Anemia Resource Review

Barbara Underwood provides a historical overview of pivotal points in the last six decades for moving micronutrient research into global reality. She highlights how micronutrients were repositioned both scientifically and politically for global action. This seminal piece demonstrates the importance of politically opportune timing for science to influence national and global policy and the availability of effective, affordable, and sustainable public health interventions. 

In this 1968 WHO monograph, Nevin Scrimshaw first introduces the link between infection and nutrition and presents the concept of a “vicious cycle” of malnutrition and disease. Early hypotheses on the mechanisms for how inadequate nutrition impairs immunity, increases the risk of infection, and, in turn, creates greater nutritional requirements consequent to the infection, is discussed. 

This paper reviews the epidemiology, anemia assessment, pathophysiology, and consequences of anemia in low-income and middle-income countries. Given the multifactorial causes of anemia, the authors noted the challenge to effectively address determinants of anemia, and highlighted the critical role of data to guide implementation of anemia prevention and control strategies.  

This study was a follow-up evaluation of a group of Costa Rican children whose iron status and treatment were documented in infancy. The study found that while no children had iron-deficiency anemia at five years of age, those with iron-deficiency anemia in infancy had lower scores on tests of mental and motor functioning. These findings indicate that children who have iron-deficiency anemia in infancy may be at risk for long-lasting developmental disadvantages and highlight the importance of efforts to prevent iron deficiency.  

The Second International Conference on Nutrition (ICN2) was held at Food and Agriculture Organization (FAO) Headquarters in Rome and brought together 192 governments for the first time in 22 years to discuss policy options to improve people’s diets in order to more effectively address the world’s major nutrition challenges. Two main outcome documents- the Rome Declaration on Nutrition and the Framework for Action- were endorsed by participating governments, committing world leaders to establishing national policies aimed at eradicating malnutrition and transforming food systems. The Framework for Action outlined recommended actions to address anemia in women and children.  

The third Micronutrient Forum global conference, Bridging Discovery and Delivery, brought together researchers, policymakers, and program implementers from a wide array of sectors. Several key findings and case studies related to anemia were presented in the conference report, including: the distinction of iron-deficiency anemia from anemia of inflammation; effective and safe use of iron fortification in malaria-endemic areas; the revitalization of iron-folic acid supplementation through antenatal care; and the impact of integrated agriculture and nutrition and health behavior change communication on children’s anemia. The conference report also highlights the Micronutrient Survey Manual, a new manual on performing cross-sectional surveys to assess micronutrients, jointly developed by the CDC, WHO, UNICEF, and MI. 

The first session of the Better Data for Nutrition series will be Using Demographic and Health Survey Data to Monitor and Evaluate Nutrition Programs. The session will describe the types of nutrition data collected in DHS surveys, provide an example of how DHS data can be used to strengthen national iron-folic acid supplementation programs, and provide a forum to discuss opportunities and challenges in the collection and use of DHS data.

There is a growing recognition of the critical role data can play in improving the nutritional outcomes of women and children. Drawing on SPRING’s team of nutrition, agriculture, and behavior change experts, SPRING will be hosting a series of webinars on Better Data for Nutrition to discuss tools and solutions on how we can address data gaps and make better use of data. 

Point-of-use fortification is increasingly being introduced and scaled-up. UNICEF, CDC, WFP and HF-TAG have organized a series of webinars tailored for program implementers who are either planning or implementing home fortification programs. The aims of the webinar series are to increase knowledge and capacity to design, implement, monitor and scale-up effective point-of-use fortification programs and to share country experiences and lessons learned. 

The upcoming Experimental Biology Conference will bring together leading nutrition scientists and will comprise of several sessions on anemia and micronutrients including:

• A symposium on "Approaches to Account for the Effects of Inflammation on Nutrient Biomarkers: Nutrition Determinants of Anemia (BRINDA)" will address the role of inflammation on micronutrient biomarker levels and factors associated with anemia using data from 15 countries. Check out this blog for more information: http://www.nutrition.org/asn-blog/
• Talks will also include information on links between nutrition and child development, hepcidin and iron homeostasis, micronutrient interventions, biofortification of staple crops with micronutrients, and links between nutrition and infections. 

The Mini-University (Mini-U), a collaborative production of USAID, the George Washington University, and the Global Health Professional and Organizational Development (GHPOD) Program, is an annual learning forum for Global Health professionals and students. It offers a variety of sessions highlighting evidence-based best practices and state-of-the-art information. In the Nutrition track this year, SPRING will be presenting Working across Sectors to Improve Nutrition, which will include principles of anemia and the implementation of multisectoral anemia platforms. 

The Food Fortification Initiative has developed country profiles which include detailed information on grain practices, legislation status, grain availability for human consumption, milling industry information, and nutrient deficiency indicators, including anemia prevalence in women and children.  

This blog discusses the first-ever human hookworm vaccine, HOOKVAC, currently being tested in Gabon. The HOOKVAC vaccine aims to reduce hookworm infection, which affects more than half a billion people worldwide and is one of the most ubiquitous infections of the poor. The authors assert that it could also be the first vaccine to indirectly reduce iron-deficiency anemia (IDA), which is caused by several factors including hookworm. 

All 34 countries with the highest rates of malnutrition are endemic for neglected tropical diseases (NTDs). This brief explores the relationship between, and opportunity to address, two types of NTDs — intestinal worm infections and schistosomiasis — and malnutrition. It makes the case for international development partners to scale up deworming treatments alongside efforts to improve nutrition and other determinants of health as a way to reach more people in need and ensure lasting impact.

Developed by the Global Panel on Agriculture and Food Systems for Nutrition, this policy brief lays out the technical evidence and arguments for supporting biofortification as an important vehicle to improve vitamin and mineral intake. The brief highlights some preliminary evidence of crops biofortified with iron resulting in improved iron status in women in Rwanda and school-age children in India.

The UN Open Working Group’s proposal for SDGs includes nutrition in SDG 2 on “End hunger, achieve food security, and improved nutrition, and promote sustainable agriculture.” This policy brief proposes priority nutrition indicators that include the WHA’s global nutrition target to reduce anemia among women of reproductive age.  

The Global Nutrition Report is the first in an annual series, based on commitments made at the Nutrition for Growth Summit in 2013. The report provides an analysis on the state of the world’s nutrition, identifies bottlenecks to change, highlights opportunities for action, and contributes to strengthened nutrition accountability. Anemia rates have not changed appreciably in the last 20 years, and only five out of 185 countries with data on anemia are on course for anemia reduction. 

In support of the World Health Assembly (WHA) nutrition target policy briefs, 1,000 Days has developed a complementary infographic series, highlighting the key messages and recommendations to achieve each WHA nutrition target. This infographic covers the second target: a 50 percent reduction of anemia in women of reproductive age

As part of a comprehensive implementation plan on maternal, infant, and young child nutrition, the World Health Assembly (WHA) has specified six global nutrition targets for 2025. The Anaemia Policy Brief covers the second target: a 50 percent reduction of anemia in women of reproductive age. The policy brief presents a framework for action, and outlines current recommendations and strategies for the prevention, control, and treatment of anemia in women. 

This guideline provides global, evidence-informed recommendations on optimal timing of umbilical cord clamping as a public health intervention for the purpose of improving maternal and infant health and nutrition outcomes.  Delayed cord clamping (waiting to clamp for two to three minutes) can improve an infant’s iron status for up to six months after birth. The guideline highlights that this practice is particularly relevant for infants living in low-resource settings with less access to iron-rich foods and thus at greater risk of anemia.  

This qualitative study assessed rural Burkinabe young women’s understanding of anemia and the role of iron in preventing and treating this condition. The study found that women did not perceive themselves as being at risk for anemia, had limited knowledge of iron’s role in anemia, and neither adolescents nor field workers were convinced of the benefits of supplementing non-pregnant adolescents. The authors highlighted the importance of improving how information is communicated on the role of iron in anemia and adapting iron-folic acid supplementation messaging and counseling to meet the special needs of adolescents.

Vitamin A deficiency may cause anemia as vitamin A is essential for hematopoiesis, mobilization of iron store, and immunity. This propensity score matched retrospective cohort study used data of the Ethiopian Demographic Health Survey 2011 to assess the effect of single high dose vitamin A supplementation on the hemoglobin status of children aged 6-59 months. The study found that children who received vitamin A supplementation had a decrease in risk of anemia than those who were not supplemented.

As inflammation during and after malaria may decrease iron absorption, the authors of this study aimed to measure iron absorption from iron supplements started immediately or delayed by two weeks after completion of treatment therapy against uncomplicated P. falciparum malaria in Malawian toddlers. The authors concluded that iron absorption is sufficiently high in the immediate post-malaria period to warrant supplementation, and there is no need to change the current practice of immediate iron supplementation in this setting.  

The authors aimed to assess hemoglobin levels and the factors associated with anemia in pregnant women attending antenatal clinic in their third trimester in the rural district of Mpigi, Uganda. This cross-sectional study showed that factors associated with increased risk of anemia in pregnancy were malaria infection, HIV infection, and lack of iron supplementation, while intermittent presumptive treatment of malaria, maternal age, and parity showed a weak association with anemia in pregnancy. The authors concluded that increased efforts in anemia-related interventions during pregnancy are critical in this setting.   

Deficiencies in micronutrients, which are essential for human life and health, are common due to poor quality diets and frequent infectious diseases in low- and middle-income countries (LMIC). This review focuses on the deficiencies of several micronutrients—vitamin A, zinc, iodine, and iron—because of their high global prevalence and important health effects. The author asserts that additional efforts and innovative approaches are needed to reduce micronutrient deficiencies, including better quantification of the prevalence and consequences of these deficiencies to help guide and prioritize interventions.  

Maternal micronutrient deficiencies can adversely affect fetal and infant health, but there is insufficient evidence to guide the use of multiple micronutrient supplements. The JiVitA-3 randomized trial in rural Bangladesh aimed to assess the effects of antenatal multiple micronutrient vs. iron-folic acid supplementation on 6-month infant mortality and adverse birth outcomes. The study found that multiple micronutrient compared with iron-folic acid supplementation did not reduce all-cause infant mortality but did result in a non-statistically significant reduction in stillbirths and statistically significant reductions in preterm births and low birth weight.  

While severe anemia is a direct cause of death in children, it is also recognized that mild and moderate anemia may also contribute to mortality risk. This meta-analysis provides estimates on the relationship between mortality and hemoglobin (Hb) levels in children with mild or moderate anemia. Results indicated that for each 1-g/dL increase in Hb, the risk of death is reduced by 24 percent. The authors concluded that ~1.8 million child deaths could be avoided each year by increasing Hb by 1 g/dL.  

An impact evaluation of Costa Rica’s national food fortification program was conducted using a one-group pretest-posttest design with data from national surveys and sentinel sites. Reductions in anemia were found among women and children, along with improvements in iron status among children. The authors present a plausible impact pathway linking these benefits to Costa Rica’s mass fortification.  

This study aimed to assess the impact of a low-cost ultrasound program on the numbers of women receiving specific antenatal care (ANC) interventions, and to assess the rate at which these interventions were provided at ANC visits. The study found an increase in the number of ANC visits and in maternity services, which included anemia-related interventions (iron-folic acid supplementation, deworming, and IPT2 treatments).