By Sandra Albert
The prevalence of anaemia among women is often used as an indicator of nutritional well-being of society. Meghalaya state has some of the poorest nutritional indicators in the northeast region. The most recent district level family health survey (DLHS-4, 2013) reports the prevalence of anaemia as 71% in children (6-59 months), 42% in adolescents (15-19 years), 54% in women (15-49 years) and 64% of pregnant women. Thus more than half our women are anaemic. Initially anaemiacan be asymptomatic (no overt manifestation) or it can cause weakness, easy fatigue, pallor, breathlessness, palpitations and headaches.Iron deficiency anaemia isdetrimental to the growthand mental development of children. Among pregnant women there is a definite association between anaemia and poor maternal outcomes such as increased risk for heavy blood loss after delivery and low birth weight among newborns.
Iron is required for the production of haemoglobin, a protein present in red blood cells, responsible for carrying oxygen from our lungs to every cell in our body. In the absence of iron the body fails to make enough haemoglobin or red blood cells, resulting in iron deficiency anaemia. Although anaemia can result from other causes, the majority are related to iron deficiency. Anaemia can also result from deficiency of other micronutrients like vitamin B12 and folate andfrom genetic factors (haemolytic anaemias). All of these alternate causes are prevalent in Meghalaya but we do not know to what extent. But iron deficiency remains the most frequent cause of anaemia in our state. Iron deficiency results from low dietary intake, low absorption or from conditions that cause chronic blood loss (eg. worms or ulcers).
Were Meghalaya’s people healthier in times past? It appears so if one refers to the earliest anthropological records of the Khasis, where theyare described as a short statured but well-nourished tribe. Of note with regards to the subject of anaemiais PRT Gurdon’s (1914) observation that Khasis used pots made of iron for cooking vegetables. The use of iron vessels in the past was not surprising as iron smelting was once a thriving local industry.A research article in Current Science,that used radiocarbon dating and other techniques to asses ancient iron slag from the Khasi hills reported evidence of continuous iron smelting in the Khasi Hills spanning 2000 years. Like a remnant of this ancient art, until a few years ago, one could observe a few blacksmith workshops along the Mylliem highway but suddenly they seem to have all disappeared! Over the years consumption patterns have changed as have cooking processes. In the present day iron vessels have largely been replaced by the ubiquitous aluminium vessels. Observation of Khasi kitchens and jadohshops demonstrates a fondness for aluminium utensils which Khasi women take pride in keeping ashine.Thus almost insidiously a potentially superior indigenous practice got replaced by something shiny and white.
Do cooking patterns and utensils matter? A clue to this can be seen in a study among the !Kungbushmen of Botswana, Southern Africa who used iron cooking vessels in their normal cooking practices. Investigators reported low prevalence of iron, folate, and vitamin B12 deficiency among this group, when compared with more economically advanced populations. This despite some of them having parasites such as hookworms (that often contribute to anaemia through chronic blood loss). The absence of anaemia among the !Kungwas attributed to the dietary iron intake being supplemented by iron derived from their cooking pots. A downside was documented among the Bantu tribe who inappropriately used these vessels for brewing alcoholic beverages, where it proved harmful as it contributed to iron overload.
The government’s health departments have been trying to ameliorate the high prevalence of anaemia amongst our people through two measures; one to give iron supplements (pills) to all pregnant women and more recently the newly introduced weekly iron supplementation scheme among adolescents and children. When a person is iron deficient, it certainly warrants some form of urgent amelioration such as providing iron supplements. But can or should this be a long term strategy? Questions of public health relevance should ideally be addressed on the basis of well-designed studies that produce good quality evidencethat is relevant locally and within contexts. Sadly this is not something we as a nation pays sufficient attention to, our health research budgets are miniscule to say the least. But on the topic of iron supplementation and anaemia there is some emerging evidence that questions old accepted notions.
In a handful of controlled studies from Africa, investigators have found that dietary iron fortification resulted in a significant increase in disease-causing gut bacteria that cause diarrhoea in children supplemented with iron as compared with those without dietary iron supplementation. Those given iron were found to have increased markers for intestinal inflammation. This is noteworthy as one of the most commonly given anecdotal reasons for “non-compliance” with iron supplementation in pregnancy in Meghalaya is intestinal irritation and stomach upsets. In other words iron supplementation is not as harmless as once assumed, it can alter the normal profile of gut microbes and promote potentially disease causing microbial flora. Recently another interesting association was reported by researchers in Karnataka; pregnant women who were not anemic but who took the routinely recommended iron supplementation gave birth to low-birth weight babies. The authors conclude that rather than a uniform approach, an individualised approach to iron supplementation in pregnancy may be warranted.
There is an additional side that needs to be considered, it is not just the presence of iron in the diet but also the ability of the body to absorb it as a nutrient. For instance one’s diet may have sufficient iron but its absorption (bioavailability) can be hampered by the immediate drinking of teawith a meal. Tea in particular interferes with absorption of iron from vegetable sources. On the other hand simple measures like squeezing lemon juice (ascorbic acid) or consuming other vitamin C rich items along with a meal can improve iron absorption from the food being consumed.
The Food & Agriculture Organization of the UNreiterates that a nutritious diet is the best approach to combat all forms of malnutrition.While food supplements can be used for specific dietary deficiencies in the short term, interventions that are food based and involve dietary diversification are proposed as better alternatives. A few NGOs in Maharashtra have demonstrated how anaemia can be improved throughhome kitchen gardens. Through this intervention, anaemia among not just women but other members of families improved considerably, average consumption of vegetables increased and medical bills reduced. Sustained alternative efforts such as improving dietary diversity through kitchen gardens, wild edibles, delaying tea drinking after a meal, and awareness raising measuresneed to be made in parallel to current efforts so that long term sustainable solutions can be found.
(The author is the Director, Indian Institute of Public Health Shillong, PHFI)