1. Iron deficiency, Anemia & Folate Deficiency: National Micronutrient Survey 2011-12 Dr. Tahmeed Ahmed Director, Centre for Nutrition and Food Security, icddr,b

2. Sampling 15000 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

3. Primary Sampling Units of the Survey

4. 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

5. PreschoolSchool age NPNL Women Total Ferritin600105015003150 Hemoglobin600105015003150 Folate 1050 Sample size Adjusting for Infection Ferritin is adjusted for infection by CORRECTION FACTORS David Thurnham 2010 Reina Engle-Stone 2011

6. Results

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

8. RDA(mg/d) % of population meeting RDA Median intake of animal iron as % of RDA PSAC 1-3 y75.814.2 PSAC 4-5 y102.87.1 SAC 6-8 y1010.49.2 SAC 9-14 y916.610.0 NPNLW 15-18 y150.06.6 NPNLW 19-49 y180.05.2 Dietary Intake of Iron

9. Strata n% National 2471.3 Rural 780.7 Urban 893.3 Slums 800.0 MNP coverage in children 6-23 mo

10. 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)

11. Drinking of tube well water and iron deficiency

12. 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

13. VariablestpEffect size Hemoglobin5.85<0.0010.25 Agricultural profession (Ref: Non-agricultural)1.670.090.08 Age7.11<0.0010.30 Slum residence (Ref: Rural)-2.050.04-0.08 Wealth index (Ref: Poorest) Poorer1.410.160.08 Middle-0.620.53-0.03 Richer-1.390.16-0.07 Richest-1.010.31-0.06 “high” IRON area (Ref: “low” Iron area)3.350.0010.21 Household food insecurity (Ref: food secure) Mild food insecure0.760.450.03 Moderate food insecure-1.210.22-0.05 Severe food insecure0.630.520.03 Multivariate regression showing associations of serum ferritin in PSAC

14. VariablestpEffect size Hemoglobin3.250.0010.14 Household’s spending-0.940.35-0.05 Profession (Reference: non-agricultural profession) Agricultural profession2.480.010.13 Female (Ref: male)1.150.250.05 Diarrhea in last 2 weeks (Ref: history of diarrhea) No diarrhea in last 2 weeks2.110.030.10 Connection of electricity (Ref: electricity connected) No connection of electricity0.190.850.01 Groundwater iron (Ref: “low” GWI area) “High” IRON area (Ref: “Low” Iron area)2.950.0030.15 Knowledge about eating iron rich foods Did not mention, iron rich food is “good for health” (Ref: Did mention)-2.870.004-0.13 Knowledge about eating iron rich foods “Do not know” (Ref: Knows “which foods are rich source of iron”) 1.340.180.06 Serum retinol3.370.0010.15 Household food insecurity (Ref: food secure) Mild food insecure-1.620.1-0.07 Moderate food insecure-0.990.32-0.06 Severe food insecure-1.010.31-0.06 Multivariate regressions showing associations of serum ferritin in SAC

15. VariablestpEffect size Hemoglobin3.69<0.0010.16 Household’s spending-2.150.03-0.11 Some institutional education (Ref: no institutional education)0.540.590.025 Wealth index (Ref: Poorest) Poorer2.470.010.13 Middle1.030.300.05 Richer1.750.080.10 Richest2.760.0060.19 “High” IRON area (Ref: “Low” IRON area)5.00<0.0010.25 7-day total iron intake-0.130.89-0.005 Knowledge about foods that are rich in iron (Ref: “knows”) “Do not know”-0.130.89-0.006 Location of residence (Ref: Rural) Urban-0.230.82-0.01 Slum-0.120.90-0.005 Serum retinol-0.530.60-0.02 No. of para-0.450.65-0.02 Serum zinc0.480.630.02 Household food insecurity (Ref: food secure) Mild food insecure1.260.210.06 Moderate food insecure2.600.010.12 Severe food insecure1.000.320.05 Serum B122.060.040.09 Serum folate3.190.0020.13 Possession of refrigerator (Ref: non possession) Possess a refrigerator2.580.010.15 Multivariate Regressions showing associations serum ferritin in NPNLW

16. 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

17. 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

18. Anemia (%) Preschool age children (6-59 mo)BDHS 2011 National33.151.0% Rural36.6 Urban22.8 Slum22.0 NPNL women (15- 49 y) National26.042.0% Rural27.4 Urban21.4 Slum20.1 Anemia: Hemoglobin <11 gm/dl (Pre-school) Hemoglobin <12 gm/dl (NPNLW) Prevalence of anemia (%)

19. School age children (6-11 yrs)Urban anemia survey 2001-3 National19.124 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, 12-14 y) Prevalence of anemia (%)

20. 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

21. VariablestpStandardized Beta Serum ferritin3.220.0010.21 Mother’s institutional education (Ref: none)0.030.970.001 Serum retinol2.660.0080.13 Age2.630.0090.13 No fever in last 2 weeks (Ref: fever)-0.630.52-0.03 No measles in last 6 mo (Ref: measles)3.89<0.0010.20 Urban location of residence (Ref: rural)4.03<0.0010.22 Agricultural profession (Ref: non-agricultural profession)4.74<0.0010.25 Wealth index (Ref: Poorest) Poorer0.670.500.04 Middle1.880.060.12 Richer-0.330.74-0.02 Richest0.010.990.001 “High” Iron area (Ref: “Low” Iron area)2.570.010.14 Serum zinc1.180.230.07 Household food insecurity (Ref: food secure) Mild food insecure-0.430.66-0.02 Moderate food insecure-3.73<0.001-0.21 Severe food insecure-0.370.73-0.02 Possession of refrigerator (Ref: non possession)1.380.160.12 Do not possess a mobile phone (Ref: possession)-4.36<0.001-0.23 Multivariate regression showing associations of hemoglobin in PSAC

22. VariablestpStandardized Beta Household’s spending2.170.030.07 Serum ferritin3.76<0.0010.11 Wealth index (Ref: Poorest) Poorer-3.160.002-0.11 Middle-2.290.02-0.08 Richer-1.440.15-0.05 Richest-1.200.23-0.05 Serum retinol5.14<0.0010.14 Agricultural profession (Ref: non-agricultural)-3.090.002-0.09 Age6.97<0.0010.20 Female (Ref: male)-3.68<0.001-0.10 No fever in last 2 weeks (Ref: fever)-1.940.06-0.05 Do not possess a mobile phone (Ref: Possession)-1.280.20-0.04 Do not possess a refrigerator (Ref: possession)-1.990.04-0.08 Urban location of residence (Ref: Rural)2.580.010.08 Multivariate regressions showing association of hemoglobin in SAC

23. VariablestpStandardized Beta Household’s spending-0.050.95-0.003 Serum ferritin3.10.0020.13 7-day animal source iron intake2.460.010.12 7-day total iron intake-0.460.64-0.02 No. of para-1.420.15-0.06 Serum folate2.130.030.09 Serum retinol2.930.0040.13 Location of residence (Ref: Rural Urban1.520.130.06 Slum1.340.180.05 Wealth index (Ref: Poorest) Poorer-1.040.30-0.05 Middle-1.670.10-0.09 Richer-1.590.11-0.09 Richest-0.350.72-0.02 Serum zinc1.800.070.08 Household food insecurity (Ref: food secure) Mild food insecure-4.34<0.001-0.20 Moderate food insecure-1.140.25-0.05 Severe food insecure-0.240.81-0.01 Multivariate regressions showing associations of hemoglobin in NPNL

24. 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

25. 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

26. Prevalence of folate deficiency n%95% CI National 8499.15.3-12.9 Rural 2948.63.6-13.5 Urban 28811.46.6-16.3 Slum 2677.93.3-12.4 Prevalence of folate deficiency(%) S. Folate level <6.8 nmol/l (Lindstorm et al 2011)

27. 7-day plant folate intake 7-day animal folate intake 7-day folate intake National1031871118 Rural951861037 Urban1237931330 Slum1550741624 Dietary intake of folate by strata

28. 7d Plant source folate (microgram) 7d Animal source folate ( microgram) 7d total folate ( microgram) Food secure1057.5109.31166 Mild insecure946.990.51037 Moderate insecure 935.562.6998 Severe insecure1153.139.61192 Dietary Intake of folate by household food security in women

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

30. 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

31. VariablesCo-efficientpEffect size Household expense-0.110.82-0.009 7 day intake of plant source folate0.810.0050.10 7 day intake of animal source folate0.220.360.036 Non married (Ref: married)-0.650.28-0.04 Serum ferritin0.860.0050.10 Serum retinol1.850.0060.10 Non possession of refrigerator (Ref: possession) -1.880.05-0.096 Rural location of residence (Ref: slum)2.110.090.13 SES (Ref: Poorest) Poorer0.120.840.009 Middle0.670.370.04 Richer1.440.140.07 Richest1.850.130.09 Household food insecurity (Ref: Food secure) Moderate insecure-0.720.36-0.03 Moderate insecure-0.380.53-0.02 Severe insecure-0.830.28-0.04 Multivariate regression showing associations of folate in NPNL women

32. 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