1. Nutritional Anemia in Bangladesh: Problems and Solutions Dr Tahmeed Ahmed Director Centre for Nutrition & Food Security ICDDR,B Professor, Public Health Nutrition James P. Grant School of Public Health, BRAC University

2. Anemia A condition in which the Hb concentration in the blood is below a defined level, resulting in a reduced oxygen-carrying capacity of red blood cells

3. Definition of Anemia at Sea Level Stoltzfus & Dreyfuss; INACG/UNICEF/WHO 1998

4. Consequences of Anemia Poor immune function and increased morbidity from infection Fatigue and lower physical work capacity Poor physical growth Impaired learning and school achievement Brabin BJ 2001 Grantham-McGregor S 2001

5. Consequences of Anemia in Pregnancy Increased risk of complications during delivery, including prolonged labor, preterm delivery, LBW and maternal and neonatal deaths Infants of mothers with iron deficiency anemia are more likely to have low iron stores and to become anemic Brabin BJ 2001 Grantham-McGregor S 2001

6. Christian P 2005 UN/SCN 2004 Anemia causes huge economic loss Results in productivity loss Economic cost of anemia in Bangladesh is estimated to be 7.9% of GDP

7. What are the causes of anemia? Iron deficiency – dietary deficiency, loss of iron Hookworm Vitamin deficiencies, eg vitamin B12, folic acid Malaria Hemoglobinopathies, eg thalassemia Chronic infections, such as TB, HIV

8. Iron Deficiency Anemia Iron deficiency is the most important cause of anemia 60% of all anemia is due to iron deficiency Stoltzfus R 1998, Black RE 2008

9. Review of literature, survey reports Meta analyses Communication with stake holders from public, private and research sectors 22 interviews - NNP, DGFP, IPHN, IEDCR, CMSD, NIPORT, EDCL, UNICEF, MI, BRAC, ICDDR,B Informal round table discussion at ICDDR,B Review of Anemia Control Program

12. AgeYearSettingsSample Size% Infants (6-11 mo) 2004 1 2003 2 2001 3 1999 4 Rural Urban CHT Rural Urban 1227 U-5 93 51 1148 U-5 183 92 83.9 90 74.1 92.3 NSP 2004 1, Anemia prevalence survey UNICEF/BBS 2003 2, NSP 2002 3, NSP 2000 4 Prevalence of Anemia in Bangladesh

13. AgeYearSettingsSample Size% Infants (6-11 mo) 2004 1 2003 2 2001 3 1999 4 Rural Urban CHT Rural Urban 1227 U-5 93 51 1148 U-5 183 92 83.9 90 74.1 92.3 NSP 2004 1, Anemia prevalence survey UNICEF/BBS 2003 2, NSP 2002 3, NSP 2000 4 Prevalence of Anemia in Bangladesh Demand for iron is high Complementary feeding is inappropriate No program for anemia control in infants

14. Complementary Foods Provide little Micronutrients to Bangladeshi Infants Kimmons J, 2006  Breast milk contributes to 75% of total energy intake  Small amounts of CF offered  Vitamin B6 50% of RNI  Vitamin A 48% of RNI  Zinc 45% of RNI  Iron 9% of RNI  Increase in CF will not substantially increase MN intake

15. AgeYearSettingsSample Size% Pre-school (6-59 mo) 2004 1 2003 2 2001 3 Rural Urban Rural 1227 861 1148 68 55.7 48.3 Adolescent (13-19 yr) 2004 1 2003 2 2001 3 Rural Urban Rural 661 1341 237 39.7 23.4 30 NSP 2004 1, Anemia prevalence survey UNICEF/BBS 2003 2, NSP 2002 3 Pre-school Children and Adolescent Girls

16. 200420032001 74.1 92 67.9 48.3 39.7 30 46 33 38.8 46.7 35 46 NSP 2004, Anemia prevalence survey UNICEF/BBS 2003, NSP 2002, WHO global database on anemia Anemia Prevalence Trends in Bangladesh

17. Strategies for Anemia Prevention and Control Micronutrient supplementation Dietary improvement Parasitic disease control Food fortification Family planning and safe motherhood National Strategy for Anemia Prevention and Control in Bangladesh, MOHFW 2007

18. Existing Programs on Iron Supplementation Age groupDepartment Infants, childrenNo national program AdolescentsDGFP PLWDGFP, DGHS, NGOs NPWDGFP

19. Dose of Iron-folic Acid Tablets Target groupDoses Adolescent girls2 tablets/week Newly wed women2 tablets/week Pregnant women2 tablets daily up to delivery (NGOs 1 tab daily) Lactating mother1 tablet daily for 90-120 d

20. Iron-folic Acid Tablets

21. DGFPGiven in a polythene bagSpoilage ? DGHSWrapped in paperSpoilage ? BRACNow giving tablets in blister pack Tk 14 for 100 tab vs Tk 12 for 100 open tabs Dispensing IFA Tablets

22. Iron Coverage among Pregnant Women HFSNA 2009

23. IFA Tablet Coverage during Pregnancy in BINP Areas NNP Baseline Survey 2004 IndicatorSurvey Area BINP (%)Comparison (%)All (%) IFA intake Regular Irregular None 25.4 9.9 64.7 16 9.5 74.5 19.5 9.6 70.9 Total (n)219337855979

24. Reasons for Not Taking IFA Tablets Regularly ReasonsN=1741 pregnant women, % Side effects (diarrhea, etc) Forget to take Did not consider necessary Lack of supply Do not receive enough tablets Economic constrains Objection of family members Lost tablets Others 25.5 19.5 16.3 12.0 6.1 4.5 1.9 0.2 7.8 NNP Baseline Survey 2004

25. Multiple Micronutrient Powder 1 RDA of Iron Folic acid Vitamin A Vitamin C Zinc

27. No color No taste of its own No odor

28. Children with the following conditions are excluded: Any acute illness Severe cough Breathlessness Severe visible wasting

29. What can we do to control anemia?

30. Increase exclusive breastfeeding rates Improve complementary feeding practices by using various foods rich in iron Consider home-based fortification of CF using multiple micronutrient powder Coordination of efforts of different agencies and the private sector in control of anemia Comprehensive Nutrition Actions Required

31. Promote factors that will increase coverage of IFA supplementation among adolescent girls, pregnant & lactating women –Effective counseling –Sustained supply –Appropriate packaging –Mass media coverage –Trained workforce