultural profession) Agricultural profession Female (Ref: male) Diarrhea in last 2 weeks (Ref: history of diarrhea) No diarrhea in last 2 weeks Connection of electricity (Ref: electricity connected) No connection of electricity Groundwater iron (Ref: “low” GWI area) “High” IRON area (Ref: “Low” Iron area) Knowledge about eating iron rich foods Did not mention, iron rich food is “good for health” (Ref: Did mention) Knowledge about eating iron rich foods “Do not know” (Ref: Knows “which foods are rich source of iron”) Serum retinol Household food insecurity (Ref: food secure) Mild food insecure Moderate food insecure Severe food insecure Multivariate regressions showing associations of serum ferritin in SAC

VariablestpEffect size Hemoglobin3.69< Household’s spending Some institutional education (Ref: no institutional education) Wealth index (Ref: Poorest) Poorer Middle Richer Richest “High” IRON area (Ref: “Low” IRON area)5.00< day total iron intake Knowledge about foods that are rich in iron (Ref: “knows”) “Do not know” Location of residence (Ref: Rural) Urban Slum Serum retinol No. of para Serum zinc Household food insecurity (Ref: food secure) Mild food insecure Moderate food insecure Severe food insecure Serum B Serum folate Possession of refrigerator (Ref: non possession) Possess a refrigerator Multivariate Regressions showing associations serum ferritin in NPNLW

Summary of Positive Associations of Ferritin Preschool children Hemoglobin Age “High” Iron area School age children Hemoglobin Agricultural profession “High” iron area Absence of diarrhea Serum Retinol NPNL Women Hemoglobin “High” iron area “Richest” quintile “Moderate” food insecurity Serum B12 Serum Folate Possession of Refrigerator S. Ferritin

Summary of negative associations of serum ferritin Preschool children Slum residence School children Mother’s lack of knowledge that iron rich food is healthy NPNL women Household expense S. Ferritin

Anemia (%) Preschool age children (6-59 mo)BDHS 2011 National % Rural36.6 Urban22.8 Slum22.0 NPNL women ( y) National % Rural27.4 Urban21.4 Slum20.1 Anemia: Hemoglobin <11 gm/dl (Pre-school) Hemoglobin <12 gm/dl (NPNLW) Prevalence of anemia (%)

School age children (6-11 yrs)Urban anemia survey National Rural21.7 Urban11.8 Slum13.2 School age children (12-14 year) National17.1 Rural18.1 Urban13.2 Slum18.1 Anemia: Hemoglobin <11.5 gm/dl (School age, 6-11 y) Hemoglobin <12 gm/dl (School age, y) Prevalence of anemia (%)

Multivariate Regressions showing association of hemoglobin Independent Variables: Age, Education, Occupation, Residence, Morbidity, SES, Household Food Insecurity, Possession of Assets, Serum level of Ferritin, Retinol, Zinc, Folate, and Groundwater Iron level Dependent Variable: Hemoglobin

VariablestpStandardized Beta Serum ferritin Mother’s institutional education (Ref: none) Serum retinol Age No fever in last 2 weeks (Ref: fever) No measles in last 6 mo (Ref: measles)3.89< Urban location of residence (Ref: rural)4.03< Agricultural profession (Ref: non-agricultural profession)4.74< Wealth index (Ref: Poorest) Poorer Middle Richer Richest “High” Iron area (Ref: “Low” Iron area) Serum zinc Household food insecurity (Ref: food secure) Mild food insecure Moderate food insecure-3.73< Severe food insecure Possession of refrigerator (Ref: non possession) Do not possess a mobile phone (Ref: possession)-4.36< Multivariate regression showing associations of hemoglobin in PSAC

VariablestpStandardized Beta Household’s spending Serum ferritin3.76< Wealth index (Ref: Poorest) Poorer Middle Richer Richest Serum retinol5.14< Agricultural profession (Ref: non-agricultural) Age6.97< Female (Ref: male)-3.68< No fever in last 2 weeks (Ref: fever) Do not possess a mobile phone (Ref: Possession) Do not possess a refrigerator (Ref: possession) Urban location of residence (Ref: Rural) Multivariate regressions showing association of hemoglobin in SAC

VariablestpStandardized Beta Household’s spending Serum ferritin day animal source iron intake day total iron intake No. of para Serum folate Serum retinol Location of residence (Ref: Rural Urban Slum Wealth index (Ref: Poorest) Poorer Middle Richer Richest Serum zinc Household food insecurity (Ref: food secure) Mild food insecure-4.34< Moderate food insecure Severe food insecure Multivariate regressions showing associations of hemoglobin in NPNL

Summary of positive associations of hemoglobin Preschool children Serum ferritin Serum retinol Age “High” iron in water Absence of measles in last 6 mo Urban residence Agricultural profession School children Household expense Serum ferritin Serum retinol Age Urban residence NPNL women 7-day animal iron intake Serum ferritin Serum retinol Serum folate Serum zinc Hemoglobin

Summary of negative associations of hemoglobin Preschool children “Moderate” household food insecurity Non possession of mobile phone School children Poor SES Agricultural profession Being a girl child Non-possession of refrigerator NPNL women “Mild” household food insecurity Hemoglobin

Prevalence of folate deficiency n%95% CI National Rural Urban Slum Prevalence of folate deficiency(%) S. Folate level <6.8 nmol/l (Lindstorm et al 2011)

7-day plant folate intake 7-day animal folate intake 7-day folate intake National Rural Urban Slum Dietary intake of folate by strata

7d Plant source folate (microgram) 7d Animal source folate ( microgram) 7d total folate ( microgram) Food secure Mild insecure Moderate insecure Severe insecure Dietary Intake of folate by household food security in women

RDA: 400 µg/d Only 5.5% women meet the RDA Dietary intake of folate in women (400 µg/d) 160 µg/d

Multivariate regressions showing association of serum folate in women Independent Variables : Household expense, Dietary folate intake, Residence, Assets, Serum level of ferritin, retinol, SES, Household food insecurity Dependent Variable: Serum Folate

VariablesCo-efficientpEffect size Household expense day intake of plant source folate day intake of animal source folate Non married (Ref: married) Serum ferritin Serum retinol Non possession of refrigerator (Ref: possession) Rural location of residence (Ref: slum) SES (Ref: Poorest) Poorer Middle Richer Richest Household food insecurity (Ref: Food secure) Moderate insecure Moderate insecure Severe insecure Multivariate regression showing associations of folate in NPNL women

Summary of positive associations of folate in women Intake of plant source folate Serum ferritin Serum retinol Rural residence S. Folate Summary of negative associations of folate in women Non-possession of refrigerator S. Folate