anemia prevention and control: program guidance, part i

Part IProgram Guidance

Anemia Prevention

and Control:WHAT

WORKS

Anemia Preventionand Control:

WHAT WORKSPart I

Program Guidance

2 Anemia Prevention and Control:What WorksPart I : Program Guidance

The opinions expressed herein are those of the author(s) and do not necessarily reflectthe views of USAID.

The findings, interpretations, and conclusions expressed here are those of the author(s)and do not necessarily reflect the views of the Board of Executive Directors of the WorldBank or the governments they represent. The World Bank cannot guarantee the accura-cy of the data included in this work. The boundaries, colors, denominations, and otherinformation shown on any map in this work do not imply on the part of the World Bankany judgment of the legal status of any territory or the endorsement or acceptance ofsuch boundaries.

The views expressed in this publication are those of the author(s) and do not necessarilyreflect the views of UNICEF. Any map in this work does not reflect a position byUNICEF on the legal status of any country or territory or the delimitation of anyfrontiers.

This document does not necessarily represent the views or opinions of the PanAmerican Health Organization (PAHO).

The views expressed in this publication are those of the author(s) and do not necessarilyreflect the views of the Food and Agriculture Organization (FAO) of the United Nations.The designations employed and the presentation of material do not imply the expres-sion of any opinion whatsoever on the part of FAO concerning the legal status of anycountry, territory, city or area or of its authorities, or concerning the delimitation of itsfrontiers or boundaries. The designations “developed” and “developing” economies areintended for statistical convenience and do not necessarily express a judgement aboutthe stage reached by a particular country or area in the development process.

The views in this document do not necessarily reflect the views expressed or promotedby the Micronutrient Initiative.

The Monitoring, Evaluation, and Design Support (MEDS) project coordinated thedevelopment and production of this document. MEDS is funded by USAID undercontract no. HRN-I-02-99-0002-00, task order no. 02. LTG Associates, Inc., and TvT

Global Health and Development StrategiesTM, a division of Social & ScientificSystems, Inc., implement the project.

The Population, Health and Nutrition Information (PHNI) Project produced thisdocument. PHNI is funded by USAID under contract no. HRN-C-00-00-00004-00.The Project is managed by Jorge Scientific Corporation with The Futures Group

International and John Snow, Inc.

ISBN 0-9742991-0-3

June 2003

3

Contents

Part I: Program Guidance

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Abbreviations and Acronyms/Units of Measure . . . . . . . . . . . . . . . . . . 9

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Chapter I Anemia: “Lost Years of Healthy Life” . . . . . . . . . . . . . . . . 15

Chapter II Taking Action: Developing a Strategy for Anemia Prevention and Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Chapter III Providing Iron Supplements to Combat Anemia . . . . . . . 45

Chapter IV Improving Dietary Iron Intake to Combat Anemia . . . . . 59

Photo and Illustration Credits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75

Part II: Tools and Resources

The contents of Anemia Prevention and Control: What Works,Part II: Tools and Resources are listed below. See the Part IIContents for page numbers.

Statistics/Technical Data Hemoglobin and Hematocrit Values Defining Anemia at Sea Level

Shifting the Hemoglobin Distribution: Hemoglobin Distribution inPalestinian vs American Children and Women

Anemia Prevalence Rates in Vulnerable Populations, Selected Countries

Anemia Prevalence by Rural/Urban Residence, Selected Countries

Substances That Inhibit and Enhance Absorption of Iron

Demands for Iron in Pregnancy

Proportion of Women Utilizing Antenatal Care (ANC) Services andReceiving/Taking Iron or Iron-Folic Acid (IFA) Supplements, SelectedCountries

Anemia Prevention and Control:What Works

Program DevelopmentRaising Awareness/Program Advocacy: Sample Fact Sheets

Selected Monitoring and Evaluation Indicators for Anemia Preventionand Control Programs

A Tool for Reviewing Micronutrient Programs

Qualitative Research Instrument on Perceptions of Anemia and Use ofIron Supplements – The Indramayu Project, Indonesia

Recommended Intermittent Presumptive Treatment (IPT) or TreatmentRegimens for Malaria, Hookworm, and Schistosomiasis

Iron Supplementation/Food FortificationIron Doses and Three-Month Hemoglobin Increase in Women

Iron and Folic Acid Doses for Universal Supplementation in VulnerableGroups

Iron and Folic Acid Doses for Treating Severe Anemia in VulnerableGroups

United States Dietary Reference Intakes for Anemia-RelatedMicronutrients (Other Than Iron and Folic Acid) for Vulnerable Groups

Counseling Pregnant Women and Mothers About Iron Supplements

Negotiating With Women to Follow Advice

Food Fortification: Seven Steps for Quality Control

Information Sources for Anemia Prevention and Control

References (to Parts I and II)


5

Preface

Anemia Prevention and Control:What Works has two purposes:

1. To bring to the attention of program andproject managers of health and relatedactivities the serious negative conse-quences of anemia for the health andphysical, mental, and economic produc-tivity of individuals and populations

2. To make managers aware of the variousapproaches to anemia prevention andcontrol they can take in policies andprograms in the health and health-relat-ed sectors

Anemia Prevention and Control: WhatWorks has two parts, Part I: ProgramGuidance and Part II: Tools andResources. Because anemia has multiplecauses, Program Guidance advocates acoordinated strategy that takes a numberof sector approaches to reducing anemia’sprevalence and effects. It provides guid-ance on important issues and componentsthat need attention in the design andimplementation of anemia prevention andcontrol strategies and programs. Tools andResources is a compilation of anemia-relat-ed data, survey instruments, programmaterials, and references that managerscan use to design and monitor programs.

In Program Guidance, this Preface is fol-lowed by Acknowledgments, Abbrevia-tions and Acronyms/Units of Measure,and an Introduction to anemia. Theremainder of Part I is organized as follows:

Chapter I, Anemia: “Lost Years of HealthyLife,” defines anemia; describes its impact,prevalence, and causes; and communicatesthe critical importance of taking actionagainst anemia.

Chapter II, Taking Action: Developing aStrategy for Anemia Prevention andControl, discusses good practices for strat-egy and program development and pres-ents sector-specific interventions in healthand related sectors for preventing andcontrolling anemia.

Chapters III and IV then cover the goodpractices associated with augmentingdietary iron by providing iron supple-ments and through food fortification, twoimportant interventions for addressingiron-deficiency anemia.

Each chapter includes a Country Exampledescribing anemia prevention and controlprogramming in a country that has incor-porated many of the elements discussed inthis document. In Chapters II, III, and IV,the country example follows a brief intro-duction to the section. A Good PracticesChecklist gives the steps to take in design-ing and implementing programs, and theGood Practices in Detail section thendescribes the specific actions involved withthese steps. The real-life experiences ofmany anemia prevention and control pro-grams are highlighted in shaded text boxesto illustrate how the information providedin Program Guidance can be put to use.Italicized references directing readers torelevant materials in Tools and Resourcesalso appear throughout the text.

Interagency Anemia Steering Group

Wilma B. FreirePan American Health Organization

Samuel G. KahnU.S. Agency for International

Development

Judith McGuireWorld Bank

Glenn L. PostU.S. Agency for International

Development

Acknowledgments

Anemia Prevention and Control: WhatWorks was written by Rae Galloway,whose time was generously funded by theU.S. Agency for InternationalDevelopment (USAID), the MicronutrientInitiative (MI), and the World Bank. Ms.Galloway received technical advice andsupport from the Interagency AnemiaSteering Group (IASG) composed ofWilma B. Freire, Pan American HealthOrganization (PAHO); Samuel G. Kahn,USAID; Judith McGuire, World Bank; andGlenn L. Post, USAID. The IASG definedthe objectives and audience of AnemiaPrevention and Control: What Works,identified reviewers, and gave essentialcomments at each step. Decisions aboutfinal content were made by the IASG.

Special thanks go to Milla McLachlan,nutrition adviser at the World Bank, forsupporting this project, and MiriamLabbok, who as chief of nutrition andmaternal/infant health at USAID’s Bureaufor Global Programs, Field Support andResearch, helped define objectives and,after moving to the United NationsChildren’s Fund (UNICEF), reviewedthe document.

Adjunct Steering GroupAdjunct organizations were partners inthis process and gave comments whenobjectives were defined and when review-ing the document. The adjunct organiza-tions included the MI, UNICEF, theCanadian International DevelopmentAgency (CIDA), the United Nations Foodand Agriculture Organization (FAO), theUnited Nations Standing Committee onNutrition (SCN), and the World HealthOrganization (WHO).

Country ContributorsThe Country Examples that appear in PartI: Program Guidance are based on casestudies of anemia prevention and controlprograms in Bolivia, Indonesia, Thailand,and Venezuela. These case studies wereessential to this document. The Bolivia

example was written by the author of thisdocument using a report prepared by con-sultant Maria Eugenia Lopez for the WorldBank and the MI. The Indonesia examplewas written by Endang Achadi and D.M.Utari, University of Indonesia; the Thai-land example by Pattanee Winichagoon,Mahidol University; and the Venezuelaexample by Maria Garcia-Casal, InstitutoVenezolana de Investigaciones Cientificas(IVIC). The Bolivian, Indonesian, and Thaistudies were made possible with fundingfrom the MI. The information on povertyand anemia prevalence was prepared byKrishna Rao, consultant for a larger studyfunded by the MI for the World Bank. Inaddition, Ritujit Chhabra at the WorldBank helped in checking prevalence datafor the document.

Review and CommentsComments were given by adjunct organi-zations, external reviewers, and USAID ondrafts of the document. The adjunctreviewers were Bruno de Benoist (WHO),Barbara MacDonald (CIDA), M. G.Venkatesh Mannar (MI), Ellen Muehlhoff(FAO), and Sonya Rabeneck (SCN).

External reviewers providing commentswere Lawrence Barat, World Bank/Centersfor Disease Control and Prevention (CDC)of the United States, on malaria; LenaDavidson, International NutritionalAnemia Consultative Group (INACG),technical/scientific aspects for the wholedocument; Patrick Friel, United NationsDevelopment Programme (UNDP), familyplanning; Victor Fulgoni, consultant, tech-nical/scientific aspects; Marito Garcia,World Bank, early childhood develop-ment; Marcia Griffiths, the Manoff Group,technical/scientific aspects; RichardHurrell, Swiss Federation Institute ofTechnology, technical/scientific aspects;Judiann McNulty, Cooperative forAssistance and Relief Everywhere, Inc.(CARE), operational issues; IbrahimParvanta, CDC, technical/scientificaspects; Peter Ranum, consultant, techni-cal/scientific aspects related to fortifica-tion; and Rebecca Stoltzfus, CornellUniversity, technical/scientific aspects.

7

USAID/Washington staff providing com-ments included Eunyong Chung, CarterDiggs, Mary Ettling, Miriam Labbok (nowwith UNICEF), Margaret Neuse, PatriciaStephenson, Joyce Turk, and EmilyWainwright. Victor Masbayi ofUSAID/Kenya and Kerry Pelzman ofUSAID/Russia also provided comments.

Staff from USAID-funded programs pro-viding comments included SuzanneHarris, the International Life SciencesInstitute (ILSI); staff from MicronutrientOperational Strategies and Technologies(MOST); and Sandra Remancus, Food andNutrition Technical Assistance (FANTA).

Coordination, Editing, andProductionThis document is the result of a multi-agency effort coordinated and facilitatedby staff of the Monitoring, Evaluation andDesign Support (MEDS) project with fund-ing from the USAID Bureau for GlobalHealth. The Population, Health andNutrition Information (PHNI) Project, alsofunded by the Bureau for Global Health,provided editorial and design staff andproduced the document. Karen Lombardi(MEDS) and Chris Wharton (PHNI) editedthe document. Muthoni Njage (MEDS)provided research and review assistance.Matthew Baek (PHNI) designed and for-matted the document. The Government ofthe Netherlands provided funding to theWorld Bank to cover some printing costs.


9

Abbreviations and Acronyms

ACC/SCN Administrative Committee on Coordination, Sub-Committee on Nutrition (United Nations)

AED Academy for Educational Development

AIDS acquired immunodeficiency syndrome

ANC antenatal care

BASICS Basic Support for Institutionalizing Child Survival (Project)

BF breastfeeding

CARE Cooperative for Assistance and Relief Everywhere

CDC Centers for Disease Control and Prevention (United States)

CF complementary foods

CIDA Canadian International Development Authority

DHS Demographic and Health Survey

ECD early childhood development

EDTA ethylene diamine tetra-acetate

FANTA Food and Nutrition Technical Assistance (Project)

FAO Food and Agriculture Organization (United Nations)

FGD focus group discussion

GTZ Deutsche Gesellschaft für Technische Zusammenarbeit (German Technical Cooperation)

Hb hemoglobin

hct hematocrit

HIV human immunodeficiency virus

IASG Interagency Anemia Steering Group

IDRC International Development Research Centre

IEC information, education, and communication

IFA iron-folic acid

ILSI International Life Sciences Institute

IMCI Integrated Management of Childhood Illness

INACG International Nutritional Anemia Consultative Group

IPT intermittent presumptive treatment (malaria)

IUD intrauterine device


IVIC Instituto Venezolana de Investigaciones Cientificas

LAM Lactional Amenorrhea Method

MEDS Monitoring, Evaluation and Design Support (Project)

MI Micronutrient Initiative

MOH ministry of health

MOST Micronutrient Operational Strategies and Technologies (Project)

NGO nongovernmental organization

NHHS National Household Survey (Indonesia)

NID national immunization day

OMNI Opportunities for Micronutrient Interventions (Project)

PAHO Pan American Health Organization

PATH Program for Appropriate Technology in Health

PHNI Population, Health and Nutrition Information (Project)

SCN Standing Committee on Nutrition (United Nations)

TBA traditional birth attendant

TIPS Trials of Improved Practices

TT tetanus toxoid

USAID United States Agency for International Development

UNICEF United Nations Children’s Fund

UNDP United Nations Development Programme

UNU United Nations University

VAD vitamin A deficiency

WHO World Health Organization

Units of Measure

dL deciliter

g gram

kg kilogram

L liter

mcg microgram

mg milligram

mL milliliter

Introduction

Anemia is defined as a low level of hemo-globin in the blood, as evidenced by areduced quality or quantity of red bloodcells. It has serious negative consequences,including increased mortality in womenand children, decreased capacity to learn,and decreased productivity in all individu-als. Its devastating effects on health andphysical and mental productivity affectquality of life and translate into significanteconomic losses for individuals and forcountries with high anemia prevalence.

Anemia is one of the world’s most wide-spread health problems. It affects morethan 2 billion people worldwide – one-third of the world’s population – and is asignificant public health problem through-out the developing world. In almost alldeveloping countries, between one-thirdand one-half of the female and child popu-lations are anemic. Prevalence among preg-nant women and children under 2 years ofage (the groups at highest risk) is typicallymore than 50 percent. In a 2002 report, theWorld Health Organization lists iron defi-ciency, a major cause of anemia, as one ofthe top 10 risk factors in developing coun-tries for “lost years of healthy life.”

Anemia has multiple causes. Its directcauses can be broadly categorized as poor,insufficient, or abnormal red blood cellproduction; excessive red blood celldestruction; and excessive red blood cellloss. Contributing causes include poornutrition related to dietary intake, dietaryquality, sanitation, and health behaviors;adverse environmental conditions; lack ofaccess to health services; and poverty. Therelative importance of these causes variesby region.

Iron deficiency causes 50 percent of allanemia worldwide. Supplementing dietaryiron with iron tablets, syrups, drops, orelixirs, and fortifying processed foods andcondiments with iron are the best offenseand defense against this cause of anemia.Where fortification has been evaluated in

specific populations, it has improved ironstatus and reduced anemia prevalence. Inmost developing countries, however, foodindustries are not well developed, and,where they are developed, most peoplecannot afford fortified foods. Supplement-ing dietary iron can meet the iron needs ofvulnerable groups who do not consumefortified foods. Iron supplementation alsohas the advantage of meeting the needs ofpregnant women and young children,whose high iron requirements cannot bemet only with fortified foods. In countrieswhere the feasibility of general dietaryimprovement is limited, iron supplementa-tion for vulnerable groups and food fortifi-cation are the most cost-effective means ofaddressing iron-deficiency anemia.

Because anemia has many causes in addi-tion to iron deficiency, many types of pro-grams in the health sector and other socialsectors have the potential to contribute toanemia prevention and control. An anemiacomponent can and should be part of pro-grams or activities in:

• Nutrition

• Infectious and parasitic diseases

• Antenatal care and safe motherhood

• Family planning and reproductivehealth

• Child health

• Schools

• HIV/AIDS prevention and treatment

• Food aid and security

• Environmental health

• Commercial sector: food and pharma-ceutical manufacturers, marketers, anddistributors

Sector-specific activities, when implement-ed concurrently as part of an anemia pre-vention and control strategy, can signifi-cantly reduce the prevalence of anemiaand its debilitating consequences in target-ed populations. In most cases, it is possibleto add anemia prevention or control activi-ties to already existing health or health-

11

related programs without large invest-ments of time or resources.

Raising awareness of anemia preventionand control, promoting behavior change inthe community, advocating for increasedfunding for national anemia programming,and training to build capacity amonghealth workers are activities that can beimplemented by any and all sectors andacross sectors. They are most effectivewhen approached in a coordinated, target-ed manner.

Health professionals, governments,donors, nongovernmental organizations,the commercial sector, and civil society allhave roles to play in achieving anemiaprevention and control. Effectively imple-menting interventions requires an inte-grated approach of financial, technical,and political commitment and support.Partnerships and collaboration amongthese various players should be built atthe national, provincial/state, district, andlocal levels from the outset of anemia pro-gramming. Input from and coordinationamong all potential parties is most criticalin the key initial phase of planning ananemia strategy.

Knowing what has worked for others canfacilitate the efforts of new programs totake action. Part I: Program Guidance ofAnemia Prevention and Control: WhatWorks thus presents good program prac-tices for anemia prevention and control,with examples of good practices fromaround the world. Part II: Tools andResources shares materials such as qualita-tive research instruments and methodolo-gies, background data, norms and proto-cols, and references to also inform andsupport such efforts.


13Chapter I Anemia:“Lost Years of Healthy Life”

Anem

ia:“Lost Years of H

ealthy Life”COUNTRY EXAMPLE

ASSESSING THE EFFECTIVENESS OF ANEMIAPREVENTION AND CONTROL IN BOLIVIA

In Bolivia, which has had a policy to give iron supplements to pregnant women since 1986,the 1997 Demographic and Health Survey (DHS) found that 27 percent of women of repro-ductive age were anemic. The survey data were not disaggregated between pregnant andnonpregnant women, but it is likely that anemia prevalence in pregnant women was higher.One study of antenatal care (ANC) clients, for example, found that 50 percent were anemic.Undoubtedly, anemia prevalence remains high because ANC coverage is low – only 50 per-cent of women have contact with health services during pregnancy. As a result, only 35 per-cent of pregnant women routinely receive iron-folic acid (IFA) supplements.

Anemia is also a problem in other population groups. In response to the 67 percent anemiaprevalence the 1997 DHS found among children under age 3, the government has extendedIFA supplementation to children under age 2. In addition, to help build the iron stores of theentire population, Bolivia now requires all wheat flour to be fortified with iron and othermicronutrients.

In 2000, a qualitative assessment of Bolivia’s public and private health systems (conducted aspart of a larger World Bank study on nutrition) identified the strengths and constraints ofIFA supplementation programs. Representative municipalities were chosen from the threegeographic zones (highland plateau, valley, and plains) according to a human developmentindex based on socioeconomic variables such as life expectancy at birth, educational level,and income, and on the presence of public and private health systems.

Observations of services and interviews with health staff, women, and mothers of young chil-dren showed that awareness of policies, norms, and protocols in support of IFA supplementa-tion was low. The low priority given to iron and other micronutrients was reflected in suchstatements as “The Expanded Program on Immunization demands a lot of effort and causeslack of attention to the micronutrient component” and “During the technical council meet-ings, micronutrients have never been an important topic or item for discussion.” The assess-ment also indicated a need to put micronutrients on the agenda of health care institutions.

In addition, most of the focus of IFA supplementation activities was on curative treatment ofanemia rather than anemia prevention. Anemia control for young children was almost non-existent, despite the policy supporting IFA supplementation for children under 2. The IFAsupplementation program for pregnant women was more active, but coverage was stilllower than expected for a 15-year-old program. Reasons for this low coverage included:

• Copies of norms and protocols on anemia prevention and treatment not available in allhealth facilities

• Lack of standardization of norms and protocols

• Lack of training in how to use norms and protocols

• Failure to seek advice from knowledgeable, experienced personnel in the lower levelsof the health system when developing norms and protocols

• Supply shortages preventing health workers and IFA users from complying withprogram norms


While supplies of IFA supplements were adequate at the national level, only 9 percent of thenational supply was distributed between January and October 1999. As a result, only 21percent of pregnant women received all of the recommended 90 supplements, and only 30percent received 60. These findings are indicative of either (or both) an ineffective distribu-tion and logistics system or a lack of demand for the supplements due to poor utilization ofANC services or poor supplement quality. In subtropical districts, problems with the qualityof the IFA supplements were severe. One health worker noted that the supplements “turnto powder because of the humidity and women refuse to take them.”

Women rarely received consistent messages on when to take IFA supplements and how tomanage side effects. Health worker training on anemia control and counseling was limited. Ina few areas, some health staff received in-depth training on IFA supplementation throughspecial programs such as the MotherCare and Opportunities in Micronutrient Interventions(OMNI) projects (funded by the U.S.Agency for International Development and implement-ed by John Snow, Inc.) and Integrated Management of Childhood Illness (IMCI) activities. Inmost cases, health workers felt they had forgotten most of what they had learned, indicatinga lack of follow-up supervision to reinforce messages. The MotherCare/OMNI projectsdeveloped counseling cards and other behavior change materials for use throughout thecountry, but their dissemination and use stopped after the projects ended.

The World Bank study made the following recommendations to improve service quality:

• Ensure adequate supplies of IFA supplements for pregnant women and young children

• Make norms and protocols available to health workers who are giving supplements topregnant women and children

• Train health workers to ensure that they 1) understand the importance of anemia, 2) fol-low norms and protocols, 3) improve their communication and interpersonal skills withwomen and mothers attending health services or receiving counseling, and 4) are able toconvey effective messages to women

• Supervise health workers and programs adequately to ensure continuous qualityimprovement in services

• Scale up the success of smaller programs that have developed effective training andbehavior change materials

• Utilize all channels in the health system (including community workers and public healthprograms such as immunization campaigns, growth-monitoring contacts, and pre- andpostnatal care) to deliver iron to ensure that the most vulnerable groups receive suppliesof IFA supplements or syrups

Chapter IAnemia: “Lost Years

of Healthy Life”1

What Is Anemia2 ?Anemia is defined as a low level of hemoglobinin the blood, as evidenced by a reduced qualityor quantity of red blood cells.

Hemoglobin is the substance in red bloodcells that carries oxygen to the cells of thebody. The body’s cells need oxygen tofunction and enable a person to performall physical and mental activities. Whenhemoglobin levels are low, as in a personwho has anemia, less oxygen reaches thecells to support the body’s activities. Theheart and lungs also must work harder tocompensate for the blood’s low capacity tocarry oxygen.

Internationally accepted hemoglobin val-ues for defining anemia in different popu-lation groups are shown in table 1.1.

Anemia is subclassified into mild, moder-ate, and severe levels as hemoglobin val-ues decline. It can also be measured interms of the hematocrit content of packedblood cell volume.

What Is the Impact of Anemia?Anemia makes it more difficult for men andwomen to earn incomes, carry out daily tasks,and care for their families. It makes womenweaker during pregnancy and delivery, reduc-ing their chances of having healthy babies andsurviving blood loss during and after child-birth. Anemic infants and children grow moreslowly than non-anemic infants and children.They are apathetic and anorexic, do not haveenough energy to play, and have trouble learn-ing. A 2002 World Health Organization reportlists iron deficiency, a major cause of anemia,as one of the top 10 risk factors in developingcountries for “lost years of healthy life.”

Adult productivity. In adults, one of thefirst signs of anemia is fatigue, whichoccurs when there is not enough oxygen inthe body to support physical activity.Work productivity and earned income suf-fer accordingly. Preventing and treating allcauses of anemia improves work output. A

literature review from 1973 to 1981 foundthat a 10 percent increase in hemoglobinlevels was associated with a 10 to 20 per-cent increase in work output. Adults withanemia are also less likely to engage insocial activities and nurture and care fortheir infants and children.

Maternal health. Anemia reduces awoman’s ability to survive bleeding dur-ing and after childbirth. Women with


Anem


ealthy Life”

1 The 2002 World Health Report of the World HealthOrganization uses this concept to measure the impactof a number of health problems, including anemia.2 The terms “anemia” and “iron-deficiency anemia” areoften used interchangeably. In this document, “anemia”means anemia from any cause, unless specified as“iron-deficiency anemia” – anemia caused only by irondeficiency.

Table 1.1Hemoglobin Values Defining Anemia

For Population Groups

Age or Sex GroupHemoglobin

Value Defining Anemia (g/dL)

Children 6-59 mos.

Children 5-11 yrs.

Children 12-14 yrs.

Nonpregnant women > 15 yrs.

Pregnant women

Men > 15 yrs.

< 11.0

< 11.5

< 12.0

< 12.0

< 11.0

< 13.0

Source: WHO/UNICEF/UNU (2001); values used inDHS.

Tools and Resources has an expanded versionof table 1.1 with hemoglobin values for mild,moderate, and severe anemia, and hematocritvalues for different age and sex groups.

In Bangladesh, India, and Pakistan, anemia-related losses in economic productivity amountto an estimated $4.5 billion annually.

severe anemia are particularly at risk andhave a 3.5 times greater chance of dyingfrom obstetric complications during orafter pregnancy than women who do nothave anemia. Anemia-related fatigue alsomakes the effort of labor more difficult,thus prolonging delivery.

Conservative estimates suggest anemia isthe direct cause of 3 to 7 percent of mater-nal deaths worldwide. Other estimatessuggest it is the direct or indirect cause of20 to 40 percent of maternal deaths.

Although it is currently accepted that onlysevere anemia causes maternal mortality, ithas been estimated that moderate anemiaincreases a woman’s chance of dying 1.35times, making it a risk for maternal mortal-ity. Many more women have mild to mod-erate anemia than severe anemia. Thisunderscores the importance of preventingand treating all forms of anemia, as the

number ofdeathsassociatedwith mildto moder-ate ane-mia ispotential-ly greaterthan the

number associated with severe anemia.This is consistent with patterns seen withvitamin A and energy deficiencies, which,because of the greater numbers of peopleaffected, also cause more deaths in theirmild to moderate forms than in theirsevere forms.

Young child development and learn-ing. Anemia is associated with prematurebirths, intrauterine growth retardation,and low birthweight in infants. In turn,premature, underdeveloped, and under-weight infants have decreased chances ofsurvival. If they survive, they may have(both as infants and later as children)physical and mental developmental prob-lems, including learning deficits, eatingdisorders such as anorexia, and poorgrowth. Full-term infants of anemic moth-ers have reduced iron stores and are at risk

of becoming iron-deficient and anemicduring exclusive breastfeeding in the firstsix months of life. Iron-deficiency anemia,particularly in children under 2 years ofage, can result in irreversible learningproblems even if the iron deficiency andresulting anemia are corrected. In malaria-endemic areas, many children are anemicbecause of a combination of iron deficiencyand untreated episodes of malaria. Thehemoglobin levels of these children candrop to life-threatening levels. Iron defi-ciency also affects iodine uptake, increas-ing the risk of iodine deficiency disordersthat can have devastating effects on fetalbrain development and a child’s IQ.Anemic children of all ages are apathetic,which affects social development.

Adolescent development. Because theyare undergoing rapid growth, adolescentshave high requirements for iron and areparticularly vulnerable to anemia causedby multiple nutritional deficiencies andhelminth infections. Both boys and girls areat risk, although prevalence peaks at differ-ent ages for each because the growth spurtsof boys and girls occur at different ages.


In Tools and Resources, “Shiftingthe Hemoglobin Distribution”shows the distribution of mild,moderate, and severe anemia in apopulation and describes itsimplications for programdevelopment.

Children and adolescents have high ironrequirements because of rapid growth.

Iron requirements for boys decrease afterthey stop growing, while those for girlsremain high throughout the reproductiveyears because of menstrual blood loss, theiron demands of the developing fetus, andblood loss during delivery.

How Prevalent Is Anemia?There are more than 2 billion people in theworld with anemia – one third of the world’spopulation. Anemia prevalence is highest indeveloping countries. Worldwide, pregnantwomen and children, particularly children lessthan 2 years old, are the most vulnerable. Inmany countries, anemia prevalence is highestin rural areas.

When national anemia prevalence surveysdisaggregate anemia prevalence by ageand sex, they generally show that the high-est rates occur in pregnant women andyoung children under 2 years of age.National surveys may also include data forother groups, such as all reproductive-age

women,childrenunder age5, school-age chil-dren, ado-lescents,

laborers with heavy workloads, farmlaborers, and the elderly.

At the national level, anemia is considereda severe public health problem when ane-mia prevalence is equal to or greater than

40 percent. By the measures given in fig-ure 1.1, anemia is a severe public healthproblem in nearly all developing countries.Anemia prevalence rates in industrializedcountries are typically in the normal tomild range.

Tables 1.2 and 1.3 show estimates of ane-mia prevalence for developing and indus-trialized countries and different worldregions. For all age groups, the risk ofdeveloping anemia is two to seven timesgreater indevelopingcountries thanin industrial-ized coun-tries. Anemiaprevalence is usually higher in rural areasthan urban areas.

Anemia prevalence is highest in WHO’sSouth East Asia,3 Eastern Mediterranean,


Anem


ealthy Life”

The table “Anemia PrevalenceRates in Vulnerable Populations,Selected Countries” appears inTools and Resources.

Figure 1.1

Public Health Significance of Anemia

Anemia Public Health Prevalence Significance

> 40% Severe20-39% Moderate5-19% Mild0-4.9% Normal

Source: WHO/UNICEF/UNU (2001).

Table 1.2Prevalence of Anemia by Risk Group, Developing and Industrialized Countries, 1998*

0-4 yrs. (%) 5-14 yrs. (%) Nonpregnant Women (%)

PregnantWomen (%) Others (%)

Developing Countries 42** 53 43 55

Men: 35Elderly: 51

IndustrializedCountries 17 8 11 19

Men: 5Elderly: 12

* Estimates using hospital populations or data over 10 years old. ** National data from countries within each region suggest that prevalence rates for children < 2 yrs. are higherthan the rates shown here for children 0-4 yrs. Source: SCN (2000).

Tools and Resources containsthe table “Anemia Prevalenceby Rural/Urban Residence,Selected Countries.”

3 WHO’s South East Asia region includes South Asia.

and Africa regions, with the highest ratesfound among pregnant women and chil-dren. Increases in anemia prevalenceoccurred during the 1990s in EasternEurope, the Caucasus, and Central AsianRepublics. Prevalence is lower in WesternEurope and in WHO’s Western Pacific andAmericas regions. Nonetheless, anemiaprevalence among pregnant women andchildren in these areas persists at moderateto severe levels, according to international-ly accepted standards. This reflects the dif-ficulty of meeting the iron needs of thesevulnerable groups even in areas wherediets are relatively high in iron. Lowerrates in some countries, however, indi-cate that targeted programs can addressthis problem.

What Are the Causes of Anemia?

There are different causes of anemia worldwide.Their relative importance varies by region.

In order of importance, the major causes ofanemia are iron deficiency; other nutrition-al deficiencies; malaria; helminth infections(particularly hookworm but also schistoso-miasis); chronic infections includingHIV/AIDS and tuberculosis; causes relatedto reproduction and contraception; andgenetic conditions such as thalassemia andsickle cell. These causes can be dividedinto direct causes and contributing causes.Table 1.4 lists these direct and contribut-ing causes and the components of each.

The relative importance of anemia’s causesvaries geographically. Table 1.5 shows theimportance of the major causes by region.In developing countries, there is seldomjust one cause of anemia, while in industri-alized countries anemia may be causedprimarily by poor dietary intake of severalnutrients.

Direct Causes: Poor, Insufficient, orAbnormal Red Blood Cell Production

Iron deficiency. Iron deficiency causes 50percent of anemia worldwide, making itthe single largest cause of anemia. Whileiron deficiency causes anemia by reducingred blood cell production, iron deficiencyitself may be exacerbated by excessive redblood cell loss (from menstruation, forexample).

Iron is an essential component of hemoglo-bin, which is needed to make red bloodcells. The body obtains iron from dietaryiron, recycled red blood cells, or stored iron.Both quantity and quality of diet con-tribute to iron sufficiency. Substances indifferentfoodshaveeitherinhibit-ing or enhancing effects on iron absorp-tion. If there is not enough iron in the dietor if it is not well absorbed, the body can-not meet its requirement for iron, causing


Table 1.3 Anemia Prevalence, Children 0-5 Years and

Pregnant Women, 1998

WHORegion

Children0-5 yrs. (%)

PregnantWomen (%)

Africa 44 51

Americas 20 35

E. Mediterranean 48 55

Europe 25 25

South East Asia* 65 75

Western Pacific 24 43

* includes South AsiaSource: SCN (2000).

In India, an estimated 131 million women ofreproductive age (52 percent of this popula-tion) and 85 million children under age 4 (74percent) are anemic. Combining these esti-mates with those for schoolchildren and ado-lescents, there are at least 360 million anemicindividuals in India.

In Cambodia, 57.8 percent of reproductive-age women are anemic. This rate increases to66 percent among pregnant women. Anemiaprevalence is 63 percent among children under5 but nearly 82 percent among 6- to 23-month-olds.

In Egypt, 29.7 percent of adolescents 11 to 19years of age are anemic.

Tools and Resources contains thetable “Substances That Inhibit andEnhance Absorption of Iron.”

a decline in red blood cell production andhemoglobin levels. If dietary iron is notincreased or some other source of iron(such as supplements) is not available,anemia occurs.

Red blood cell production increases as theiron requirements of individuals increase.Iron requirements are high during periodsof rapid growth, which occur in the fetus,children less than 2 years old, preschooland school-age children, and adolescents.Individuals who experience excessiveblood loss also have high iron require-

ments. Pregnant women are particularlysusceptible to anemia, as the growth of thefetus and other physiological changes dur-ing pregnancy increase the need for iron.In bothindustrialanddevelop-ing coun-tries, stan-dard diets do not provide the amount ofiron needed during pregnancy, so ironsupplementation is necessary. Healthy


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ealthy Life”Table 1.4 Causes of AnemiaDirect Causes Components (in order of importance)Poor, insufficient, orabnormal red blood cellproduction

Poor dietary intake and/or absorption of ironPoor dietary intake and/or absorption of vitamins (A, B-12, folicacid, and possibly B-6, C, and riboflavin) and copperIncreased needs for nutrients due to growth or disease (diarrhea)HIV/AIDSOther infectious diseases (tuberculosis, malaria)Genetic blood diseases (sickle cell disease or trait, thalassemia)

Excessive red blood celldestruction

Malaria

Excessive red blood cellloss

Helminth (worm) infections (hookworm, schistosomiasis)Bacterial or viral infections (peptic ulcers, gastritis, diarrhea)Reproduction (excessive blood loss during menstruation, delivery,and postpartum period; too many pregnancies; shortened postpar-tum amenorrhea)Contraceptive methods (intrauterine devices)

Contributing Causes ComponentsKnowledge and behavior Poor knowledge among health workers about anemia, iron supple-

mentation, and other anemia prevention and control interventionsPoor knowledge among vulnerable groups about the importance ofanemia and anemia prevention and control interventionsCultural taboos or biases (e.g., women eating after others)Practices that restrict food intake, including poor infant breastfeed-ing practices and inadequate introduction of complementary foodsPoor compliance with recommended behaviors (iron supplementation;malaria, tuberculosis, and other medication regimens; use of familyplanning; use of sanitation facilities; HIV prevention behaviors)

Environmental Contamination by heavy metals (lead)

Lack of access to services Low use of antenatal and other services providing iron supplements Lack of trained birth attendants to manage bleeding during deliveryLack of access to sanitation services that mitigate helminth infestationLack of access to bednets to prevent malaria transmission

Poverty Lack of income to buy foods with adequate amounts of absorbableiron or to obtain iron supplements, malaria treatment, insecticide-treated bednets, shoes to prevent helminth infection, and other pre-ventive commodities or services

Source: Adapted from Gillespie and Johnston (1998).

In Tools and Resources, the table“Demands for Iron in Pregnancy”outlines the iron losses and gainsin pregnant women.

infants of healthy mothers receive suffi-cient iron from their stored iron as well asa small but absorbable amount of ironfrom breast milk. Complementary foods tosupply iron need to be introduced at sixmonths, when iron stores are exhausted.Children between 6 and 24 months of ageneed iron supplements because most stan-dard diets do not supply enough iron (seebox The Special Iron Needs of ChildrenUnder Age 2).

Not all individuals with iron deficiencydevelop anemia and not all people withanemia are iron-deficient, as demonstratedin figure 1.2. Anemia is the most seriousmanifestation of iron deficiency, and inplaces where iron deficiency is the maincause of anemia, many more people areiron-deficient than anemic. In areas wheremore people have anemia due to othercauses, iron deficiency may still be a signif-icant cause of anemia.

Deficiencies in other nutrients. Anemia isalso caused by poor dietary intake and

poor absorption of other key nutrientsneeded for red blood cell production. Inconjunction with iron deficiency, deficien-cies of folic acid and vitamins A and B-12cause nutritional anemia. Deficiencies ofvitamins B-6 and C, riboflavin, and copperare also associated with anemia, but thereis little evidence that these deficienciescontribute significantly to anemia in devel-oping countries. Deficiencies in othernutrients can cause other devastating prob-lems. For example, if a woman is deficientin folic acid around the time of conception,the deficiency can cause neural tube andother developmental defects in the fetus.

Undernutrition itself can cause poor redblood cell production (as well as retardedgrowth, immunodeficiencies, and learningdeficits independent of iron-deficiencyanemia), and addressing undernutrition invulnerable groups is essential to correctinganemia in a sustainable way. The quantityof micronutrients consumed, particularlyiron, depends both on the type andamount of food consumed. Knowledge of


Table 1.5 The Importance of Anemia’s Major Causes by Region

IronDeficiency

Malaria Sickle Cell Thalassemia HIV/AIDS

Hookworm HighFertility

Sub-SaharanAfrica

+++ +++ ++ + ++ ++ +++

North Africa +++ + + ++ + + ++

Americas +++ + + + + + +

Central Asia/Caucasus

+++ ++ ++ ++ + + ++

EasternMediterranean

+++ ++ ++ ++ + + ++

Europe(Industrial)

+ — + + + — —

South EastAsia*

+++ ++ + + + + ++

WesternPacific**

+++ + + + + ++ +

* includes South Asia **includes ChinaKey: +++ very important as a cause; ++ of medium importance; + of mild importance or important on aregional basis; --- not significant or not of public health significanceSource: Warren et al. (1993); Fairbanks (1999); various DHS.

the kinds and amounts of food that shouldbe eaten may be inadequate and thus affectmicronutrient consumption. Inequities infood distribution within families and chron-ic or recurrent health conditions may alsoprevent the food and micronutrient needsof vulnerable groups from being met.

HIV/AIDS. People who have HIV infec-tion and are anemic are at greater risk ofdying than those without anemia. Theirrisk of dying increases as their hemoglobindecreases, and they have high require-ments for iron and other micronutrients.Their risks of anemia may increase becauseof poor diet and inadequate nutritionalcare affecting their red blood cell produc-tion. People living with HIV/AIDS areoften anorexic and may have mouth soresthat cause eating problems, resulting inreduced food intake. Iron deficiency andthe presence of other infections can furtherreduce appetite and exacerbate anemia.HIV infection itself suppresses red bloodcell production. When HIV infection devel-ops into AIDS, anemia may become severeas iron is sequestered in the liver and mus-cle. Certain types of AIDS treatmentsreduce this iron build-up and alter thebody’s iron balance. If iron deficiency

already exists, further negative effects onimmune function may result.

Other infectious diseases. Other infec-tious diseases make anemia more severeby increasing metabolism, thus increasingiron and other micronutrient requirements.Measles, for example, can increase the riskof vitamin A deficiency, which in turn canincrease the risk of anemia. There is anassociation between malnutrition, anemia,and tuberculosis. Chronic diarrheal diseasein children causes malabsorption andundernutrition, affecting red blood cellproduction. Some of the anemia in chronicdiseases is due to inflammation or swellingof tissues and not related to poor nutrition-al status.

Genetic conditions. Genetically linkedblood diseases and hemoglobin abnormali-ties such as sickle cell and thalassemiacause abnormal hemoglobin production.People with sickle cell disease or sickle celltrait have genetically altered hemoglobinthat offers some protection against malariabut increases risks of anemia. About 1 to 2percent of infants in Africa are born withsickle cell disease and are at high risk ofsevere anemia and death. People with


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ealthy Life”The Special Iron Needs of Children Under Age 2

Until 6 months of age, normal-weight, full-term infants who are born to healthy mothers andare exclusively breastfed receive enough iron from their own stored iron and from breast milk.Their stored iron is exhausted in about six months.Additional iron is then required becausethe iron content of unfortified conventional complementary foods is insufficient to meet thehigh iron requirements of growing 6- to 24-month-old infants and children. Infants and childrenwho do not obtain adequate iron will suffer cognitive impairment that will affect their ability tolearn and to perform income-earning tasks later in life. Iron supplements provided after 24months of age may not correct this cognitive impairment.

Low-birthweight infants, premature infants, and infants of mothers with anemia need additionaliron starting at about 2 months of age to build iron stores and meet the requirements of theirrapid growth. Non-exclusively breastfed infants also may need small amounts of additional ironto compensate for the iron they do not receive through breast milk.The iron requirements ofchildren with severe malnutrition and anemia need special attention.

National iron-deficiency anemia programs for young children exist only in a few countries, butnew products for supplementing or fortifying diets may lead to promising interventions inmore areas. Products under study and development include multimicronutrient sprinkles,spreads, and other forms of micronutrients to add to food.Work on these and other productsneeds to increase and accelerate to facilitate new and expanded programs in countries whereiron deficiency is still a major cause of anemia in children less than 2 years old.

sickle cell trait (which occurs in 30 percentof Africa’s population) do not have severeanemia but have a slight reduction in func-tional hemoglobin. Thalassemia (bothalpha and beta) is concentrated in Africa,Asia, the Middle East, and the Mediter-ranean region. It can be life-threatening inchildren but does not represent a signifi-cant public health problem worldwide.Identifying individuals with thalassemia isprobably not cost-effective in most devel-oping countries because the number ofpeople affected is relatively small and testsare expensive.

Direct Causes: Excessive Red BloodCell DestructionMalaria. Malaria parasites destroy redblood cells and suppress red blood cellproduction. All persons living in or visit-ing areas with endemic malaria transmis-sion are at risk of anemia from malaria. Inareas of intense malaria transmission,malaria infection – usually accompanied

by iron deficiency – causes life-threateningsevere anemia in children under 2 years ofage and in women in their first and secondpregnancies.

Direct Causes: Excessive Red BloodCell LossHelminth (worm) infections. In develop-ing countries, excessive red blood cell lossand resulting iron-deficiency anemia arecaused by worm or helminth infections.Two types of hookworm, three types ofschistosomes, and whipworm all causeblood loss. Among these infections, hook-worms are the most common cause of ane-mia and schistosomes the second mostcommon. Hookworms are contractedwhen parasites enter the skin, generallythrough the feet as people walk barefooton feces-contaminated soil. They consume


In Nepal, anemia prevalence in women hasbeen associated with intensity of malaria andhookworm infections.

Figure 1.2. Relationship Between Iron Deficiency, Iron-Deficiency Anemia, and Anemia ina Population. More people are affected by iron deficiency than have iron-deficiency anemia. Whileanemia can be caused by factors other than iron deficiency, most people with anemia in developingcountries are also iron-deficient.

the blood of their host and cause signifi-cant blood loss. Endemic hookworms are asignificant cause of anemia in childrenafter the ages of 2 or 3 years.

Bacterial and viral infections. Infectionsthat cause peptic ulcers and gastritis (specif-ically Helicobacter pylori) are common indeveloping countries. They cause anemiaby increasing blood loss but also by reduc-ing stomach acid, resulting in poor absorp-tion of iron. Diarrhea caused by particularbacterial infections may also cause anemia,especially if the diarrhea is chronic andcharacterized by bloody stools.

Reproduction and contraception: men-struation, childbirth, breastfeeding prac-tices, contraceptive practices. Womenwho have excessive blood loss duringmenstruation and childbirth haveincreased risks of developing anemia.

Also, hav-ing manycloselyspacedpregnan-cies cancause“maternaldepletion”syndrome,

in which a number of nutritional deficien-cies lead to anemia. Introducing food andwater in an infant’s diet before the infanthas completed six months of exclusivebreastfeeding may increase the mother’sanemia risk because the period of lactation-al amenorrhea (which reduces menstrualblood loss) is shortened. Intrauterinedevices can increase blood loss, as opposedto oral and injectable contraceptives (suchas Depo-Provera), which reduce menstrualblood loss.

Contributing CausesPoor knowledge and behaviors. Lack ofknowledge contributes to high anemiaprevalence worldwide. Poorly trainedhealth workers may not know or believeanemia is important and thus may fail topromote preventive behaviors. People atrisk of anemia may not know it is animportant contributor to poor health andmay not be aware of preventive behaviorssuch as good nutrition and dietary prac-tices, good infant feeding practices, sanita-tion-related practices, and sleeping underbednets for malaria protection. Culturalbiases and taboos (such as those prohibit-ing certain foods or requiring women toeat after others have finished) also con-tribute to anemia risk, as does noncompli-ance with modern family planning meth-ods, IFA supplements, and malaria orhookworm medications.

Environmental causes. Anemia caused bylead poisoning, which interferes withhemoglobin production, is a problem incrowded urban areas where lead paint isstill used or where automobiles still useleaded gasoline. Lead competes with ironduring absorption, so poor dietary intakeof iron exacerbates lead poisoning byallowing more lead absorption than wouldoccur in an iron-replete individual.

Lack of access to health services and poorsanitation. Poor access to health servicesand poor sanitation conditions and prac-tices also contribute to higher anemia rates.Antenatal care services are an appropriatevenue for delivering anemia interventions.However,access tothese serv-ices is lowin manycountries,with manywomenhaving fewvisits orbeginning them late in pregnancy.Additionally, in many countries, womendo not have trained attendants duringdelivery to manage severe bleeding if it


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ealthy Life”

Demographic and Health Surveys in Armenia,Egypt, Kazakhstan, Kyrgyz Republic,Turkmenistan, and Uzbekistan have reportedanemia rates among intrauterine device (IUD)users 1.6 to 14.5 percentage points higher thanrates among women not using IUDs.

The table “Anemia PrevalenceRates in Vulnerable Populations,Selected Countries” in Tools andResources shows anemia ratesamong pregnant women,intrauterine device users, andother women of reproductive age.

Tools and Resources contains thetable “Proportion of WomenUtilizing Antenatal Care (ANC)Services and Receiving/TakingIron or Iron-Folic Acid (IFA)Supplements, SelectedCountries.”

occurs. In many areas, lack of sanitation orpoor sanitary practices, such as walkingwithout shoes through feces-contaminatedsoil, contribute to anemia by increasing therisk of helminth infection.

Poverty. The poor are at greater risk ofanemia due to lack of income and otherresources that prevents them from con-suming a diet with adequate, well-absorbed iron. Iron is a highly income-elastic micronutrient. As family incomesrise, families tend to purchase more meat,which contains a type of iron that is betterabsorbed than the iron in most plantproducts.

In addition, lack of income may preventthe poor from utilizing health services.Anemia risks are increased by the inabilityto pay for maternal and child health servic-es, iron supplements, malaria and de-worming medications, bednets, and otherprotective interventions.


In Andra Pradesh, India, anemia rates arehighest among the lowest income group.Although iron supplementation is high, 14 per-cent of the poor do not receive iron in preg-nancy, compared to 8 percent in the highestincome group.This contributes to higher ane-mia prevalence among the poor.

Chapter IITaking Action:Developing a

Strategy for AnemiaPrevention and Control

Most anemia prevention and control pro-grams have focused only on reducing theanemia caused by iron and folic acid defi-ciencies. However, because anemia has anumber of different causes (see Chapter I,Anemia: “Lost Years of Healthy Life”), it isbest addressed by adding anemia preven-tion and control activities to existing pro-grams in public health and other sectors,and, where needed, by introducing newprograms.

This chapter recommends that to initiateanemia prevention and control, a strategyor long-term plan should be developed.This strategy or plan should cover:

• Surveying the anemia problem

• Assessing related programs

• Suggesting improvements to currentprograms or introducing new programs

• Designing monitoring and evaluationactivities

As part of the planning process, partnersshould be identified and brought in toassist in strategy development. Howeverthe process begins – in the efforts of oneindividual, as an initiative of private citi-zens, or as a new public sector activity – itshould become a collaborative ventureinvolving all potential stakeholders,including governments and governmentagencies, donors, civil society, nongovern-mental organizations, health professionals,and the commercial sector. Building thesepartnerships is critical in the initial plan-ning phase.

Existing data about which populationgroups are anemic, where these groupsare concentrated geographically, and thespecific causes of anemia provide the basis

for developing an anemia prevention andcontrol strategy. In most cases, it is possi-ble to add anemia prevention or controlactivities to already existing health orhealth-related programs without largeinvestments of time or resources. Potentialprogram partners in anemia preventionand control include the following healthand health-related sectors:

• Nutrition




• Child health

• Schools




• Commercial sector: food and pharma-ceutical manufacturers, marketers, anddistributors

Specific activities to prevent and controliron deficiency, which is a major cause of

25Chapter II Taking Action: Developing a Strategy

Taking A

ction:D

eveloping a Strategy

A child in Cambodia receives vitamin A, ironsupplements, and de-worming medication.

anemia, should be part of the strategy.Chapter III, Providing Iron Supplementsto Combat Anemia, and Chapter IV,Improving Dietary Iron Intake to CombatAnemia, provide guidance for supplement-ing dietary iron and increasing the amountof iron in the diet through food fortifica-tion, the major interventions for address-ing iron-deficiency anemia.

The anemia prevention and control strate-gy should include indicators for monitor-ing and evaluating anemia prevention andcontrol activities. These indicators and aplan for collecting relevant data should bedeveloped in the strategy planning stage.

Effectively implementing interventions ofany kind requires an integrated approachwith financial, political, and technical com-mitment and support. The key to theimmediate success and long-term sustain-ability of an anemia prevention and con-trol strategy is the support of governmentat all levels – national, provincial/state,and local – and, where needed, interna-tional organizations.

The Country Example that followsdescribes how Indonesia worked toimprove its anemia prevention and controlprogram by targeting antenatal care clientsand by introducing an integrated approachof activities across a number of sectors andprograms.

The Good Practices Checklist shows thesteps for developing an anemia preventionand control strategy. The steps are present-ed in a suggested order of implementation.The Good Practices in Detail sectiondescribes specific actions that managers,concerned policy makers, and othersshould take in following these steps todevelop a strategy. It emphasizes theimportance of taking an integratedapproach to anemia programming and ofbuilding partnerships at all levels toaccomplish anemia prevention and controlobjectives. It also suggests “sector-specificinterventions” that can be added to healthand other programs to help prevent andcontrol anemia.

Part II of this document, Tools andResources, provides research instrumentsand methodologies, background data,norms and protocols, and references thatprovide additional information to helpprogram and project managers design,implement, and monitor interventions.



Taking A

ction:D

eveloping a StrategyCOUNTRY EXAMPLE

EXPANDING ANEMIA PREVENTIONAND CONTROL IN INDONESIA

Anemia prevalence is high in a number of groups throughout Indonesia. After initiatingefforts to reduce anemia in pregnant women in 1985, Indonesia has since expanded its ane-mia prevention and control strategies and is addressing anemia prevalence in other vulnera-ble groups through a number of measures.

As the table below indicates, the 1995 National Household Survey (NHHS) found preva-lence highest among adolescent girls, followed by pregnant women, school-age children, chil-dren less than 5 years old, and all women of reproductive age.

National survey data show that anemia prevalence in pregnant women decreased from 73.7percent in 1985 to 50.9 percent in 1995, a 31 percent decline. This suggests that progresshad indeed occurred by the mid-1990s. As seen in the figure below, anemia prevalence inpreschool children (0 to 5 years of age) also decreased from 55.5 to 40.5 percent between1992 and 1995.

The change in anemia prevalence in pregnant women accompanied increased attention toanemia prevention and control in antenatal care (ANC) services. Several good practiceswere identified as responsible for the improvements in this program:

Anemia Prevalence in Vulnerable Populations in Indonesia

Vulnerable Group % Anemic

Pregnant women 50.9

All women of reproductive age (15-44 yrs.) 39.5

Young children (0-5) 40.5

School-age children (5-11) 47.2

Adolescent girls (10-14) 57.3

Source: 1995 NHHS.

Prevalence of Anemia (%) in Pregnant Women and Preschool Children, 1985-1995


• High commitment from the Indonesian government to control anemia

• Monitoring systems for anemia and iron-folic acid (IFA) supplement use

• Improved packaging to protect IFA supplements from humidity and make them moreattractive to consumers

• A change to a red, film-coated supplement that did not have the fishy taste of the previ-ous supplements

• Messages about when and how to take IFA supplements to mitigate side effects

• Increased supply and availability of IFA supplements at each level of the health system,including distribution by community health workers (village midwives and traditional birthattendants) and private sector sales by drug vendors and small shops

• Availability of program guidelines and protocols on how many IFA supplements to give

These improvements have increased the number of pregnant women receiving and taking IFAsupplements. Demographic Health Surveys in 1994 and 1997 indicated a 36 percent declinein pregnant women receiving no IFA supplements (from 26.4 to 16.9 percent) and a 69 per-cent increase in pregnant women receiving 90 or more IFA supplements (from 14.4 to 24.4percent). There were not commensurate increases in the number of women receiving ANCfrom a trained provider or in the number of women receiving four or more ANC visits. Theincrease in coverage for IFA supplements thus was not due to an increase in ANC use but tospecific actions taken to improve IFA supplement distribution.

Indonesia has also developed protocols for giving iron supplements to children ages 6 to 60months, but these recommendations have not been extensively implemented. Nonetheless,anemia prevalence also declined for this group between 1992 and 1995. This decline mayhave been due to improvements in overall nutritional status or in maternal iron status,resulting in better iron stores in newborn infants.

In addition, the Directorate of Nutrition in Indonesia’s Ministry of Health has collaboratedwith a number of other ministries to address anemia and introduce IFA supplementation tovarious population groups. Collaborating ministries include the Ministry of Religious Affairs towork with engaged or newly married women and children attending Islamic schools; theMinistry of Education to reach other school-age children; the Ministry of Manpower to intro-duce IFA in workplaces; and the Ministry of Industry and Trade to introduce iron-fortifiedflour.The Government has worked with parastatal and private sector pharmaceutical compa-nies to sell IFA supplements in retail shops throughout the country. While the commitmentof these various sectors needs strengthening, as do behavior change communications,Indonesia has made important steps in improving anemia prevention and control provided byANC services and in expanding activities beyond those targeted at pregnant women.

(Note: These steps are presented in a suggestedorder of implementation.)

KNOW THE PROBLEM: SITUATIONANALYSIS

❑ Determine anemia prevalence; identifypriority target groups, areas of greatestanemia prevalence, and anemia causes

❑ Determine what people know aboutanemia and their experience with ane-mia prevention and control programs

RAISE AWARENESS AND DEVELOPPARTNERSHIPS

❑ Raise awareness across sectors: advocateand educate to prevent and controlanemia

❑ Build partnerships in the health, agricul-ture, food, and pharmaceutical sectorsamong government ministries andagencies, nongovernmental organiza-tions (NGOs), donors, industry, andcommerce

DEVELOP INTERVENTIONS ANDIMPLEMENTATION PLANS

❑ Identify priorities, responsibilities, andtimeframes

❑ Identify specific objectives

❑ Identify potential collaborating groups(universities, government agencies,NGOs, civic groups, commercialentities)

❑ Review existing programs and deter-mine and develop anemia preventionand control activities

❑ Determine and secure staffing, funding,and other resources for implementingactivities

❑ Develop a monitoring andevaluation plan

SECTOR-SPECIFIC INTERVENTIONSTO PREVENT AND CONTROLANEMIA

The following health and related sectorscan implement anemia prevention andcontrol interventions:

• Nutrition




• Child health

• Schools




• Commercial sector: food and pharma-ceutical manufacturers, marketers,and distributors


Taking A

ction:D

eveloping a StrategyTaking Action: Developing a Strategy for Anemia

Prevention and ControlGood Practices Checklist


Taking A

ction:D


Know the Problem:Situation Analysis

❑ Determine anemia prevalence;identify priority target groups,areas of greatest anemia preva-lence, and anemia causes

National anemia surveys provide convinc-ing evidence of the need for anemia pre-vention and control and help programdevelopers and project managers advocatefor programs.

In the lastfive years,nationalanemiasurveysfrom all

parts of the developing world have con-firmed the findings of smaller surveys thatanemia rates are high in reproductive-agewomen and children under 2 years of agein all regions. National studies are neededfor all developing countries. If resourcesare available, data on anemia in preschooland school-age children, adolescents,heavy laborers, farm workers, and the eld-erly should also be collected. Baseline sur-veys on existing interventions may be nec-essary to collect quantitative informationon, for example, the number of people invulnerable groups receiving and correctlyusing iron or iron-folic acid (IFA) supple-ments, anthelmintics, and antimalariadrugs; the number of people sleepingunder insecticide-treated bednets; thenumber of women using intrauterinedevices (IUDs) and oral contraceptives(with and without iron); the number ofhealth workers and workers in other fieldstrained in anemia control; and nationalsupply and distribution figures for supple-

ments andother com-modities.If nationalor otherbroad sur-veys aretoo expen-sive or notfeasible for other reasons, anemia preva-lence can be estimated using hemoglobinvalues collected from smaller populationsduring other health surveys.

Figure 2.1 shows groups affected by ane-mia and the suggested priority for address-ing them. Pregnant women and childrenunder age 2 are the highest priority groupsbecause they have the highest require-ments for iron and are most vulnerable toparasitic infections. Lactating women are

of higher priority than other women ofreproductive age because of blood loss atdelivery and during the postpartum peri-od. Newly or soon-to-be married womenare of high priority because many are ado-lescents who are still growing. Most ofthese women will become pregnant soonafter marriage, and many will have anemiawhen they become pregnant.

The 1998/99 Family Health Survey in Indiacollected data on both anemia prevalence andiron supplementation coverage.

Tools and Resources containsthe table “Anemia PrevalenceRates in Vulnerable Populations,Selected Countries.”

Tools and Resources contains“Selected Monitoring andEvaluation Indicators for AnemiaPrevention and ControlPrograms,” which lists indicatorsthat can help formulate surveyquestions.

Taking Action: Developing a Strategy for AnemiaPrevention and Control

Good Practices in Detail

Figure 2.1

Prioritizing Target Groupsfor Anemia Control

(From Highest to Lowest Priority)

Pregnant women; children 0-2 yrs.

Lactating women; engaged or newly married women

Women of reproductive age; adolescents;children 2-10 yrs.; physical laborers

Elderly

Men


Anemia prevention and control programsshould address anemia where it is geo-graphically concentrated. Prevalence sur-veys can help disaggregate anemia preva-lence by province, district, rural and urbansettings, and altitude. Disaggregation ofdata from national to lower levels requiresgreater sample sizes, however, and will bemore costly.

In most countries, the major causes of ane-mia are known. They include iron deficien-cy; other nutritional deficiencies; malaria;helminth infections (particularly hook-worm but also schistosomiasis); chronicinfections, including HIV/AIDS; causesrelated to fertility, reproduction, and con-traception; and genetic conditions such asthalassemia and sickle cell. The relativeimportance of the different causes of ane-mia varies by world region (see table 1.5 inChapter I, Anemia: “Lost Years of HealthyLife”); it may also vary by regions withincountries. Iron deficiency is always a con-tributing cause of anemia in developingcountries. In most areas of Africa, othernutritional deficiencies, malaria, and hook-worm are regionally significant. Thesecauses are usually known from evidence ofworm infestation or knowledge of dietaryintake in the general population or vulnera-ble groups. Reviews of health-related pro-grams can supplement information aboutanemia’s causes in particular areas or set-

tings. Studies to determine the relativeimportance of iron deficiency and othercauses of anemia are expensive, however,and should be limited to population sub-samples. In some individual cases, clinicalassessment may be necessary to confirm aspecific cause of anemia.

An analysis of a population group’sdietary intake can help ascertain the extentor importance of iron deficiency or othernutritional causes of anemia in the group.Dietary intake often varies widely by geog-raphy and season, an important factor indetermining prevalence.

It may also be important to analyze intakeof other micronutrients and determine ifthere are serious deficiencies that warranttheir addition to foods or supplements.Other micronutrients associated with ane-mia and other health problems includefolic acid, riboflavin, vitamins A and B-12,thiamin, and zinc. Adding these to ironsupplements and fortified foods should beconsidered, especially if inexpensivemicronutrient mixtures containing themare available. Folic acid is particularlyimportant for preventing neural tubedefects, which are prevalent in developingcountries with 370,000 cases reported glob-ally every year.

❑ Determine what people knowabout anemia and their experiencewith anemia prevention and con-trol programs

Formative research – both qualitative andquantitative – is an important step indeveloping an anemia strategy. It can clari-fy what people know about anemia andwhat behaviors they are able and willingto change to prevent and control it. It canhelp determine how consumers, healthworkers, policymakers, and program andproject managers perceive anemia.Formative research can also help evaluateexisting programs and aid in the develop-ment of products such as iron tablets,other forms of iron supplements, and forti-fied foods. Research findings can helpidentify appropriate interventions with

Bangladesh targeted newly married women,providing them with iron tablets andcounseling to improve their iron status.

In Peru, adolescent girls are a priority group.They receive iron and are targeted forimproving dietary iron through schools andcommunities.

In India, pregnant women are a primary targetgroup for anemia prevention and control.Children ages 1 to 5 years, IUD users, adoles-cent girls, women in post-abortion care, andpreterm/low-birthweight infants are alsotargeted.

Thailand targeted anemia prevention and con-trol activities to factory workers, schoolchild-ren, and adolescents.


Taking A

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appropriate monitoring and evaluationindicators. They can also suggest themesand messages for advocacy, counseling,and social marketing, as well as ways toimprove training, education, and products.For example, qualitative research helpedestablish that women taking iron supple-ments preferred small sugar-coated redtablets over large fishy- or chalky-tastingbrown ones. A single study can determineoverall perceptions of anemia as well asattitudes about iron tablets, antimalariaand anthelmintic drugs, bednets, and forti-fied foods. Qualitative research can alsotest products such as iron tablets and forti-fied foods once they have been developed.

The first step is to develop a researchinstrument that is primarily qualitative innature. Communication specialists and

marketingexpertshave theskills andexperienceto gatherthe qualita-tive dataneeded forinformedplanning. Nutritionists should be involvedin qualitative data collection to ensure thatthe right nutrition questions are beingasked.

Formative research should also review:

• Programs that are already having a pos-itive impact on anemia

• The potential of these programs to havea greater impact

• The potential impact of programs notyet involved in anemia

These include programs in nutrition, infec-tious and parasitic diseases, antenatal careand safe motherhood, family planning andreproductive health, child health, schools,HIV/AIDS prevention and treatment, envi-ronmental health, and food aid, as well asactivities in the commercial food and phar-maceutical sectors. Findings about thepotential roles and contributions of theseprograms should be presented to and dis-cussed with program and project managers,policymakers, donors, consumer groups,and commercial representatives to obtaintheir input and find common grounds andgoals for program activities.

Some Qualitative Research Findings About Anemia

Qualitative research among women in several countries suggests that they often recognize the signsof anemia but do not know or understand its consequences. In most cases, women are not aware ofmedical terms such as “anemia” but have local terms like “lack of blood” for anemia’s signs of pallorand fatigue.Where women are familiar with iron-folic acid (IFA) supplements, they report that theylike taking them, at least initially, and side effects are not a problem.They have concerns, however,about taking supplements for a long time – they fear, for example, that long-term use causes womento have large babies.They seldom receive counseling to counter such misperceptions and encouragecontinued use of supplements. Research also shows that because prevention is not a well-under-stood concept in most countries, women might stop taking IFA supplements once they feel stronger.(See Chapter III, Providing Iron Supplements to Combat Anemia.)

Qualitative research includesasking consumers about their

health-related beliefs and practices.

Tools and Resources contains “ATool for ReviewingMicronutrient Programs” and“Qualitative ResearchInstrument on Perceptions ofAnemia and Use of IronSupplements – The IndramayuProject, Indonesia.”


Raise Awarenessand DevelopPartnerships

❑ Raise awareness across sectors:advocate and educate to preventand control anemia

In many cases, program managers, healthprofessionals, policymakers, the public atlarge, and groups vulnerable to anemia arenot aware that anemia is a significantproblem. There are many interventionsthat can be implemented by any and allprograms in the health sector and othersocial sectors to raise awareness in thesegroups. These include interventionsdesigned to encourage behavior or policychanges and introduce and sustain pro-gram improvements. Advocacy may betargeted at policymakers and the public (orboth) to raise their awareness of anemia; athealth professionals to encourage them totake action against anemia; and at the pub-lic to promote behavior change. Information, education, and communication (IEC)activities, such as training in counselingand capacity building for communication,may also be targeted to these groups toimprove existing programs.

To accomplish these cross-sector objec-tives, programs can:

• Recruit a well-known person with highname recognition as an anemia “cham-pion” or spokesperson who will advo-cate for anemia prevention and controlin different sectors and raise politicaland public support for anemia preven-tion and control programs

• Take advantage of national health cam-paigns such as “national immunizationdays” and “micronutrient days” to raiseawareness about anemia

• Engage the media – radio, newspapers,television – to disseminate anemia pre-vention and control messages

• Develop and use fact sheets (which canbe tailored for use in different sectors)

to educate target groups about anemia’sprevalence, its causes and effects, andprevention and control interventions

• Secure the support of respected reli-gious leaders and involve them inadvocacy activities

In Indonesia, community meetings wereheld with men and community leaders totalk about anemia and distribute leaflets onthe importance of women taking iron sup-plements. Respected religious leaders pro-moted the value of iron tablets and enlistedfamily support. Reaching out to communitiesthrough the media was also effective. Donorassistance supported nutritionist training.

In Chile, a national anemia champion pro-moted anemia prevention and control. Also,scientists were trained in anemia preventionand control both in Chile and the UnitedStates to increase technical capacity, espe-cially at the implementation level.

In China, the government translated inter-national documents on the consequences ofanemia to build support for anemia control.

In Egypt, the government publicized scien-tific research about the safety of dietaryiron to combat public perceptions that itwas dangerous.

In Thailand, a public relations campaignemphasized private sector contributions tosocial sector programs.

In Mali, Mozambique, and Indonesia, sup-plements have been distributed on nationalmicronutrient days and through community-based outlets.

In Niger, IFA supplements have been dis-tributed on national immunization days.

In Malawi, health worker training empha-sized the role of iron supplements in com-bating anemia in pregnant women.

In India, improvements were made in in-service training on anemia prevention andcontrol for health workers.

In Peru, teachers were trained in anemiaprevention and control.


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eveloping a Strategy• Convince government officials and rep-

resentatives from the commercial foodand pharmaceutical sectors of the impor-tance of anemia prevention and control

• Build capacity and provide training forhealth workers in technical knowledge,communication for behavior change,counseling skills, program design andimplementation, program management(including supervision), and monitoringand evaluation

• Provide pre- and in-service training forpersonnel from food, sanitation, educa-tion, and other sectors to incorporateanemia prevention and control in theiractivities

❑ Build partnerships in the health,agriculture, food, and pharmaceuti-cal sectors among government min-istries and agencies, nongovern-mental organizations (NGOs),donors, industry, and commerce

Addressing anemia through and across anumber of sectors requires close coopera-tion and coordination among governmentagencies, NGOs, donors, and commercialsector entities. A national intersectoralcommittee can help achieve and coordinatean integrated approach with counterpartsat the regional, provincial/state, district,and community levels. Participating sec-tors and groups should include ministriesof health, education, women’s affairs,youth, trade, industry, agriculture, andplanning; donor agencies; the food andpharmaceutical industries; consumers; andtechnical experts in science, research, andmarketing. Such a committee should haveits own budget and staff. Committee mem-bers should agree there is an anemia prob-lem and agree upon a common goal towhich each organization can contribute.

Develop Interventions andImplementation Plans

❑ Identify priorities, responsibilities,and time frames

Working toward their common goal, thepartners need to decide what anemia pre-vention and control activites are impor-tant, who is responsible for them, andwhen they will be carried out. These deci-sions should be based on the nature of thenational anemia problem and a review ofexisting programs. When making thesedecisions, the partners should clearly artic-ulate priorities and goals, delegate respon-sibilities to appropriate sectors, and estab-lish time frames for initiating actions.

❑ Identify specific objectives

Specific objectives or results may includeincreased awareness of anemia as a publichealth problem, improvement of existinganemia programs, introduction of new pro-grams to prevent and control anemia, andreduction of anemia prevalence. Objectivesshould be time-bound and measurable toallow for monitoring and evaluation.

Tools and Resources contains the sam-ple fact sheets “How Can EarlyChildhood Development (ECD)Programs Beat Iron Deficiency?”, “TheImpact of Preventing and Treating IronDeficiency Anemia”, and “Risk of IronOverload From Iron-Fortified Foods.”

In Chile, politically adept nutrition plannerswere able to bring government, industry, andthe research community together on a nationalcommittee to work for anemia prevention andcontrol.The committee raised community andconsumer support for nutrition and anemiaprevention and control programs.

In Thailand, medical professionals convincedcommercial sector partners about the impor-tance of iron fortification and supplementation.

In Tanzania, a favorable sociopolitical environ-ment and the government’s commitment tosocial action with community involvement con-tributed to a successful national strategy toimprove nutrition programming. Specialistsfrom the national nutrition coordinating body,the Tanzania Food and Nutrition Centre, helpedthe government with anemia programming.


❑ Identify potential collaboratinggroups (universities, governmentagencies, NGOs, civic groups, com-mercial entities)

Organizations with interests and capabili-ties in anemia prevention and control arepotential resources and collaborators. Inaddition to the health ministry, other min-istries such as agriculture, education, andindustry can contribute. Some NGOs willbe able to link anemia to their organiza-tional goals and missions – women’s andhuman rights organizations, for example,might consider protection from anemia abasic right and thus support and assistanemia prevention and control. For techni-cal assistance, food industry specialists,regulatory specialists, social scientists,researchers in health and consumer behav-ior, program designers, communicationexperts, training experts, and monitoringand evaluation specialists are potential col-

laborators. All of these professionalsshould be approached for the added valuethey can bring to anemia prevention andcontrol programs.

❑ Review existing programs anddetermine and develop anemiaprevention and control activities

Existing programs need to be reviewed todetermine how anemia prevention andcontrol is working and can be strength-ened. This review should go beyond earli-er formative research activities and identi-fy specific anemia prevention and controlactivities in all sectors. Some activities arebest implemented by and through certainsectors and existing programs; others arebest implemented by coordinating acrosssectors. Examples of activities that can beadded to health programs and programs inother social sectors are listed in Sector-Specific Interventions to Prevent andControl Anemia.

Indonesia used marriage registrations to tar-get women who were about to be married.Other programs were established to reach tar-get populations in factories and other work-places. A partnership between a women’shealth project and several pharmaceutical com-panies manufactured attractively packaged IFAsupplements to appeal to more women, includ-ing postpartum women. Small communityshops and village midwives sold the supple-ments. By the end of the project, 21 percent ofwomen were buying these supplements.

Cambodia promoted iron supplementation aspart of an entire ANC package of services.Prizes for health centers and clients who metprogram goals motivated women to take alltheir IFA supplements.

In Kenya and Malawi, antimalaria drugs givento pregnant women helped control anemia.

Chile used school lunch programs to intro-duce fortified foods.A special cookie for use inchildren’s school lunches was fortified with atype of highly absorbable iron.

In India, Sri Lanka, and Zimbabwe, a de-worming component was recommended foranemia programming.

In India, the National Human RightsCommittee made a commitment to anemiaprevention and control.Women’s and children’sgroups, NGOs, the media, and the food, agricul-ture, and education sectors were also involved.

In Indonesia, a local religious leader promotediron supplements for women.

In Guatemala, the anemia program surveyedmillers to determine their interest in iron forti-fication and rally their support.

In Thailand, village volunteers were used toincrease community commitment to andinvolvement in anemia programming.

In Thailand, political commitment, goodstrategic planning, and motivational program-ming in communities and the health care sys-tem were instrumental in implementing a basic“minimum needs” approach to improve thenutritional status of the population. Objectivesincluded control of micronutrient deficiencies.Although anemia control was a clearly statedgoal in Thailand’s Sixth National Plan in 1982,the country has not had a specific anemia con-trol strategy. Instead, anemia control activitieshave been implemented at the suggestion of adhoc technical committees.


Taking A

ction:D

eveloping a Strategy❑ Determine and secure staffing,

funding, and other resources forimplementing activities

Once the program’s activities and collabo-rating organizations have been deter-mined, a work plan and budget for imple-menting activities are necessary. Eachactivity must be fleshed out with descrip-tions of its timing, responsible parties, cost,and indicators of success. Each activityneeds a management plan. Negotiationswith partners and collaborating groupsabout their respective commitments arenecessary for developing a mutually agree-able implementation plan.

❑ Develop a monitoring andevaluation plan

Each activity also needs a monitoring andevaluation plan. Process, outcome, andimpact indicators should be identified tomeasure the program’s achievement of itsobjectives or to indicate the need for

changes.Indicatorsshoulddovetailwith exist-ing infor-mation

systems – for example, if national informa-tion systems track the number of IFA sup-plements distributed to pregnant women, asimilar indicator at the program levelshould be used.

Monitoring and evaluation activities mustbe designed during the planning phasebefore program implementation begins.Resources and budgets have to be procuredto ensure that monitoring and evaluation iscarried out continuously and as planned.Monitoring and evaluation data must alsobe analyzed and reported in a timely man-ner that enables program and project man-agers to use the information to improve

program implementation and outcomes.

Monitoring should be an ongoing exercise,and a monitoring timeline should bedeveloped in the planning stage.Monitoring a program will provide infor-mation about effectiveness throughoutprogram implementation by measuringhow well benchmarks of progress areachieved. Program monitoring shouldoccur at all levels, from central govern-ment agencies down to local communitypartners. It is imperative to use the infor-mation from each level to improve pro-gram implementation at all levels. Infor-mation should not be collected without aplan to use it for program improvements.

Evaluation is more rigorous and frequentlyincludes impact indicators, such as actualchanges in anemia prevalence. Evaluationsshould be used to improve the nationalprogram. Impact evaluations are needed tomeasure program effectiveness, adjust pro-gram components that are not working,and provide justification for continuing theprogram. These evaluations should be con-ducted periodically in the context of thelarger anemia prevention and control pro-gram. Anemia rates should be measured,and information about the types of foodsconsumed should be collected. If iron sta-tus is selected as an indicator, iron statustests of population subsamples can be con-ducted to keep costs down.

See “Selected Monitoring andEvaluation Indicators forAnemia Prevention and ControlPrograms” in Tools andResources.

Indonesia uses the number of pregnantwomen taking iron as an indicator in its nation-al information system. National surveys havemonitored the impact of anemia programming.


NutritionMicronutrient supplementation• Provide iron or IFA supplements to

pregnant women and children 6 to 24months of age

• As resources become available, provideIFA supplements to other vulnerablegroups such as lactating women, school-age children, and adolescents

• To maximize iron absorption, counselwomen to take IFA supplementsbetween meals or before going to bedwith a small amount of juice or water

• Counsel women about the importanceof taking the full dose of IFA supple-ments and help them solve any prob-lems they have in complying (such asmanaging side effects)

• Counsel women about the importance ofgiving their young children the full doseof IFA supplements between meals orbefore going to bed with a small amountof juice or water; help them solve anyproblems they have in complying

• Promote other vitamin, mineral, andnutrition supplements such as folic acidand vitamins A and B-12 to combatanemia caused by these nutritionaldeficiencies

• Use campaigns such as micronutrientdays to promote anemia prevention andcontrol and distribute IFA supplements

• Promote complementary interventionsto reduce anemia, such as birth spacingand malaria and hookworm preventionand treatment

Dietary approaches • Encourage consumption of fortified

foods, if available

• Promote year-round production andcollection of micronutrient-rich foods

• Counsel mothers that infants less than 6months old should be exclusivelybreastfed to ensure adequate energyand micronutrient intake

• Disseminate information about ade-quate dietary intake of energy andmicronutrients (particularly vitamin A,folic acid, vitamin B-12, and iron), espe-cially to pregnant women and mothersof 6- to 24-month-old children

Because iron deficiency causes 50 percent ofanemia worldwide, iron supplementation andfortification of staple and processed foods withiron are important elements of anemia preven-tion and control. See Chapter III, ProvidingIron Supplements to Combat Anemia, andChapter IV, Improving Dietary Iron Intaketo Combat Anemia.

Taking Action: Developing a Strategy for AnemiaPrevention and Control

Sector-Specific Interventions to Prevent and Control Anemia

This poster from Peru promotes foodswith high iron content.


Taking A

ction:D

eveloping a Strategy• Suggest that foods rich in vitamin C

(such as fruits, tubers, and green leafyvegetables) be consumed at meal times.Vitamin C improves absorption of ironfrom plants that contain iron-absorptioninhibitors such as phytates. Since vita-min C is quickly destroyed by exposureto air, foods should be prepared imme-diately before they are consumed andshould not be overcooked.

• Educate families about the importanceof animal products (meat, organs, orblood) in the diet. If animal products areavailable, children 6 to 24 months of ageand pregnant women should have pri-ority in consuming small amounts atmealtimes. Animal products not onlyprovide iron that is well absorbed (20 to30 percent is absorbed compared to lessthan 5 percent of the iron in plants) butalso counter the effects of iron inhibitorsin plant products. Animal products arealso the only source of vitamin B-12, animportant micronutrient for preventinganemia.

• Promote the consumption of legumes,which are excellent sources of folic acid

• Promote consumption of foods withadequate vitamin A activity (retinolfrom animal products or beta-carotenefrom plant products), because vitamin Adeficiency can result in anemia. Foodscontaining vitamin A should be dried inthe shade and receive minimal cookingto minimize loss of vitamin A activity.Greens containing vitamin A should becooked just before they are served.

• Consume low-iron foods and iron-inhibiting foods in the same meals (forexample, cereal-based porridge, whichis low in iron and contains inhibitors ofiron, can be consumed with milk and tea)

• Restrict consumption of tea, coffee, andcocoa to between meals or at least onehour after meals, since caffeine inhibitsiron absorption

• Do not give tea, coffee, and cocoa toyoung children

• Consume milk and milk products as

between-meal snacks rather than atmeals, since calcium in milk inhibitsiron absorption

• Encourage food processing techniques(such as cooking, germinating, ferment-ing, and soaking of grains) that reducefactors that inhibit iron absorption

• Promote complementary interventionsto reduce anemia, such as IFA supple-mentation, malaria and hookworm pre-vention and treatment, and birth spacing

• Evaluate the impact of these activitieson anemia prevalence

Infectious and Parasitic Diseases• Provide rapid access to malaria treat-

ment in areas of malaria transmission

• Encourage the use of insecticide-treatedbednets, particularly by vulnerablegroups, and teach how to re-treat netswith insecticides

An insecticide-treated bednet helps protectthis family in the Gambia from malaria.


• Provide information on danger signs ofmalaria and hookworm, how to prevent

them, andwhen andhow to treatthem

• Give inter-mittent pre-sumptivetreatment(IPT) formalaria towomen, par-

ticularly those in their first or secondpregnancy

• Treat malaria in young children withsymptoms of fever or anemia

• Provide hookworm medications

• Promote good sanitation practices, suchas wearing shoes and using latrines

• Treat other infectious diseases, such astuberculosis

• Promote and provide complementaryinterventions to reduce anemia, such asIFA supplementation, adequate dietaryintake, and birth spacing

• Control diarrhea in young children


Antenatal Care and Safe Motherhood• Provide all pregnant women with IFA

supplements and counsel them abouttaking the full dose

• In areas of low health service coverage,provide IFA supplements through com-munity-based distribution or retailshops and use social marketing to pro-mote sales of IFA supplements

• To prevent malaria-induced anemia,provide rapid treatment with effectivemedication to pregnant women whohave malaria

• Provide IPT for malaria to pregnantwomen in malaria-endemic areas, espe-cially women in their first or secondpregnancy

• Provide presumptive hookworm treat-ment, starting in the second trimester, topregnant women in hookworm-endemicareas

• Encourage pregnant women to sleepunder insecticide-treated bednets

• Provide messages on good breastfeed-ing practices and good nutrition to ante-natal and postpartum clients

• Train health workers about the dangersof anemia

• Train health workers how to managecomplications and how to mitigateblood loss during delivery and in thepostpartum period

• Provide safe blood transfusions forwomen with severe anemia

• Train staff to clamp the umbilical cordin newborns to increase their iron stores


See Tools and Resources for thetable “RecommendedIntermittent PresumptiveTreatment (IPT) or TreatmentRegimens for Malaria,Hookworm, andSchistosomiasis,” which notesthe recommended iron dosagesfor people who have malaria,hookworm, or schistosomiasis.

This poster from Indonesia warns of thedangers of anemia during pregnancy.

It has been estimated that treating malaria inyoung children who have symptoms of fever oranemia and giving intermittent presumptivetreatment for malaria to women (particularlythose in their first or second pregnancy) canincrease hemoglobin by 1 to 3 g/dL.


Taking A

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eveloping a StrategyFamily Planning and ReproductiveHealth• Promote modern family planning meth-

ods to delay and space births, therebypreventing maternal iron depletion

• Promote and provide counseling on theLactational Amenorrhea Method(LAM)1 to women of reproductive age,particularly pregnant and newlydelivered women

• Intensify efforts with adolescents todelay their first pregnancy, improvediet, and improve IFA status

• Use family planning extension and mar-keting activities to provide and promoteother services addressing anemia, suchas malaria and hookworm treatment,IFA supplementation, and improvementof dietary intake

• Prevent anemia and maternal iron deple-tion by placing IFA tablets in oral contra-ceptive packets to be taken during the“blank” week of oral contraceptive cycles

• Explain that preventing anemia andavoiding maternal iron depletion byconsuming IFA supplements during the“blank” week of oral contraceptivecycles are added benefits of familyplanning

• Provide information about iron-savingcontraceptives, such as Depo-Proveraand certain oral contraceptives, toclients who have no contraindications tousing them

• Provide training to ensure thatintrauterine devices (IUDs) are properlyinserted to mitigate blood loss; monitorblood loss of IUD users


Child Health (including IntegratedManagement of Childhood Illness andEarly Childhood Development)

• Provide caregivers with information oninfant feeding, including good breast-feeding practices; timely introduction ofcomplementary foods rich in iron, vita-min A, folic acid, and vitamin B-12; useof iron-fortified foods; and avoidance ofsubstances inhibiting iron absorption

• Provide IFA supplements in the form ofelixirs, drops, crushed tablets, spreads,or sprinkles through facility-based pro-grams for all children under 2 years ofage and for anemic children 2 to 5 yearsof age

• Counsel mothers to ensure compliancewith the full supplement dose

• Provide children 6 to 59 months of agewith semiannual doses of vitamin A incapsule form

• Use campaigns such as micronutrientdays and national polio immunizationdays to promote anemia prevention

• Use community-based growth monitor-ing and promotion programs to counselmotherson infantfeedingand IFAsupple-ments fortheir chil-dren 6months to2 years ofage

• Integratenutrition,health,and psychosocial stimulation in earlychildhood development programs;include actions to address anemia

1 LAM is a method of delaying pregnancy based on the physiology of lactation. To use LAM, a woman must fullybreastfeed, have not had return of menses, and be less than six months postpartum.

Under the IntegratedManagement of ChildhoodIllness (IMCI) protocol, eachchild health contact is used asan opportunity to address ane-mia. For access to IMCI mate-rials, see the World HealthOrganization listing in“Information Sources forAnemia Prevention andControl” in Tools andResources.


• Check for pallor of the palms. If posi-tive, provide IFA supplements (elixirs,drops, crushed tablets, spreads, sprin-kles). If the child lives in a malaria- orhookworm-endemic area, treat formalaria and hookworm.

• Immunize children against childhooddiseases

• Manage diarrhea by continuing to feedchildren during diarrhea episodes andwith oral rehydration therapy; childrenages 6 to 24 months with bloody stoolsshould receive extra iron

• Provide caregivers with information ondanger signs of malaria and hookworm;counsel about malaria preventionthrough use of insecticide-treated bed-nets for children 6 months to 2 years ofage and proper hygiene and sanitationpractices


Schools• Include fortified foods in school feeding

programs

• Teach schoolchildren about nutrient-rich indigenous foods

• In helminth-endemic areas, de-wormschoolchildren twice a year

• Provide IFA supplements, especially toadolescent girls, if fortified foods are notavailable

• Provide adolescent girls with informa-tion about family planning methods thatcan reduce menstrual blood loss, suchas oral and injectable contraceptives,and methods that can increase bloodloss, such as IUDs

• Include information in school curriculaabout anemia, good hygiene and sanita-tion, and the importance of IFA supple-ments, adequate diet, and insecticide-treated bednets


HIV/AIDS Prevention and Treatment• Promote a well-balanced diet for people

living with HIV infection

• Promote dietary management for peopleliving with AIDS, including adequatedietary intake of energy and micronutri-ents (particularly vitamins A and B-12and folic acid) and IFA supplements tostimulate red blood cell production andcombat anorexia caused by irondeficiency

• Give presumptive malaria treatment topregnant women living with HIV/AIDSin malaria-endemic areas

• Diagnose people living with HIV/AIDSfor other diseases that contribute to ane-mia (e.g., hookworm, diarrhea, tubercu-losis) and treat them appropriately

• To mitigate risks of HIV transmission,limit intravenous blood transfusions forsevere anemia to clients who do notrespond to other ways to increase theirhemoglobin

• Evaluate the impact of these activitieson anemia prevalence in people livingwith HIV/AIDS

In a school feeding program in Malawi,children receive porridge fortified

with iron and other micronutrients.


Taking A

ction:D

eveloping a StrategyFood Aid and Security• Fortify food aid cereals with iron and

other micronutrients

• Use monetized food aid to provide pro-gram support for anemia control

• Provide IFA supplements in areaswhere food aid is available

• Where food is made available at healthservices or through schools, make sureit is fortified with iron and that nutritioninterventions (including IFA tablets)and education are also available

• Identify, promote, and produce varietiesof staple foods that are high in iron (bio-fortification)


Environmental Health• Discourage the use of night soil (human

feces) as fertilizers

• Provide potable water

• Promote the use of sanitation facilitiesto reduce transmission of hookwormand other helminths

• Support programs to eliminate use ofleaded gasoline and lead-based paints

• Eradicate conditions that breedmosquitoes

• Modify water habitats to prevent breed-ing of snails that carry schistosoma


Commercial Sector: Food andPharmaceutical Manufacturers,Marketers, and Distributors • Develop, produce, and market foods

fortified with iron and/or othermicronutrients (including folic acid,vitamin B-12, and vitamin A) for thegeneral population

• Develop, produce, and market foodsfortified with iron and/or othermicronutrients for specific vulnerablegroups, particularly young children

• Develop, produce, and market IFA andother micronutrient supplements thataddress all nutritional causes of anemia

• Encourage food suppliers to market for-tified foods and pharmaceutical suppli-ers to market IFA and other micronutri-ent supplements

• In areas where malaria or hookwormare endemic, promote and marketinsecticide-treated bednets, de-wormingand antimalaria medication, and appro-priate footwear

• Market contraceptives at the communitylevel

• Fortify foods used in school feedingprograms with iron, folic acid, andvitamins A and B-12

• Investigate the feasibility of developingand marketing fortified foods that canbe targeted to children 6 months to 2years of age


Chapter IIIProviding Iron

Supplements toCombat Anemia

Because iron deficiency is the major causeof anemia (see Chapter I, Anemia: “LostYears of Healthy Life”), providing ironsupplements (often with folic acid added)to vulnerable groups is a key interventionin anemia prevention and control. Iron sup-plements and fortified foods targeted topregnant women and children 6 months to2 years of age will always be necessarybecause these groups have such high ironrequirements. Supplementation in thesetwo groups, along with fortification of astaple food with iron, is the most cost-effec-tive means of addressing iron-deficiencyanemia in most developing countries. If itis not possible to fortify a staple food forthe general population (see Chapter IV,Improving Dietary Iron Intake to CombatAnemia), iron supplements for high-riskgroups such as school children, adolescentgirls, and postpartum women will be need-ed in addition to supplements for pregnantwomen and young children.

Efforts to provide iron supplements shouldbe part of a country’s overall anemia strat-egy (see Sector-Specific Interventions inChapter II, Taking Action: Developing anAnemia Prevention and Control Strategy).For iron supplementation programs to suc-ceed, appropriate government agenciesmust work with one another and with theprivate sector to provide iron or iron-folicacid (IFA) supplements appropriate to thecountry’s specific anemia problem.Managers of health-related programs needto be included in planning so they can pro-vide accurate estimates of the quantities ofsupplements required to meet the ironneeds of the target populations. Thesemanagers can also help address the tasksof making supplements affordable, avail-able, and accessible to those populations.

Planning should also include research todevelop effective messages to ensure

clients take iron or IFA supplements andto determine the best ways to get supple-ments to users through either public orprivate sector channels. Public and privatesector distributors need to develop ways tomonitor and evaluate their efforts.

Effectively implementing interventions ofany kind requires an integrated approachwith financial, political, and technical com-mitment and support. The key to theimmediate success and long-term sustain-ability of an iron supplementation programis the support of government at all levels –national, provincial/state, and local – and,where needed, international organizations.

This chapter includes a Country Examplefrom Thailand that describes how thecountry improved iron supplementationfor pregnant women and effectivelydecreased anemia prevalence in thatgroup. In addition, the Country Examplepreceding Chapter I describes Bolivia’siron supplementation program, some ofthe constraints it has faced, and possiblesolutions.

The Good Practices Checklist gives stepsfor designing iron supplementation pro-grams presented in a suggested order ofimplementation. The Good Practices inDetail section describes the specificactions that managers, concerned policymakers, and others should take in eachstep as they design and implement ironsupplementation programs. It is based ona review of good practices of existing pro-grams. Part II of this document, Tools

45Chapter III Providing Iron Supplements to Combat Anemia

Providing Iron Supplements

to Combat A

nemia

IFA supplements can be packagedand distributed in a number of ways.

and Resources, provides research instru-ments and methodologies, backgrounddata, norms and protocols, and referencesto help program and project managersdesign interventions.




to Combat A

nemia

COUNTRY EXAMPLE

ANEMIA PREVENTION AND CONTROL IN THAILAND

Over the past several decades,Thailand has dramatically reduced the prevalence of undernu-trition in children under 5 years old. While rapid economic growth (7 percent per year)over the past 20 years may have contributed to some of this reduction, targeted nutritionprograms aimed at reducing undernutrition and micronutrient deficiencies were the majorfactors in this success.

More recently,Thailand has made great strides in reducing anemia prevalence, although thishas been little publicized in the international community. Between 1986 and 1996/97, nation-al surveys showed that anemia prevalence in pregnant women fell from 40 to 15.5 percentin rural areas and from 41 to 20.5 percent in urban areas (see figure).These declines repre-

sent a greater than50 percent reduc-tion in anemiaamong pregnantwomen. Anemia inchildren less than 5years old alsodeclined, from 40.6to 25.2 percent (a38 percent reduc-tion) during thisperiod. In men andlactating women,however, anemiaprevalenceincreased.

Thailand made an early commitment to anemia control, citing it as a major nutrition prob-lem as early as 1982 and establishing anemia reduction as a national goal. Although Thailandhas never had a permanent national committee for anemia control, it has used ad hoc com-mittees of scientists and program managers to examine and discuss issues related to anemiaprevention and control.

To reduce anemia among pregnant women,Thailand took the following actions:

• Increased the early use of antenatal care (ANC) services. With the help of 500,000 vil-lage health volunteers, 98 percent of women receive ANC and 84 percent make at leastfour ANC visits. The volunteers identify pregnant women and encourage them to obtainANC services immediately.

• Provided iron-folic acid (IFA) supplements to all pregnant women, regardless of theirhemoglobin levels

• Used qualitative research findings to improve communication and help health workerscounsel women taking IFA supplements

• Decentralized the supply and logistics of IFA supplements by permitting provincial officesto estimate their own needs and provided easily accessible back-up supplies

National Prevalence of Anemia by Group


• Monitored anemia prevalence in young children and women at public health servicefacilities

To further reduce anemia,Thailand could improve health worker training and monitoring ofcompliance with IFA supplementation. In addition, programs targeted at children less than 2years old are needed. While there has been progress in reducing anemia in children underage 5, most of this reduction has come from improvements in maternal iron status and byincreasing young children’s intake of foods containing absorbable iron. More targeted effortsare underway with pilot testing of fortified foods and iron sprinkle supplements to findeffective interventions for the under-2 age group as well.


CONDUCT INITIAL FORMATIVERESEARCH WITH CONSUMERSAND PROGRAM MANAGERS ❑ Develop a research instrument, conduct

field research, and review results

DETERMINE AND PROVIDE THEAPPROPRIATE IRON AND FOLICACID DOSES❑ Determine if iron and folic acid doses in

current supplements conform to inter-national recommendations

❑ Consider adding other micronutrients tothe supplement

INCREASE DEMAND ANDENSURE COMPLIANCE❑ Conduct qualitative research on

attitudes and behaviors related toanemia and iron-folic acid (IFA)supplementation

❑ Ensure that the characteristics (color,taste, size) of IFA tablets, elixirs, andother types of supplements are accept-able to users

❑ Develop attractive yet affordablepackaging

❑ Develop and deliver effective messagesto overcome consumer resistance andensure compliance in taking IFAsupplements

IMPROVE SUPPLIES ANDDISTRIBUTION❑ Estimate the quantities of IFA supple-

ments needed for target groups

❑ Improve the logistics for delivering IFAsupplements

❑ Increase the use of antenatal care andchild health services

❑ Provide a buffer stock or other back-upsources of IFA supplements

❑ Provide IFA supplements through com-munity-based and private/retail outlets

MONITOR AND EVALUATE IRONSUPPLEMENTATION PROGRAMS❑ Incorporate indicators for monitoring

and evaluating IFA coverage/compli-ance into program monitoring andevaluation



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Providing Iron Supplements to Combat AnemiaGood Practices Checklist



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Conduct Initial FormativeResearch With Consumers

and Program Managers

❑ Develop a research instrument,conduct field research, and reviewresults

Conducting early formative research willinform program managers about the statusof current supplementation activities andthe need for changes and new activities.The research should cover the extent andsuccess of coverage, supplies, the distribu-tion system, the importance of anemia inthe minds of policymakers, consumer per-ceptions of anemia, and consumer knowl-edge of supplementation programs. Theinitial research carried out in developingthe overall anemia strategy can includeiron supplementation (see Know the prob-lem … in Chapter II). This will give anoverview of the situation that can enhancemore detailed subsequent qualitativeresearch to increase demand and ensurecompliance through public promotion andclient counseling.

The first step is to develop a researchinstrument that is primarily qualitative innature. Quantitative data on national sup-plement supplies and the proportion ofhealth and other workers trained in ane-mia control are also useful. A specialist incommunications or marketing should con-duct the research at the national, provin-cial/state, and community levels. Theresearch results should be discussed withpolicymakers, program managers from thevarious professional sectors interested inanemia prevention and control, donors,and representatives from civil society togain their insights about overcoming pro-gram constraints and integrating programactivities (see Raise awareness anddevelop partnerships in Chapter II).

Determine and Providethe Appropriate Iron and

Folic Acid Doses

❑ Determine if iron and folic aciddoses in current supplements con-form to international recommenda-tions

Programpersonnelshoulddetermineif currentiron andfolic aciddosesmeet inter-nationallyaccepted standards. These doses differdepending on the prevalence and severityof anemia and the group affected by it. TheWorld Health Organization provides thegold standard for doses of iron and folicacid in supplements for different groups.

If the iron doses in the current supple-ments are not included on package labelsor are not clear, laboratory tests should beconducted to determine the dose. Thesetests should determine the amount of ele-mental iron in the supplement, not theamount of the compound (such as ferroussulfate) used to deliver the iron. If the cur-rent doses do not meet requirements andinternational recommendations, normsand protocols must be changed to recom-mend the appropriate doses.

For pregnant women, the recommendediron dose has decreased in recent yearsfrom a five-month regimen during preg-nancy of two daily iron-folic acid (IFA)supplements each containing the equiva-lent of 60 mg of elemental iron (for a totalof 18,000 mg) to a six-month regimen ofone daily 60-mg supplement (10,800 mg).For postpartum women in areas of high

Providing Iron Supplements to Combat AnemiaGood Practices in Detail

Tools and Resources containsthe tables “Iron and Folic AcidDoses for UniversalSupplementation in VulnerableGroups” and “Iron and FolicAcid Doses for Treating SevereAnemia in Vulnerable Groups.”


anemia prevalence, an additional threemonths of daily supplements is recom-mended. Although studies show that a

120-mgdose ofelementaliron rais-es hemo-globin

levels more than a 60-mg dose, the changeto the lower dose for pregnant women wasmade in order to decrease the side effectsassociated with higher doses. Slow-releaseiron tablets have also been shown toreduce side effects. These tablets are notwidely available in developing countries,however, and their effect on compliance isunclear. Counseling women about manag-ing side effects may be more effective atimproving compliance.

Because of their high iron requirements,pregnant women need to take iron on adaily basis. One 60-mg supplement perday may not be enough to significantlyreduce anemia prevalence during and afterpregnancy, particularly where the inci-dence of severe anemia is high. The effec-tiveness of the daily dose should be moni-tored. While it is most cost-effective to givea presumptive routine dose for anemia inareas of high anemia prevalence, screeningwomen and young children for severe ane-mia is recommended so they can receiveadditional iron and follow-up if necessary.Clinical tests for pallor can be used inresource-poor settings and hemoglobintests can be used where supplies and labo-

ratory facilities are available. If two ormore daily doses are prescribed forwomen with severe anemia, they should betaken at different times of day to enhanceeffectiveness and minimize side effects.

For most groups other than pregnantwomen, weekly iron doses may be helpfulin improving iron status. While an analysisof studies of dosing regimens concludedthat pregnant women, and probably youngchildren, need daily doses, it also suggest-ed that weekly doses may be provided toschoolchildren, adolescents, and nonpreg-nant women under supervised settings.

The recommended dose of folic acid hasincreased, from 250 to 400 mcg, followingfindings that women have higher folic acidrequirements than previously thought. Theincreased dose improves folic acid status,helping to prevent macrocytic anemia,which is caused by a deficiency of folic acid.

❑ Consider adding other micronutri-ents to the supplement

If other nutritional deficits (such as insuffi-cient vitamin A, B-12, C, riboflavin, or themineral copper) are causing or contribut-ing to anemia, a supplement containingiron andthe appro-priatemicronu-trients, ifavailable,should beprovided.If tabletscombiningthe required micronutrients in appropriatedoses do not exist or are not available, pro-grams should provide standard-dose IFAsupplements until the multimicronutrientsupplements become available. As multi-micronutrient supplements are developed,they should contain adequate iron for thetarget vulnerable population (for example,60 mg for pregnant women).

Tools and Resources contains thetable “Iron Doses and Three-Month Hemoglobin Increase inWomen.”

Tools and Resources contains thetable “United StatesRecommended DietaryAllowances of Anemia-RelatedMicronutrients (Other Than Ironand Folic Acid) for VulnerableGroups.”

A clinic worker examines a client’s fingernailbeds for pallor, a sign of anemia.



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Increase Demand andEnsure Compliance

❑ Conduct qualitative research onattitudes and behaviors related toanemia and IFA supplementation

Qualitative research is an excellent tool foridentifying barriers to and facilitators ofIFA supplementation, both among clientsand health workers, and for designing pro-gram improvements. Ideally, it should beconducted as part of anemia programplanning, but it may also be conductedindependently (see Know the problem …in Chapter II).

Qualitative research can provide informa-tion that will suggest communicationstrategies to promote behavior change andcompliance with IFA supplementation reg-imens. In a number of countries, qualita-tive research has studied the reported sideeffects of IFA supplements as an obstacle

todemandfor andcompli-ance withiron sup-plementa-tion. Theresearchhas gen-erallyfoundthat thesideeffects

associated with a 60-mg dose of elementaliron do not deter users as once thought.Other qualitative research efforts havereported high compliance with IFA sup-plements even in unsupervised settings.Such research also can determine theacceptability and feasibility of alternativesupply channels (such as community-based providers), ascertain the willingnessof clients to pay for supplements, and esti-mate how much they can and will pay.

❑ Ensure that the characteristics(color, taste, size) of IFA tablets,elixirs, and other types ofsupplements are acceptable tousers

IFA supplements need to be acceptable toconsumers, and programs need to developand use IFA supplements that are attrac-tive in size, color, taste, and smell.Attractive qualities enhance complianceand communicate the message that IFAsupplements are products of high value.Qualitative research can provide informa-tion about consumer preferences.

Supplements in the form of a small film- orsugar-coated red tablet may be moreacceptable to women. Small tablets are eas-ier to swallow than the large tablets com-monly used in many countries. A sugar orfilm coating can mitigate the “fishy” tasteand smell that women complain aboutwith uncoated tablets. IFA supplementsthat are red or a shade of red may beattractive because women in many coun-tries associate red with powerful or healthyblood. The most acceptable color may varyfrom culture to culture, however.

In a qualitative research study in Thailand, 10to 30 percent of pregnant women taking IFAsupplements reported side effects, but mostfound they subsided in a few days and contin-ued to take the supplements.

In Andra Pradesh, India, 80 percent of womenreported consuming all the IFA supplements orsyrup they were given.

Qualitative research in Sri Lanka andTanzania found that side effects were not amajor problem among girls who were givenIFA supplements.

In Tanzania, compliance among girls taking IFAsupplements increased to 90 percent whentheir parents (who feared they were takingcontraceptives) were made aware of the truecontents of the supplements.

In Indonesia, 98 percent of pregnant womentook at least some supplements. On average,they took 66 of the recommended 90 tablets.

The Trials of Improved Practices,or TIPS, methodology is part ofthe “Qualitative ResearchInstrument on Perceptions ofAnemia and Use of IronSupplements – The IndramayuProject, Indonesia” that appearsin Tools and Resources. TheProject used TIPS to test recom-mendations about IFA supple-ments with mothers and otherwomen and determine barriers totheir use.


It is less clear what type of supplementsmothers prefer to give their young chil-dren. Iron tablets for young children needto be crushed to make them easier to swal-low. Different preparations of iron supple-ments that are more palatable to childrenthan tablets (such as elixirs, syrups, drops,and recently developed sprinkles foradding to or putting on food) are available,although they often cost more.

❑ Develop attractive yet affordablepackaging

Women prefer attractive and convenientpackaging to newspaper or other paperwrappings, which in humid climates donot protect supplements from breaking,cracking, or melting. Blister packaging is apopular type of packaging but may beexpensive. Programs should carefullyweigh budgetary decisions to use it or notagainst other program needs.

Packaging should be distinctive so thatIFA supplements are not confused withother medications or products such as con-traceptives. Supplement packaging shouldbe specific to the targeted group, with pic-tures and specific messages for that groupincluded on the package. The packageshould give clear information about thenumber of tablets to take, how often theyshould be taken, and why. Tablet packsshould be childproof to prevent youngchildren from opening them and ingestingthe tablets. They should also give adult

caregivers clear instructions to keep thesupplements out of the reach of children.Qualitative research can determine con-sumers’ packaging preferences.

IFA supplements should be affordable.Research with target groups can helpdetermine if and at what price clients arewilling to buy supplements. Governmentpolicies can determine sales and pricingpolicies. If IFA supplements cannot bemade affordable for target groups, theircosts may be covered with other healthservices or they may be provided free.

❑ Develop and deliver effectivemessages to overcome consumerresistance and ensure compliancein taking IFA supplements

Effective messages to promote compliancewith IFA supplementation regimensshould be based on in-depth qualitativeresearch with the target population.

In Bolivia, a pilot project provided IFA supple-ments in small film containers.This protectedthe tablets from disintegrating and appeared toincrease the value of the supplements inwomen’s minds and increase demand.

Indonesia used attractive lettering and colordesigns on its packaging and changed to foilsachets to prevent tablets from disintegrating.

Mali and Senegal used blister packs to makesupplements more attractive and last longer instorage.

In Indonesia, the government approved consis-tent pricing policies to support private sectorsales of IFA supplements.

In Bolivia, the cost of IFA supplements wasincluded in the cost of ANC services pur-chased by most women.

In Thailand, IFA supplements were providedfree, with costs of anemia tests for poorwomen covered by the welfare system.

Programs in Caribbean countries havefinanced IFA tablet supplies through an ANCpackage that women were required to buy.

Red sugar-coated iron tablets are popularin many countries. Protective packaging is

preferrred to paper, however.

Thailand introduced a small sugar-coated redtablet that was easy to swallow.



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Messages should be developed to addressclients’ perceptions of anemia, concernsabout iron supplements, packaging prefer-ences, and so on. In some cultures, anemiaitself is not a recognized term; instead, itssigns and symptoms are recognized.Women may report both positive and neg-ative experiences with IFA supplements, asthese comments from several countriessuggest:

• Improved well-being: “Because of theiron supplements every day I feel better.I feel like doing everything. Now I ameating better and I have gained a littleweight.” – Bolivia

• Tablet characteristics: “The medicinehas the smell of blood, but that didn’tworry me because they are helpful andgood.” – Malawi

• Fears: “I don’t take iron supplements toavoid a big baby and suffering atdelivery.” – Honduras

• Inadequate counseling: “They just gavethe supplements; they don’t giveinstructions.” – India

• Suspicion: “We prefer to go to the pri-vate doctor and buy supplements.”– India

• Economic barriers: “Vitamins increasethe appetite. If we don’t have anythingto eat, why would we want to becomemore hungry?” – Honduras

• Forgetfulness: “If I take it while eating,I remember, but sometimes after eatingI must return to work quickly, so Iforget.” – Indonesia

Messages can be delivered through socialmarketing, advocacy campaigns, andcounseling. Good counseling by healthworkers includes “negotiating” with

women and mothers to follow instructionsand giving them advice about how to takeiron supplements and how to give them totheir children. These are essential toimprove compliance. Follow-up counsel-ing and reminders like calendars to rein-force messages and help women rememberto take their supplements have been popu-lar in many programs. They can help over-come thedrudgeryof taking asupple-ment for along time,whichreducescompli-ance toabout 50percent over the long term. Follow-upreminders also may be needed for mothers

In India, women were given a red rose, whichattracted them to the program and also pro-moted the red color of iron pills. Information,education, and communication (IEC) effortsand counseling messages were improved todispel worries and encourage continuation.Follow-up visits by providers to new clients,particularly in the first two weeks of takingsupplements, helped reinforce messages.

Bolivia and Indonesia also improved IECand counseling messages.

In Thailand, Indonesia, Bolivia, andMalawi, women were given calendars to helpthem remember to take their iron supple-ments daily.

To improve compliance in Malawi, IFA sup-plements were promoted as a nutrition sup-plement rather than a medication.They weretaken as instructed by 86 percent of women.

This poster from Honduras promotes irondrops and citrus fruits and juices for youngchildren while discouraging tea and coffee.

In Tools and Resources, see“Counseling Pregnant Womenand Mothers About IronSupplements,” which gives coun-seling points and shows samplecounseling cards from Indonesia,and “Negotiating With Womento Follow Advice.”


who are giving their children daily IFAsupplements.

Training health workers how to counselwomen receiving iron supplements isespecially important, as many women mayperceive the quality of care as poor ifhealth providers have poor interpersonalskills. Supervisors need to ensure thatworkers adhere to training messages. On-the-job training to reinforce more formaltraining should be a recurring activity.

Improve Suppliesand Distribution

❑ Estimate the quantities of IFA sup-plements needed for target groups

Ensuring that a continuous adequate sup-ply of IFA supplements is available to tar-

get populations is essential for a successfulprogram. Inadequate supplement supplyhas been the largest obstacle to success formany programs. To determine the quanti-ties of IFA supplements needed, drug pro-curement personnel need accurate esti-mates of the size of each target group. Inareas where ANC use is high, estimates ofthe number of pregnant women can bebased on the number of women usingANC services. If ANC use is low, needsestimates for supplements should not bebased on the number of pregnant women,because this may lead to an oversupply ateach level of the health system. If commu-nity supplies of supplements are available,needs can be estimated using the numberof pregnant women as indicated by popu-lation size and fertility rates. Estimates ofthe number of young children should alsobe based on birth rates. A decentralizedprocess of estimating the size of targetgroups provides more accurate estimates.

❑ Improve the logistics for deliveringIFA supplements

Bottlenecks in logistics and supply systemsfor IFA supplements must be identifiedand cleared. It is probably most effective todo this in coordination with efforts toimprove the distribution logistics for otheressential drugs. The needs of different

In Thailand, IFA requirements are estimated atthe provincial level, not the national level.Theestimates are based on the number ofpregnant women in the province or the num-ber using ANC services, which works wellbecause ANC use is high.

In Grenada, St.Vincent, and the Grenadines,the iron status of pregnant women improvedonly when supplies of supplements increasedand a continuous supply was ensured.

India decentralized its supply system to thestate and district level and created a specialunit to monitor supplies.

Indonesia decentralized its IFA supply systemto the province level, which reduced traveltime when orders were placed and ensuredsupplies were available to meet local needs.

This calendar card from Bolivia helps womenremember to take their IFA tablets daily.



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distribution channels for IFA supplements,such as schools and private sector chan-nels, should be assessed. Storing stocks ofIFA supplements at lower levels in thesupply system (the district level, for exam-ple) facilitates procurement for health cen-ters and other distributors.

❑ Increase the use of antenatal careand child health services

In many countries, use of antenatal care(ANC) services is low or begins too late inpregnancy to supply all the services need-ed by pregnant women, including IFAsupplements. Increased use of ANC servic-es will increase the number of women whoreceive iron. In many countries, IFA sup-plements have been used to attract womento ANC services.

In order to deliver iron to children 6 to 24months of age, child health services needto expand their activities beyond theirfocus on immunizations for children under12 months. This can be accomplishedthrough outreach services or specialmicronutrient days during which micronu-trients are distributed.

❑ Provide a buffer stock orother back-up sources of IFAsupplements

To ensure continuity of supplies, an addi-tional buffer stock of 20 percent of the esti-mated need should be provided. Otherback-up supply mechanisms, such asrevolving drug funds, can also bearranged. The procedures for obtainingadditional supplies from these sourcesshould be straightforward and not requireapproval from central levels.

❑ Provide IFA supplements throughcommunity-based and private/retail outlets

IFA supplements should be made avail-able through community-based distribu-tion or sales outlets, especially in areas oflow ANC and child health coverage orpoor services. Community-based workersmust be trained to counsel clients and givethem the recommended number of tablets.Communities may need to be assured ofthe workers’ competence.

In some countries, private sector work-places are providing IFA supplements.Programs should make every effort to pro-duce or import supplies of affordable IFAsupplements for local sale.

In Thailand, ANC coverage has increasedbecause 500,000 community volunteers identi-fy women early in pregnancy and encouragethem to use ANC. More than 98 percent ofwomen have at least one ANC visit and 84percent have at least four visits. Iron supple-ments are routine for all pregnant womenregardless of their hemoglobin level and diet.Clear protocols on IFA supplements, increasediron for severely anemic women, and physicianfollow-up are included in ANC manuals.

In Thailand, there are several easily accessiblesources of IFA supplements, including a fundfor the poor and a revolving fund for purchas-ing health commodities.

In Malawi, a World Bank project financedadditional IFA supplements.

In Cambodia and Indonesia, workplaces suchas factories and plantations provide IFA supple-ments to improve the health and productivityof women workers.

Indonesia increased community distribution ofIFA supplements in areas of low ANC use.Village midwives distributed IFA supplementsto women, and small shops and communityworkers also sold them.

In India, community health workers have deliv-ered IFA supplements during community visits.In one NGO project, clinics distributed supple-ments and provided information on obtainingadditional supplies from other sources, includ-ing the village health nurse, health subcenters,and primary health care facilities.

In Malawi, traditional birth attendants haveprovided IFA supplements. Local markets iden-tified as acceptable by clients are alternativesources.

In Honduras, volunteers in growth monitoringand promotion programs have distributed aniron supplement syrup to mothers of childrenunder age 2.


Monitor and EvaluateIron Supplementation

Programs

❑ Incorporate indicators formonitoring and evaluating IFAcoverage/compliance into programmonitoring and evaluation

Monitoring and evaluation activitiesshould be designed and incorporated intoIFA supplementation from the outset ofstrategy and program planning. (SeeDevelop a monitoring and evaluationplan ... in Chapter II). Monitoring is anongoing exercise, while evaluation maytake the form of cross-sectional studies ofanemia prevalence and other key indica-tors taken every few years. Data collectedby these activities must be reported andanalyzed in a timely manner to have posi-tive impacts on programs.

Anemia prevalence is the most appropriateimpact indicator for evaluating the effec-tiveness of anemia prevention and controlprograms. Measuring changes in iron defi-ciency in a population is the best indicatorof the impact of IFA supplementation pro-grams, but it is expensive and not appro-priate in a field setting. Collecting informa-tion in smaller subpopulations can provideinformation on progress in reducing iron-deficiency anemia at less cost.

Because the success of IFA supplementa-tion programs depends on supply anddemand, indicators should include theproportion of pregnant women, children 6months to 2 years old, and other identifiedtarget populations who are:

• Receiving any supplements (reflectingsupply and maybe demand if there hasbeen a campaign to promote IFA sup-plements)

• Receiving the recommended number ofsupplements (reflecting supply andquality of services)

• Purchasing supplements (reflecting sup-ply and demand)

• Reporting they took (or gave to theirchildren) all the supplements they

received (reflecting demand and com-pliance)

These indicators can be collected by check-ing the records of the supplement quanti-ties distributed to different populationgroups by health facilities, health outreachprograms, schools, and others, and byinterviewing pregnant women, mothers,and others about the supplements theyreceived and took. Counting leftovertablets is often used to determine compli-ance. Insomeareas, bio-logicalmarkerssuch asiron instool sam-ples have been used, but such advancedmeasures usually require access to labora-tories and are seldom feasible in resource-poor settings. They are also expensive andmay be culturally unacceptable.

Self-monitoring can also be effective. Forexample, a woman receives a remindercard with her supplements and records onit how many supplements she has taken.Providers can ask women to bring thesecards back to record compliance. Such con-tact also provides an opportunity forhealth workers to reinforce the importanceof taking IFA supplements every day.

In Bolivia, a program provided supplements insmall containers and asked women to bring thecontainers at their next visits, when tabletswere counted and compliance recorded.

Thailand counted iron tablets as a measure ofcompliance when women came in for follow-up ANC visits.

India made monitoring an integral part of itsiron supplementation program by includingindicators related to distribution of iron sup-plements in the national information system.

For more indicators see “SelectedMonitoring and EvaluationIndicators for Anemia Preventionand Control Programs” in Toolsand Resources.

59Chapter IV Improving Dietary Iron Intake to Combat Amenia

Improving D

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Chapter IVImproving Dietary

Iron Intake toCombat Anemia

Because iron deficiency is the major causeof anemia (see Chapter I, Anemia: “LostYears of Healthy Life”), improving dietaryintake of iron – mainly through food forti-fication – is another key intervention inanemia prevention and control.Fortification of staple foods with iron is themajor way to increase dietary intake ofiron in countries where iron-rich foods aretoo expensive for the poor to purchase.Where it has been evaluated, fortifyingfoods with iron has been found to increasedietary intake of iron, improve iron status,and reduce anemia prevalence in specificpopulations. While other means of improv-ing dietary intake are also possible andshould be part of anemia prevention andcontrol (see Sector-Specific Interventionsin Chapter II, Taking Action: Developing aStrategy for Anemia Prevention andControl), food fortification should also bepart of a country’s overall anemia strategy.

For the most part, food fortification effortsin developing countries have been slow totake shape because food industries are notwell developed and because vulnerablegroups do not widely consume centrallyprocessed foods. However, as processedfoods become more available, anemia pre-vention and control programs shouldmake efforts to ensure they are fortifiedand targeted to vulnerable groups. Thiscan only occur if food manufacturers, dis-tributors, and retailers are engaged as fullpartners with the public sector and civilsociety. Establishing public-private part-nerships to develop and implement foodfortification strategies is essential andshould be one of the first steps in planningan anemia prevention and control strategythat includes food fortification.

Planning needs to include market researchto develop iron-fortified food products,

develop messages to convince populationsto consume these products, and determinethe best ways to get them to target popula-tions, either through public or private sec-tor channels. All involved parties need todevelop ways to monitor and evaluatetheir efforts.

Effectively implementing interventionsrequires an integrated approach withfinancial, political, and technical commit-ment and support. The key to the immedi-ate success and long-term sustainability ofa food fortification program is the supportof government at all levels – national,provincial/state, and local – and, whereneeded, international organizations.

This chapter’s Country Example describesVenezuela’s experience with food fortifica-tion. The Good Practices Checklist thengives the steps for initiating and buildingfood fortification programs in a suggestedorder of implementation. The GoodPractices in Detail section furtherdescribes these steps and the specificactions that managers, concerned policy-

Fortifying food staples and condiments withiron can help protect children against anemia.


makers, and others can take to design andimplement programs. It is based on areview of good practices of existing pro-grams. Good practices for iron supplemen-tation are discussed in Chapter III,Providing Iron Supplements to CombatAnemia.

In Tools and Resources (Part II of AnemiaPrevention and and Control: WhatWorks), background data, research instru-ments and methodologies, norms and pro-tocols, and references for additional infor-mation are provided to help managersplan and implement interventions.


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COUNTRY EXAMPLE

IRON FORTIFICATIONOF STAPLE FOODS IN VENEZUELA

In the 1990s, national statistics on food production and consumption in Venezuela suggestedthat iron and some vitamins were becoming less available in the country’s food supply. Inresponse, the government embarked on a program to fortify widely consumed foods withiron and other micronutrients. Precooked corn flour, precooked wheat flour, and wheatflour used for making bread were identified as the best vehicles for fortification becausethey are consumed by the entire population and make up a large portion of the diet ofVenezuela’s poor populations. For example, an estimated 45 percent of the calories con-sumed by people in the lowest socioeconomic group come from these foods.

Precooked fortified flours started reaching the population in February 1993; by August,wheat flour for bread was being fortified. At first, precooked flours provided 50 mg of iron,as ferrous fumarate, per kilogram, as well as vitamin A, thiamin, riboflavin, and niacin. Theywere later changed to provide 30 mg of iron per kilogram as ferrous fumarate and 20 mgper kilogram as electrolytic iron. Fortification of wheat flour for bread started with addi-tions of iron (20 mg per kilogram as ferrous fumarate), plus thiamin, riboflavin, and niacin. Asa result of education about the seriousness of micronutrient malnutrition, some companiesbegan to voluntarily fortify foods such as breakfast cereals and infant foods. This increasedthe general availability of fortified foods.

Issues such as consumer acceptability and fortificant costs were addressed early in the pro-gram. For most of the population, consumer acceptability was high because there were fewchanges in the appearance, taste, or cooking properties of the fortified foods. However, intwo regions where the mineral content of water was high, corn bread baked with fortifiedflour came out noticeably darker. This occurred only with 1 percent of the population, butto ensure that the products were acceptable to everyone, ferrous fumarate was substitutedfor electrolytic iron. This caused fewer changes in the appearance of corn bread in theaffected areas.

The cost of adding these fortificants to these flours was less than 1 percent of the market-selling price. After educational and partnering initiatives with the private sector, industryagreed to completely absorb the cost.

Both the food industry and the government monitor fortificant levels. Industry monitors thefortification mix and the amount of iron in the product at the factory and consumer levels.The government also monitors the amount of iron at the consumer level and determinesthe impact of the program through annual surveys. During the first two years of the pro-gram, anemia prevalence decreased in the groups monitored. After that, anemia prevalencedid not decrease, even though iron stores of the Venezuelan population continued toimprove. Despite initial gains in reducing anemia prevalence, the true impact of fortificationin Venezuela needs further evaluation because the methodologies of studies to evaluate itsimpact were difficult to compare. It may be that anemia prevalence did not decline furtherbecause of a change to the more stable but less absorbable electrolytic iron, a 10 percentdecline in the sale and consumption of some of the fortified products, or an increase in par-asitic infections.


The main factors identified as responsible for the success of Venezuela’s iron fortificationprogram are:

• The choice of the most effective iron compound based on absorption, cost, consumer acceptability of the fortified product, and the prevalence levels of anemia and iron defi-ciency

• The choice of a food for fortification that was centrally processed and consumed bymost of the population, including the poor, with little variation in consumption through-out the year

• Flexibility in norms and legislation, so that changes could easily be made to programcomponents (such as changes in the amount of iron or type of compound used)

• Monitoring of the amount of iron in fortified foods at the production and retail levels

• Measurement of the impact of the program on national anemia and/or iron deficiency levels

Decline in Anemia Prevalence in Children, 1997-2000


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CHOOSE THE BEST FOODS TOFORTIFY❑ Study consumption of iron-containing

foods and potential foods for fortifica-tion by vulnerable group, geographiclocation, season, ethnic group, and othernational and demographic factors

❑ For the general and target populations,determine if widely consumed foodsmeet the criteria for effectivefortification

❑ Consider the availability of “value-added” nonstaple foods for possible tar-geting to vulnerable groups

❑ Decide which foods will be fortified andfor whom – the entire population orspecific vulnerable groups such asyoung children

CHOOSE THE APPROPRIATEFORTIFICANT❑ Review the different fortificants, includ-

ing their relative costs, compatibilitywith food vehicle, absorption, and avail-ability in domestic and internationalmarkets

❑ Decide which and how much fortificantto use

DETERMINE EFFICACY ANDEFFECTIVENESS❑ Review information on the efficacy of

the fortificant for the chosen food;conduct trials if needed

❑ Plan to measure effectiveness

STUDY INDUSTRIAL CAPACITYFOR FOOD FORTIFICATION❑ Determine industry’s commitment and

capacity to fortify foods in terms oftechnology, equipment, laboratoryavailability, and qualified personnel

❑ Determine availability of (or potentialfor developing) structures and systemsfor distributing the fortified foods

DETERMINE THEMARKETABILITY OF THEFORTIFIED FOOD❑ Conduct consumer acceptability tests in

different income groups about the forti-fied food and their motivation forconsuming it

❑ Conduct market analysis to determinethe ability and willingness of consumersand industry to pay additional costs offortification

ENSURE PROPER PRODUCTPACKAGING, UNIFORMITY, ANDSTABILITY❑ Select packaging and labeling for the

product

❑ Test for uniformity and stability of thefortificant in the manufactured productunder environmental conditions overtime

❑ Test-market product stability andpackaging with consumers

(Continued next page)

Improving Dietary Iron Intake to Combat AnemiaGood Practices Checklist

ESTABLISH NATIONALGUIDANCE FOR FORTIFYINGFOODS AND REGULATING FOODFORTIFICATION❑ Determine if legislation is desired or

needed

❑ Develop guidance for food fortification

❑ Ensure that food imports are fortifiedand comply with regulations

❑ Increase government capacity to legis-late and enforce fortification

RAISE SUPPORT FOR FORTIFIEDPRODUCTS❑ Motivate and educate consumers and

health and food professionals aboutconsuming fortified foods

MONITOR AND EVALUATE IRONFORTIFICATION PROGRAMS❑ Monitor consumption of the fortified

food by different vulnerable groups

❑ Develop and expand the food productdistribution system



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Choose the BestFoods to Fortify

❑ Study consumption of iron-con-taining foods and potential foodsfor fortification by vulnerablegroup, geographic location, season,ethnic group, and other nationaland demographic factors

Program managers and their partners inanemia prevention and control can workwith data collection and survey experts todesign and conduct food consumption sur-veys. These surveys should provide infor-mation about consumption patterns andhow adequately they meet nutritionalrequirements. This information can thensuggest the best foods to fortify, accordingto which foods are most commonly con-sumed, when they are consumed, and whoconsumes them. They can also provideindicators of the need for fortification bygeographic location, urban or rural resi-dence, income, season, ethnicity, gender,and age. In determining consumption pat-terns, it is important to consider whetherfoods come from animal or plant sourcesand if they inhibit or enhance absorptionof dietary iron. These considerations willhelp determine the amount of iron neededfrom fortification. Surveys should be con-

ducted during the initial program plan-ning phase (see Know the problem … inChapter II).

❑ For the general and target popula-tions, determine if widely con-sumed foods meet the criteria foreffective fortification

To be a good choice for fortification, a foodshould:

• Be consumed in all or most mealsthroughout the year. This will ensureregular iron consumption and also max-imize iron absorption, because iron ismore efficiently absorbed when avail-able from several meals throughout theday and not just in one meal.

• Be consumed by vulnerable groups ineach region of the country

• Be dark in color and/or have a strongtaste or odor. These characteristics helpmask the effects of iron compounds onfoods. Foods with these characteristicscan be fortified with less expensive,well-absorbed fortificants that causeundesirable changes in color, taste, andother food qualities.

• Demonstrate good stability in storage,or not require prolonged storage, partic-ularly under hot and humid conditions

An extensive consumption survey inGuatemala determined that maize flour wasan appropriate food for the most vulnerableincome groups but that the amount of maizeconsumed, especially by children less than 5years old, varied considerably by region. Basedon regional, cultural, and economic variationswithin target groups, recommendations weremade to fortify foods on a regional rather thannational basis.

Chile made special efforts to determine whatfoods children most widely consume, and howmuch, in order to identify possible foods tofortify.

Improving Dietary Iron Intake to Combat AnemiaGood Practices in Detail

In Latin America, tortillas made with fortifiedmaize flour increase consumers’ iron intake.

• Have patterns of consumption that areunrelated to socioeconomic status

• Be economical to produce and be avail-able for purchase at an affordable price

• Be produced through central processingat relatively few production facilities

• Not interfere with absorption of thefortificant

• Have a low content of inhibitors of ironabsorption

• Have a high content of enhancers ofiron absorption

• Have a balance of inhibitors andenhancers that maximizes absorption

• Be linked to energy intake (i.e., staplefoods)

• Have low risk of being consumed inexcess

White wheat flour is a good food for forti-fication because milling removes the branand germ that contain most of the sub-stances that inhibit iron absorption. Otherprocesses that reduce inhibitors include fermentation of leavened bread and high-

temperature baking. Milling removes ironas well as inhibitors, but fortificationreplaces this iron and can add more.Industrialized countries have added ironand other micronutrients to wheat flour fordecades. Approximately 10 percent of theiron added to fortified white flour may beabsorbed by iron-deficient individuals.

Most of the wheat flour used in develop-ing countries is either whole-wheat flouror flourthat stillcontainssome ofits branand thusstill con-tains significant amounts of inhibitors.With these types of flour, iron absorptiondeclines to 4 percent or less. Inhibitors ofiron absorption may also be present inother foods consumed during a meal,which will further decrease the amount ofiron absorbed.


In Egypt, tests showed that 13.5 percent ofthe iron in the fortified flour used to makeFrench bread was absorbed, compared to only8.6 percent of the iron in fortified flour usedto make Shami bread.These differences werethought to be due to the higher baking tem-perature for the French bread. For village-milled flour used to make Baladi bread, only 2.1percent of the iron was absorbed because ofthe fortified flour’s higher bran content.Absorption increased by 2.5 to 3 times after amore absorbable type of iron was added to thedough before baking.

Guatemala identified maize flour as the foodmost likely to reach low-income groups inrural areas. Maize flour is also fortified inMexico and Venezuela.

In Bahrain, Bolivia, Egypt, Grenada, Iran,Jamaica, Kuwait, Mexico, Oman, SaudiArabia, and Venezuela, wheat flour is fortified.

The Philippines has experimented with andconducted efficacy testing on iron-fortified rice.

Tools and Resources containsthe table “Substances ThatInhibit and Enhance Absorptionof Iron.”

Grain products are widely consumed andsuitable for fortification in many countries.

Maize meal, a staple in many developingcountries, also contains inhibitors. Iron-for-tified maize meal yields only 1 to 3 percentabsorption. When maize meal is fermentedor processed with lime, inhibitors arereduced, and iron is absorbed at a higherrate than from white wheat flour. Thistype of processing is preferred when maizemeal will be fortified with iron.

❑ Consider the availability of “value-added” nonstaple foods for possi-ble targeting to vulnerable groups

Recent efforts to improve the reach of forti-fication programs have focused on fortify-ing nonstaple foods that general popula-tions or targeted vulnerable groups partic-ularly like and consume. Fortifying condi-ments and seasoning products such assugar, fish sauce, and curry powder can beeffective but need to be implemented morewidely at a national scale. Fortified cerealstargeted at vulnerable groups, mainlyyoung children, have improved iron statusin the target groups. Snack foods andbreakfast buns are other possibilities. Thetechnology for fortifying salt with bothiodine and iron has been improved, and itseffectiveness is being tested in severalcountries (see box The Potential ofDouble-Fortified Salt). Experimentationcontinues with other condiments andspices as well.

❑ Decide which foods will be forti-fied and for whom – the entirepopulation or specific vulnerablegroups such as young children

Based on the information gathered, thepartners in the food fortification programmust choose an appropriate food or condi-ment to fortify based on the needs of theentire population or specific vulnerablegroups and the foods that reach them.Foods that can be fortified for childrenunder age 2 need particular attentionbecause of this group’s high iron needs(see box The Special Iron Needs ofChildren Under Age 2 in Chapter I). Thefood industry’s capacity to fortify, distrib-ute, and monitor the quality and coverageof the food should also be considered.

Choose theAppropriate Fortificant

❑ Review the different fortificants,including their relative costs, com-patibility with food vehicle,absorption, and availability indomestic and international markets

Food fortification specialists should adviseon choosing an appropriate iron com-


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In China, the government is testing the efficacyof iron-fortified soy sauce. It is an attractivecandidate for fortification because most vulner-able groups consume it as a condiment. Inaddition, national production is relatively cen-tralized, with just 10 percent of the country’ssoy sauce manufacturers producing 42 percentof the country’s supply.

Bouillon cubes are used throughout WestAfrica, where flour is not widely consumed. Itmay be possible to fortify them with iron.

In Argentina, milk is fortified.

Salt is fortified on a small scale in India. Othercondiments considered for fortification includesugar in Guatemala and Venezuela and fishsauce in Vietnam and Thailand.

In South Africa, iron deficiency existed mainlyin the Indian population, so iron fortification ofcurry powder was proposed. Fortification ofmaize meal is being considered for the generalpopulation. Biscuits for schoolchildren havebeen fortified to reach this vulnerable group.

In Chile, a number of foods have been devel-oped to address iron needs in young children.Studies have shown the efficacy of iron-forti-fied cowmilk-based powdered formula, cookiescontaining dried bovine blood, and iron-forti-fied weaning cereals. Anemia prevalence fellfrom 23 to 4 percent in this population.

Indonesia determined that wheat flour usedto make noodles could supply 25 percent ofyoung children’s iron needs The governmenthas mandated that all wheat flour be fortified.

Children’s foods are fortified in Argentina,Chile, Guatemala, and Peru.

pound to use as the fortificant. Outsidetechnical assistance may be needed todetermine the best fortificant to use inlocal circumstances.

In choosing the fortificant, a number offactors should be considered, including:

• The amount of iron absorbed and thusits impact on iron status

• Affordability

• Market availability

• Stability when stored over time so thatno or minimal changes occur in foodtaste, smell, and appearance

Very few compounds meet all these crite-ria, and even the four most commonlyused – ferrous sulfate, ferrous fumarate,elemental iron, and sodium iron ethylenediamine tetra-acetate (EDTA) – vary great-ly in their cost, absorbability, stability, andeffects on food (see box Comparing FourCommonly Used Fortificants).

❑ Decide which and how much forti-ficant to use

Program and project managers should con-sult with food technologists and foodchemical suppliers about the relative bene-fits and limitations of available fortificants

in order to decide about the best ones touse with foods proposed for fortification.Fortificant mixes containing othermicronutrients should also be considered,if there are other micronutrient deficienciesthat fortification can address.

With input and advice from technicalexperts or food industry specialists, theamount of fortificant to add to the selectedfood can be determined by applying thefollowing calculation:

1) Estimate the daily per capita iron intakeof the targeted population

2) Estimate the amount of additionalabsorbed iron needed to meet the rec-ommended daily dietary allowance

3) Estimate the proportion of the recom-mended dietary allowances for iron tobe met by food fortification

4) Estimate the amount of the fortifiedfood consumed daily per capita

5) Calculate the fortificant level based onadditional absorbed iron needed percapita daily consumption, the absorp-tion of the chosen iron fortificant, andthe amount of food consumed


The Potential of Double-Fortified Salt

Because of the commitment of governments and donors, salt iodization has been the most success-ful fortification program in most developing countries. Salt is an ideal condiment for fortificationbecause it is consumed by all population groups in all cultures. Adding other micronutrients to saltcan help address other micronutrient deficiencies. Fortification of salt with iron, in addition toiodine, would reduce iron deficiency and greatly improve iron status in developing countries. Sinceiron deficiency affects iodine uptake, it makes sense to fortify salt with both iron and iodine.

The technology to double-fortify salt with iodine and iron was developed in India 30 years ago, andone private company continues to produce double-fortified salt. Its effect in reducing anemia wasdemonstrated in a recent study that found that hemoglobin levels increased from a mean of 8.9 g/dLto 10.2 g/dL in tea pickers in southern India who consumed double-fortified salt. The study alsoshowed that the tea pickers’ productivity increased.

Problems with product stability and consumer acceptability have limited the use of double-fortifiedsalt on a larger scale. Researchers are experimenting with a process of encapsulating both the ironand the iodine in the salt to improve its stability and acceptability. This may permit broader promo-tion and distribution of double-fortified salt worldwide, provided the cost is acceptable to con-sumers. Initial efficacy trials are promising, but further study is needed to determine the effectivenessof double-fortification of salt on a wide scale.


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Determine Efficacyand Effectiveness

❑ Review information on the efficacyof the fortificant for the chosenfood; conduct trials if needed

An efficacy trial conducted by a humanbiologist or nutritionist can ascertain thefortificant’s impact on nutritional status ina controlled setting. A trial may also beneeded to determine the fortificant’s effica-cy in the chosen food in the intended pop-ulation. During the program planningphase, existing information on the fortifi-cant’s efficacy from in vitro, animal, andhuman studies should be reviewed. If thereis sufficient evidence that the fortificant inthe fortified food has the desired impact onnutritional status, a trial is not necessary. Ifa trial appears necessary, its cost, size, andduration need to be determined and bud-geted for in the planning phase.

❑ Plan to measure effectivenessMeasuring the effectiveness of the fortifi-cant by determining its impact on nutri-tional status in an uncontrolled setting isjust as important as showing biologicalimpact in a controlled setting. Programmanagers should anticipate and includethis activity in program planning andbudgets. The evaluation of the effective-ness trial should occur once the targetaudience has been motivated to purchaseand consume the fortified food.

Study Industrial Capacityfor Food Fortification

❑ Determine industry’s commitmentand capacity to fortify foods interms of technology, equipment,laboratory availability, and quali-fied personnel

Undertaking food fortification requires

Comparing Four Commonly Used Fortificants

Ferrous sulfate: Ferrous sulfate is the iron fortificant against which others are measured. It is rela-tively inexpensive and well absorbed, dissolving easily in gastric juices. It has some disadvantages,however, such as promoting fat oxidation, which can cause rancidity and changes in food color.Ferrous sulfate is the preferred fortificant for use in baked goods that are stored for relatively shortperiods (less than three months) and in cool places (temperature less than 30°C). New processes ofencapsulating ferrous sulfate to reduce sensory changes are promising, but they require sophisticatedtechnology and are expensive.

Ferrous fumarate: Ferrous fumarate is just as absorbable as ferrous sulfate and causes fewer senso-ry changes. It is more expensive, however. It is often used in blended cereal foods that may require along shelf life. It is better absorbed in gastric juices than elemental iron compounds, but children,who produce less gastric acid, may not absorb it well.

Sodium iron ethylene diamine tetra-acetate (EDTA): Sodium iron EDTA is absorbed two tothree times better than ferrous sulfate and does not cause rancidity or changes in food color. It hasreceived approval from the FAO/WHO Codex Alimentarius Joint Committee on Food Additives assafe when used in iron-deficient populations. Sodium iron EDTA has limited application because it isrelatively expensive and not widely produced, but it is possible to add disodium EDTA, which is lessexpensive, to ferrous sulfate and achieve the same advantage of improved iron absorption at lowercost. However, the negative effects of ferrous sulfate on food remain.

Elemental iron: Elemental iron has only half the bioavailability of ferrous sulfate. It is less costly andmore stable than ferrous sulfate and is probably best suited for flour that is stored for a long time.Of the five types, electrolytic iron is the best absorbed. Its absorption, however, is just half that offerrous sulfate, so more than twice the amount of electrolytic iron is often used to provide a similarcontent of absorbable iron. It is thus more expensive over the long term. Many countries use ele-mental iron, although its impact on iron status is unknown. Programs that are using elemental iron tofortify cereal products should be evaluated to optimize its use or, if necessary, suggest changes tocompounds that are better absorbed.

industrial commitment, capacity, andresources, including an adequate level oftechnology, equipment and laboratories,and qualified technical personnel. Programplanners must consult with partners in thefood industry to determine its potential toundertake food fortification on a largescale, which can be constrained by a lackof central processing capacity or by limitedpurchasing power of target populations.

Industry’s commitment to food fortifica-tion can be strengthened if it realizes thatinvestment in this area will improve itslong-term competitiveness. Donors initial-ly may need to help national programsand food industries finance activities thatwill allow the industries to later increasetheir food fortification capacity and efforts.

Food fortification also requires industrialequipment and personnel capacity to carryout the technical processes involved withadding fortificants and packaging foods ina way that preserves their nutritional qual-ity. Quality control at the production levelis essential to ensure cost containment, con-sumer satisfaction, and regulatory compli-ance. Experts in fortification may be neededto help determine and develop industrialand quality control capacity in these areas.

❑ Determine availability of (orpotential for developing) structuresand systems for distributing thefortified foods

Food fortification programs must alsodetermine the ability of the food industryand other partners to deliver fortifiedfoods to their intended consumers.Distances between central processing facili-ties and target populations, transport capac-ity, and transportation conditions are factorsthat may affect a program’s ability to reach

its target populations. Government and thefood industry should also develop stan-dards to ensure that the quality of the forti-fied food is maintained during distribution.Government agencies responsible for foodand drug regulation should be involved inquality control at each level of food distribu-tion, including the household level.

Determine theMarketability of the

Fortified Food

❑ Conduct consumer acceptabilitytests in different income groupsabout the fortified food and theirmotivation for consuming it

Program managers and the food industry,with technical assistance from advertisingor marketing firms, should work together todesign and conduct tests among differentincome groups to determine the fortifiedfood’s acceptability to consumers. Thesetests should measure the acceptability of thefood’s taste, texture, color, odor, cookingcharacteristics, and appearance before andafter cooking. Additional information onpackaging, labeling, and consumer motiva-tion to purchase and consume the food,including the perceived health value of theproduct, should be collected.

❑ Conduct market analysis to deter-mine the ability and willingness ofconsumers and industry to payadditional costs of fortification

The cost of the fortificant is the major costto food fortification programs. Equipmentcosts for adding fortificant and costs ofquality control tests are considerably lower.The fortificant cost is usually passed on to


In Venezuela, the food industry was educatedabout the benefits of fortification and thentook pride in absorbing the cost of the fortifi-cant as its contribution to national health.

In Guatemala, millers were surveyed to deter-mine their interest in and rally their supportfor fortification.

In Tunisia, testing revealed that consumerspreferred flour made from locally grown wheatover centrally processed flour because theyperceived the local flour as purer, better tast-ing, more filling, and healthier.

In Guatemala, consumer testing ensuredproduct acceptability after fortification.

the consumer but only increases the priceof the fortified food product by 1 percent.

Even so, the cost of fortification can be sig-nificant for large volumes of food. Eitherthe food company absorbs these costs outof its profits, or consumers pay higherprices to cover them. Because food indus-tries often have a low profit margin tobegin with, it may not be realistic to expectthem to pay for the additional cost of forti-ficant. Governments or donors can initiallysubsidize costs and waive tariffs on equip-ment and fortificant, but experience showsthat programs will not be sustainable untilconsumers cover these costs.

To determine if millers, other producers, orconsumers of different income levels areable to bear the added costs of fortification,program managers should arrange to sur-vey each involved group about its abilityand willingness to pay extra (and howmuch extra). It is important to determinehow the product can be made available toconsumers who cannot afford to buy it.

Ensure ProperProduct Packaging,

Uniformity, and Stability

❑ Select packaging and labeling forthe product

Appropriate packaging that ensures anadequate shelf life and accurate labeling

(including, if possible, seals of approvalfrom government agencies) are essential tothe success of food fortification programs.Experts in the areas of packaging andlabeling should help design new packag-ing or conduct an analysis of current pack-aging and suggest changes, if needed.

❑ Test for uniformity and stability ofthe fortificant in the manufacturedproduct under environmental con-ditions over time

Industry and government should worktogether to monitor the manufacturedproduct, industry at the production leveland government inspectors at the retailand household levels. The fortificant mustbe uniformly distributed in the final pack-aged product. The food industry’s qualitycontrol sys-tems canconfirmthat themanufac-turing lineis functioning properly to ensure this uni-formity. The stability of the fortificant inthe packaged product and its effect on ironcontent and product color, taste, odor, andtexture must also be evaluated to ensurean acceptable shelf life in warehouses,stores, and households. Samples need to bekept in appropriate conditions and testedat regular intervals.

❑ Test-market product stability andpackaging with consumers

After testing the uniformity and stability ofthe fortificant in the fortified product, thenext step is to test product stability as it ispackaged for consumer use. These steps areoften conducted separately because thefindings of the fortificant testing will affectthe choice of packaging. Effectiveness trialsto test the impact of the fortified food in


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In a survey in Thailand, few rice millersbelieved that consumers would pay a higherprice for a fortified product. However, in a sur-vey of consumers, one-third of respondentssaid they would pay more for a product ofgood quality. To encourage the private sectorto fortify foods, the government reduced taxeson fortification equipment and supplies andsimplified registration of new foods.

In Indonesia, donors covered fortificant costsfor wheat flour fortification for several years.

In Venezuela, the government and nutritionspecialists convinced the private sector to rec-ognize the problem of iron deficiency and topay fortificant costs.

“Food Fortification: Seven Stepsfor Quality Control” can befound in Tools and Resources.

In Grenada, the quality of flour was moni-tored at the retail and consumer levels.Specialists assessed quality control at thefactory level and iron content of flour atdifferent delivery levels.

households can include testing the effective-ness of product packaging. Research shouldalso determine if consumers understandlabels and the information they provideabout nutrition and proper storage, prepa-ration, and serving of the fortified food.

Establish NationalGuidance for Fortifying

Foods and Regulating FoodFortification

❑ Determine if legislation is desiredor needed

Food fortification can be voluntary ormandatory. Mandatory fortification isgenerally the most desirable approach forachieving the highest and broadest impactin terms of reducing iron-deficiency ane-mia. However, voluntary fortification canserve a useful purpose; it gives companiesa transition period to make the necessaryadjustments in their production processesand also allows forward-looking foodproducers to gain market share by mov-ing to food fortification before their com-petitors. If voluntary or permissive fortifi-cation is established, it should be for afixed period, after which mandatory forti-fication is required.

Program managers should work with rep-resentatives of government food regulato-ry agencies and industry to develop thenecessary guidance and policies on forti-fying foods and regulating food fortifica-tion. In some cases, non-binding guidancefrom government agencies may accom-plish as much as legislation. If standardsare to be enforced nationwide, legislationmay be necessary. In some situations,however, it may be better to have a gener-al umbrella food law and establish fortifi-cation as a regulation.

❑ Develop guidance for foodfortification

Government norms and regulations forfood fortification must be consistentlyfollowed and enforced. Guidance on

fortification should give information to thefood industry about the level of fortifica-tion, acceptable foods, acceptable ranges ofnutrients, and how to measure levels ofnutrients. Producers will also need guid-ance on what constitutes compliance ornoncompliance with norms and regula-tions. If fortification is voluntary, monitor-ing compliance may be impractical, espe-cially in countries with many small millersor producers.

When government makes fortificationmandatory, procuring the fortificantthrough commercial channels is optimal.Guidance for public procurement systemsshould emphasize transparency, accounta-bility, and speed, as well as the need toensure that all millers are supplied withthe proper amount of fortificant.

❑ Ensure that food imports are forti-fied and comply with regulations

Government customs agents are responsi-ble for overseeing food imports and ensur-ing that fortification regulations are fol-lowed. To do this, they need to beinformed of requirements and trained andequipped to ensure that imported foodsmeet them. Good relations with othercountries are helpful for controlling legaland illegal imports of unfortified foodsand protecting consumers and industriesthat are fortifying their products.

For imported foods, including food aid,the exporting countries should be requiredto deliver fortified products. These foodsneed to be monitored by the exporter ordonor for quality. This is more cost-effec-tive and easier to control, administer, andfinance than adding iron to food when itarrives in the country. It also protects


Bolivia improved regulatory systems so thatall imported food met legislative criteria andcontraband was minimized.

In Central America, the Middle East, andNorth Africa, industries and governments haveworked together to ensure that food produc-ers in these regions follow the same standardsand regulations.

indigenous companies committed to forti-fication from competition from unfortifiedcheaper products. However, if wholegrains are imported and processed incountry, the food needs to be fortified incountry during processing, and theexporter or donor should be responsiblefor ensuring this occurs.

❑ Increase government capacity tolegislate and enforce fortification

Governments can do a number of things toenforce fortification:

• Validate quality control systems at plants

• Conduct spot checks through laboratoryanalysis of food samples from produc-tion facilities, markets, and retail outletsto examine fortificant levels, productstability, and food appearance and taste

• Inform the public about the quality ofthe fortified food

• Establish procedures for fining or clos-ing food plants that do not comply withregulations

• Register and act on consumer com-plaints about products

• In countries where industries are “self-regulating,” verify that self-regulation isworking and that food is adequatelyfortified

• Establish and maintain good relationswith other countries and supportregional initiatives to control imports ofunfortified foods

Building the capacity of government to reg-ulate and enforce legislation is one of themost challenging aspects of fortification.The different players involved in makingregulation and enforcement successfulinclude government, industry, and con-sumer groups. This effort may also requiremodifications to existing infrastructure,including creating positions at each level tomonitor and regulate fortified foods.

Raise Support forFortified Products

❑ Motivate and educate consumersand health and food professionalsabout consuming fortified foods

Market research and analysis can deter-mine barriers to and facilitators of accept-ance and consumption of fortified foodsand provide information on consumerneeds and preferences. Some of this infor-mation may already be available fromresearch conducted early in the process ofdeveloping an anemia prevention and con-trol strategy (see Know the problem … inChapter II).

Advocacy, education, and marketing cam-paigns can use such information to raiseawareness, prompt behavior change, andinfluence consumer purchasing.Consumers should be informed whenfoods are fortified; it is especially impor-tant to tell them of the benefits of fortifiedfoods to ensure that fears about taintedfoods do not undermine the fortificationprogram. Raising awareness among politi-cians and public health and food officialsabout the dangers of iron-deficiency ane-mia and the benefits and safety of fortifiedfoods can only enhance the promotion andacceptability of the fortified food (seeRaise awareness ... in Chapter II).

In general, the government will motivateconsumers to buy iron-fortified products,while private companies will advertisetheir own brand-name iron-fortified prod-ucts following government guidelinesabout health claims for the product.


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In Central America, quality monitoring wasimproved to assist in enforcement.

Indonesia carried out promotional campaignsto dispel public worries about iron in fortifiedfoods.

Monitor and Evaluate IronFortification Programs

❑ Monitor consumption of the forti-fied food by different vulnerablegroups

Monitoring and evaluation activities andindicators should be designed and incor-porated into fortification programs fromthe outset. Anemia prevalence is the most

appropri-ate indi-cator oftheimpact ofanemiapreven-tion andcontrol

programs. Population-level changes in irondeficiency are the best indicators of theimpact of food fortication with iron, butmeasuring these changes is expensive andnot appropriate in a field setting. Collectinginformation about iron status in smallersubpopulations may be possible, however.

Government and industry monitoring ofthe consumption of fortified products bydifferent vulnerable groups is essential.Data about the amount of iron in foodsconsumed can be collected, if desired,although this may be expensive.Collecting data about sales volume andlocations also provides useful informationand is easier and less expensive. Indicatorsof program impacts, as well as changingconsumer habits and the evolving healthprofile of the population, may dictatemodifications in the fortificant levels of the

fortified foods (see Develop a monitoringand evaluation plan ... in Chapter II).

❑ Develop and expand the foodproduct distribution system

Ongoing monitoring of the market for for-tified foods can confirm if there is continu-ing demand and that the fortified foodprogram is sustainable. Government andindustry representatives should ensurethat such information is shared withprogram managers.

Based on the changing perceptions andneeds of consumers, new messages mayneed to be developed to sustain demand.This monitoring can be conducted throughmarket research evaluation. If the evalua-tion confirms sustained demand for thefood, private industry should be encour-aged to plan for expanded productdistribution.


“Selected Monitoring andEvaluation Indicators forAnemia Prevention and ControlPrograms” in Tools andResources includes indicators formonitoring and evaluating foodfortification programs.

Chile has several decades of experience withfood fortification programs that have addediron to staple foods and reduced iron deficien-cy in the general population. Extensive researchhas also identified appropriate foods to fortifyin order to address iron deficiency in children.Monitoring and evaluating the changes in irondeficiency in children generated by theseefforts has been part of the country’s strategyto control iron deficiency.

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Photo and Illustration Credits

Cover P. Bennett/IDRC (top), D. Sing/IDRC (middle),

D. Marchand/IDRC (bottom)

p. 14 Armando Waak/WHO

p. 23 Longfils/GTZ, Kampot, Cambodia

p. 31 BASICS

p. 36 International Institute of Nutrition, Peru

p. 37 C. Lengeler

p. 38 MotherCare Project/ University of Indonesia/PATH

p. 40 Rae Galloway

p. 43 Antoinette Tisa

p. 50 USAID

p. 52 WHO

p. 53 Atención Integral a la Niñez, Honduras

p. 54 MotherCare and OMNI Projects, Bolivia

p. 57 D. Marchand/IDRC

p. 63 Jim Stipe/Lutheran World Relief

p. 64 Maggie Murray-Lee/Lutheran World Relief

anemia prevention and control: program guidance, part i

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