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Dietary predictors of iron-deficiency anemia in rural India

Iron-deficiency anemia (IDA) is a
global, multifactorial nutritional disorder having severe health and economic
implications. The burden of IDA is most prevalent in resource-limited settings
that rely primarily on staple cereals and a few vegetables for nourishment. Specifically
in India, anemia
affects 74% children below the age of 3 years, 85% expectant mothers, and over
90% of adolescent teens
1. IDA, as a result of persistent
malnutrition, lack of dietary iron bioavailability*, or physiological factors,
adversely affects cognitive performance, work capacity and productivity, and increases
the risk of maternal morbidity and mortality.

[* Note: Bioavailability can be defined as the amount
of nutrient released from the food and absorbed into the body, that is actively
available for use in human processes.
]

This
summer, I visited marginalized rural communities in Songadh block in Tapi
district of Gujarat and Dorma
village in Torpa block of Khunti district
of Jharkhand to evaluate their iron-related dietary consumption patterns and
conduct a village-level market assessment. For both sites, 10-12 households
were surveyed. Focus group discussions were also held to determine the locals’ knowledge,
attitude and practices towards IDA.

From
field to plate

Since
these two study sites are located in two distinct regions of India, the dietary
patterns were very different. It was unexpected that even with wealthier
households (based on higher reported incomes and visual assessment), Songadh had
markedly diminished dietary diversity relative to Torpa.

image

A typical Songadh village meal comprising of pigeon peas, dry green gram, rice chapati, pickle, onion and lemon. (Photo credit: Rohil Bhatnagar)

Songadh diet (Gujarat)

In Songadh, rice is the primary
cereal of choice. Villagers consume rice during the day and rice chapatis
during the evening, with an occasional wheat chapati from the wheat grown in
their own farms. Lentils form a major part of their daily nutrition. The majority
of the households surveyed reported having brinjal (eggplant), potatoes,
tomatoes and cauliflower as the most frequently consumed vegetables. Red chilies
were used to add spice to dishes. Raw mangoes, or keri, were widely consumed in season. Along with meals, most people
reported consuming buttermilk, locally called as chaas, or a sorghum-based fermented beverage called bhadku.

Torpa diet (Jharkhand)        

Similarly, in Torpa, rice is the
preferred staple. Conversely, the wheat that is used to prepare chapatis is
purchased from government ration shops, and lentils are not as frequently
consumed. Instead, villagers depend on the forests for nourishment. Consequently,
traditional
green leafy vegetables
― such as mountain
ebony
(koinar saag), spine gourd (kakrol), water spinach (kalmi saag), amaranth leaves (lal gandhaari saag), kenaf leaves (kudrum) and Malabar spinach (poi saag) ― are widely consumed2.
In fact, according to the households surveyed, these vegetables were included
more than three times per week in their typical diet. Additionally, other
vegetables that were regularly consumed included locally picked mushrooms, jackfruit,
lemons, okra, onions, tomatoes and potatoes, further enriching the dietary
diversity. In contrast from Songadh, only green chilies were used in Torpa. Mangoes
and java plums (jamuns) were consumed every day in season. Water served as the
most common meal accompaniment.

image

Iron-rich greens being sold at
Torpa district village-level market in Jharkhand. (
Photo credit: Rohil Bhatnagar)

The
irony of iron nutrition awareness

Villages
in both Songadh and Torpa have had nutritional awareness outreach programs in the
past. As a result, the women were slightly familiar with the need for iron in the
human body and its deficiency symptoms. However, the majority of the
respondents were unaware of the function of iron in the body, which food
sources are iron-rich, and what dietary habits may affect iron absorption and
iron status.

Some
females in Torpa reported using government-administered iron-folic acid pills,
although compliance was low. Furthermore, the respondents with infants had not
introduced their infants to nutritionally adequate complementary foods after 6
months of breastfeeding and reported feeding them wheat-flour based biscuits
and breastmilk only. None of the village stores stocked infant foods (e.g. Cerelac,
etc.).

Discussions with medical officers in the Singpur village of Songadh revealed that there were inadequate IDA-diagnostic facilities. Moreover,
community turnout for such nutritional programs was also not encouraging. As a
result, iron deficiency and practices that affect dietary iron bioavailability are
widely prevalent.

image

Rohil Bhatnagar holding a focus
group discussion with women from Bedvan Khadka village in Songadh block,
Gujarat. (Photo credit: Karuna Salve)

Concluding
remarks
 

Rice
and wheat have typically low iron content. These cereals are also rich sources
of potent iron inhibitors, such as phytate. Dietary ascorbic acid (vitamin C),
an iron promoter, keeps iron in its reduced state, hence increasing absorption.
Unfortunately, according to the National Institute of
Nutrition
, the traditional rural Gujarati diet has been associated with
having a high concentration of phytate and low levels of ascorbic acid3.
My study confirms this pattern in Songadh. Moreover, respondents reported
buttermilk consumption along with meals. A calcium-iron interaction is also
known to interfere with iron absorption. Together, a reduced intake of
iron-rich fruits and vegetables, low dietary diversity, and a simultaneous intake
of calcium-rich beverages (e.g. buttermilk) with meals, can be termed as a classic
iron-deficient dietary pattern.

Conversely,
the surveyed households in Jharkhand frequently consumed iron-rich vegetables
in the form diverse green leafy vegetables. Dietary inclusion of ascorbic acid-dense
green chilies and lemon would further enable iron bioavailability in this
population. Not surprisingly, the average daily intake of vitamin C in
Jharkhand has been estimated at 101.5 mg4, much higher than the recommended
dietary allowance of 40 mg/d5. Yet, Jharkhand is severely affected
by anemia6. Why could this be? As anemia is multi-causal, are we overlooking
other underlying etiologies?

While
this interpretation is representative of only the surveyed households, the
villages I visited in both states are infection-prone, having high frequency of
hemoglobinopathies, along with poor hygiene and sanitation – all strongly associated
with anemia. The relative contribution of these factors towards anemia can vary
a lot depending on the population and its geographical location. Moving
forward, it is imperative that a comprehensive community-based structural
framework aimed towards improving nutrition, sanitation and education be
implemented at both the household and individual level to effectively control
and overcome iron malnutrition and anemia.

By
Rohil Bhatnagar

Rohil
Bhatnagar is a Ph.D. Student and a Tata-Cornell Scholar in the Field of Food
Science and Technology at Cornell University
. With Tata-Cornell, he studies
location-specific community trends that modulate nutritional iron status.

 

References

 1 Sharma, K.K., 2003. Improving bioavailability of iron in
Indian diets through food-based approaches for the control of iron deficiency
anaemia. Food Nutrition and Agriculture, (32), pp.51-61.

2 Ravishankar, M., Kaur, D.P., Bhushan, K.B. and Easdown, W.,
2014. Traditional leafy vegetables of a tribal community in Jharkhand, India.
In 29th International Horticultural Congress (pp. 17-22).

3 National Institute of Nutrition
(NIN) Annual Report 2005-2006. Retrieved from: http://www.ninindia.org/AnnualReports/2005-06.pdf. pp. 18-26.

4 Indian
Council of Medical Research. Expert Group, 2009. Nutrient Requirements and Recommended Dietary Allowances for
Indians: A Report of the Expert Group of the Indian Council of Medical Research
. Indian Council of Medical Research. pp. 288.

5 Chakravarty,
I. and Sinha, R.K., 2002. Prevalence of micronutrient deficiency based on
obtained from the national pilot program of micronutrient malnutrition results
on control. Nutrition reviews60(s5).

International Institute for Population Sciences
(IIPS) and Macro International. 2007. National
Family Health Survey (NFHS-3), 2005–06: India: Volume II. 
Mumbai: IIPS.