Measures to control iron deficiency

• Available iron in food : Food has primarily non-heme iron (From cereals, legumes, etc) as ferric complexes, which partly convert to readily absorbable ferrous form during digestion (Hydrochloric acid in stomach).The absorption of iron from non-heme containing food is 1-6%. In contrast heme iron from flesh and sea foods has absorption of 20-30%. Iron absorption is enhanced from diets having ascorbic acid/vitamin C (Fruit juices, green leafy vegetables) and other organic acids e.g. citric, malic and tartaric acid. The process of fermentation/germination and malting increases vitamin C, lowers phytic acid and tannin contents. The dietary iron absorption inhibitors were cereal bran, phytates, fibre, oxalic acid, polyphenols (Tannin), soya protein, calcium and zinc. While planning supplementation of iron/fortification of food items, the above dietary aspects should be kept in mind.
  
• Promotion of regular consumption of foods rich in iron :
  
  

  • Baby should be breast fed colostrum and mature milk. Both have 49% absorbable iron. This is sufficient with available stores till baby doubles the birth weight.
    
    
  • Weaning foods from 4 months onwards should have one iron rich dietary item and iron supplementation be given as recommended. If cows milk is used as complementary and weaning food boil it in cast iron pot to get enriched with absorbable iron.
    
    
  • Green leafy vegetable rich in iron-mustard leaves (Sarson saag), amaranth (Chaulai saag), colocasia leaves (Arvi saag), Bengal gram greens (Channa saag), shepu of sow, turnip greens (Shalgum saag), radish green (Mooli saag), spinach (Palak saag). Include one or more of these items in family meal.
    
    
  • Cereals and sprouted pulses
    
    
  • Vitamin C rich - lime, lemon, orange, amla, green mango etc.
    
    
  • Jaggery (gur).
    
    
  • Meat ,fish, liver etc.
    
    
• Availability of dietary iron by cooking in cast iron utensils: WHO 1992 (34) prevalence of pregnancy anemia report, records that lowest rates of anemia of all the sub-regions of the developing world were observed in southern Africa, due to wide spread use of iron cooking pots by indigenous people. Lal et al (35) had demonstrated that cooking in cast iron utensils, which were traditionally used in Indian families until 4 decades back for boiling milk, cooking vegetables etc, provided extra dietary iron. Cutting by cast iron knife and cooking without washing the potato doubled the iron content. This available dietary iron is well absorbed.
  
• Anemia control by food fortification : Studies conducted since 1970 on fortifying a broad range of foods and condiments have led to the successful use of two forms of iron for food fortification: iron EDTA and hemoglobin. Iron EDTA has been highly effective in fortification trials with Egyptian flat breads, curry powder in South Africa, fish sauce in Thailand, and sugar in Guatemala, to name only a few examples. In Grenada, flour used in commercial baking is enriched with iron and B vitamins. Indian researchers have field tested with success iron fortified salt. In India, the cost of fortification increases the price of salt by about 20%, while adding iron to sugar in Guatemala raised its cost by only 2%. It should be noted, however, that the price of salt is low and the amount consumed every day is small, so that a 20% increase is still acceptable. It is estimated that the cost per person per year in a large scale programme of fortification with iron is about $ 0.20-0.30. The cost would probably be double if ascorbic acid was added as well.
  
• Regular weekly/ bi-weekly/ iron supplementation: In rats, iron administered (weekly/biweekly) was equally effective as compared to daily dosing, relating it to mucosal renewal time (36,37). The available studies (38,39) and our data (In press) tentatively conclude : a) In pregnancy daily iron dosing is needed to provide iron stores. b) In growing children with mild to moderate severity of iron deficiency - biweekly or weekly therapy is effective. However in moderate to severe iron deficiency areas, to meet growth needs, daily iron is required. c) Adolescent girls do well on weekly iron supplementation. Thus weekly iron supplement was effective in all the groups' a-c , as it reduced the risk of developing anemia.
  

1. Dallman PR, Yip R, Oski FA. Iron deficiency and related nutritional anemias. In Hematology of infancy and childhood. 4th edition, Vol. I Chapter 12. Editors Nathan DG & Oski FA Publ. W B Saunders Phil. Penn. USA 1993: 413-438.
2. Lee GR .Iron deficiency and iron - deficiency anemia. In Wintrobe's Clinical Hematology . 10th edition Vol.1 Chapter 34. Editors Lee GR, Foerster J, Lukens J et al. Publ. William & Wilkins Baltimore, Maryland USA 1993: 979-1010.
3. Nair GTR, Agarwal KN, Kotwani BG. Nutritional deficiency anemia in later months of pregnancy. J Obstet Gynecol India. 1970; 20: 594- 601.
4. Agarwal KN. The effects of maternal iron deficiency on placenta and foetus. In advances in international maternal child health. Vol 4. Editors Jelliffe DB & Jelliffe FE, Clarendon P. Press Oxford. 1984: 26-35.
5. Indian Council Medical Research. Evaluation of the national nutritional anemia prophylaxis programme. ICMR report 1989,New Delhi.
6. Indian Council Medical Research. Field supplementation trial in pregnant women with 60, 120 and 180 mg of iron and 500 ug of folic acid ICMR report 1992, New Delhi.
7. Agarwal KN, Agarwal DK & Mishra KP. Impact of anemia prophylaxis in pregnancy on maternal hemoglobin, serum ferritin and birth weight. Indian J Med Res.1991; 94:277-280.
8. Vahlquist BC, Das. Serumerrisen, eine paediatrisch kinische und experimental studies. Acta Paediatr 1941 (Suppl 6 ); 28:1-4.
9. Sturgeon P. Studies of iron requirements in infants: II: Influence of supplemental iron during normal pregnancy on mother and infant. Brit J Haemat 5: 45-55.
10. Rios E, Lipschitz DA, Cook JD, Smith NJ. Relationship of maternal and infant iron stores as assessed by determination of plasma ferritin. Pediatrics 1975; 55: 694-699.
11. Steer P, Alam MA, Wadsworth J, Welch A. Relationship between maternal haemoglobin concentration and birth weight in different ethnic groups. Brit J Med 1995;310: 489-491.
12. Singla PN, Chand S, Khanna S & Agarwal KN. Effect of maternal anemia on the placenta and the newborn Acta Paediatrica Scand. 1978;67: 645-648.
13. Singla PN Chand S, Agarwal KN. Cord serum and placental tissue iron status in maternal hypoferremia. Amer J Clin Nutr. 1979; 32: 1462-1465.
14. Agarwal RMD, Tripathi AM, Agarwal KN. Cord blood hemoglobin iron and ferritin status in maternal anemia. Acta Paediatr Scand 1983; 72: 545-548.
15. Fletcher J, Suter PEN. The transport of iron by the human placenta. Clin Sci. 1969;36: 209-220.
16. Khanna S, Chand S, Singla PN, Agarwal KN. Morphological study of placenta in pregnancy anemia. Indian J Path Microbiol 1979;22: 7-12.
17. Agarwal KN, Krishna M, Khanna S. Placental morphological and biochemical studies in maternal anemia before and after treatment. J Trop Pediatr. 1981;27: 162 - 165.
18. Agarwal KN. Functional consequences of nutritional anemia. Proc Nutr Soc of India. 1991;37: 127-132.
19. Singla PN, Gupta VK, Agarwal KN. Storage iron in human fetal organs. Acta Paediatr Scand 1985;74:701 - 706.
20. Franson GN, Agarwal KN, Mehdin GM, Hambraeus L. Increased breast milk iron in severe maternal anemia: Physiological trapping or leakage. Acta Paediatr Scand 1985;74: 290-291.
21. Khurana V, Agarwal KN, Gupta S, Nath T. Estimation of total protein and iron content in breast milk of Indian lactating mothers. Indian Pediatr 1970;7:659.
22. Fel BT, Lozoff B. Brain iron and behaviour of rat were not normalized by treatment of iron deficiency anemia during early development. J Neurochem 1996;126:693-701
23. Youdim MBH, Ben-Schachar Yehuda S. Putative biological mechanisms of the effect of iron deficiency on brain biochemistry and behavior. Amer J Clin Nutr 1989;50: 2282-2285.
24. Taneja V, Mishra KP, Agarwal KN. Effect of maternal iron deficiency on GABA shunt pathway of developing rat brain. Indian J Exptl Biol 1986;28: 466-469.
25. Shukla A, Agarwal KN, Shukla GS. Effect of latent iron deficiency on metal levels of rat brain regions. Biol Trace Elem Res 1989; 22: 141-152.
26. Taneja V, Mishra KP Agarwal KN. Effect of early iron deficiency in rat on the gamma-amino butyric acid shunt in brain. J Neurochem 1986;46: 1670-1674.
27. Shukla A, Agarwal KN, Chansuria JPN, Taneja V. Effect of latent iron deficiency on 5-hydroxytryptamine metabolism in rat brain. J Neurochem 1989;52: 730-735.
28. Shukla A, Agarwal KN, Shukla GS. Latent iron deficiency alters gamma-amino butyric acid and glutamate metabolism in rat brain. Experientia 1989; 45: 343-345.
29. Shukla A, Agarwal KN, Shukla GS. Studies on brain catecholamine metabolism following latent iron deficiency and subsequent rehabilitation in rat. Nutr Res 1989;9: 1177-1186.
30. Mittal RD, Pande A, Mittal B, Agarwal KN Effect of latent iron deficiency on GABA and glutamate neuroreceptors in rat brain. J Neurchem (sub).
31. Prasad C, Devi R, Agarwal KN. Effects of dietary proteins on fetal brain protein and glutamic acid metabolism in rat. J Neurochem. 1979;32: 1309-1314.
32. Prasad C, Agarwal KN. Intrauterine malnutrition and the brain. Effects on enzymes and free amino acids related to glutamate metabolism. J Neurochem. 1980;34: 1270-1273.
33. Agarwal K N et al. Roentgenologic changes in iron deficiency anemia. Amer J Roent Rad Therp Nuc Med CX 1970; 635.
34. World Health Organization. The prevalence of anemia in woman: A tabulation of available information 2nd edition, Geneva. 1992.
35. Lal H Agarwal KN, Gupta M, Agarwal DK. Protein and iron supplementation by cooking practices in community. Indian J Med Res 1973; 61:918-925.
36. Wright AJA, Southern S. The effectiveness of various iron supplementation regimes in improving the Fe status of anemic rats. Brit J Nutr 1990;63: 579-585.
37. Viteri FE, Xunian L, Tolomei K, Martin A. True absorption and retention of supplemental iron is more efficient when iron is administered every three days rather than daily to iron- normal and iron deficient rats. J Nutr 1995;125: 82-89.
38. Beaton GH et al. Efficacy of intermittent iron supplementation in the control of iron deficiency anemia in developing countries: An analysis of experience. Final report to the Micronutrient Initiative. 1999
39. Das BK, Bal MS, Tripathi AM, Singla PN, Agarwal KN . Evaluation of frequency and dose of iron and other hematinics- An alternative strategy for anemia prophylaxis in rural preschoolers. Indian Pediatr 21: 933-938.