Anaemia burden: iron alone is no solution

Why in the News

Double-fortified salt is often proposed as a national answer to anaemia (too little haemoglobin, the protein in red blood cells that carries oxygen). Its case rests on convenience rather than proven benefit, and it treats a condition with many causes as a shortage of one nutrient.

What is double-fortified salt, and why is it proposed?

1. Double-fortified salt (DFS): DFS is common salt with both iodine and iron added. It works like iodised salt, with iron in the same packet.
2. Scale of anaemia: The fifth National Family Health Survey (NFHS-5) found more than half of women and about two-thirds of young children anaemic.
3. The takeaway: Everyone eats salt, which makes DFS convenient, but convenience does not prove that it works.

Why is salt a poor carrier for iron?

1. Clash with salt reduction: Indians already eat about twice the World Health Organization’s recommended 5 grams of salt a day, yet DFS works only if salt intake stays high.
2. Hypertension and salt targets: About one in three adults has hypertension (high blood pressure), and India’s non-communicable disease (NCD) action plan commits to cutting salt intake by 30%.
3. Uneven intake: Adult men eat the most salt and young children and women the least, so those needing iron most get least.
4. Poor absorption: DFS carries non-haem iron, which the body absorbs poorly. Phytates in cereals and pulses, polyphenols in tea and coffee, and calcium in milk cut absorption further.
5. Infection blocks uptake: During infection or inflammation, the hormone hepcidin blocks iron uptake, so fortification works least where infection is highest.

Can extra iron do harm?

1. No exit for iron: The body has no regulated way to excrete iron, so excess builds up. It causes oxidative stress (cell damage from reactive oxygen) and is linked to metabolic disease.
2. Inherited blood disorders: Millions of Indians carry beta-thalassaemia, and sickle cell disease is concentrated in tribal belts. People with thalassaemia, especially those on transfusions, risk iron overload.
3. Screening impractical: The Public Distribution System (PDS) reaches about 800 million people, far too many to screen first.
4. Stacking of programmes: Fortified rice already flows through the PDS, Pradhan Mantri Poshan Shakti Nirman (PM POSHAN) and Integrated Child Development Services (ICDS), alongside iron tablets, with no analysis of total iron intake.

Why is iron alone not the answer?

1. Anaemia is not only iron deficiency: Globally, about half of anaemia cases stem from iron deficiency. India’s Comprehensive National Nutrition Survey (2016-18) found it explained only part of anaemia in children and adolescents.
2. Other causes: Other sources include:
   • folate and vitamin B12 deficiency, common among vegetarians;
   • infections, chronic inflammation, hookworm, malaria and poor sanitation;
   • haemoglobinopathies (inherited disorders of haemoglobin);
   • low protein and vitamin A, early marriage and pregnancy, and menstrual losses.
3. Gaps in Anaemia Mukt Bharat: The Health Ministry’s revised Anaemia Mukt Bharat strategy, the 7x7x7 approach, still leans on iron-folic acid tablets, which many people do not take regularly.
4. One-solution thinking: A DFS flagship would revive the single-fix approach the revised strategy aims to leave behind.

What do experiences abroad show?

1. Tanzania, Pemba trial (2006): Iron and folic acid given to children in malaria-endemic Pemba were linked to more hospitalisations and deaths, a warning for India’s large malaria-endemic and poorly sanitised areas.
2. Kenya trial (2015): Iron-fortified foods shifted infants’ gut bacteria toward harmful types and raised diarrhoea.
3. Peru: Peru cut child anaemia by double digits in the early 2010s through name-based tracking, cash transfers and regional accountability, until COVID-19 disruptions reversed the gains.
4. Vietnam: Anaemia among women fell sharply with weekly iron-folic acid, deworming and fish sauce fortified with better-absorbed NaFeEDTA iron, helped by rising incomes and varied diets.

Challenges

1. Trials versus kitchens: Supervised trials do not capture household cooking losses, uneven dosing and varied diets.
2. Affordable diets: “Eating Right” stays a slogan unless households can afford eggs, dairy, greens and millets.
3. Neglected causes: Deworming, malaria control and sanitation remain at the margins of anaemia policy.

Way Forward

1. District pilots first: The Health Ministry should run monitored district pilots measuring ferritin, haemoglobin, inflammation and total iron exposure, especially in malaria-endemic and haemoglobinopathy-prone areas.
2. Targeted fortification: Fortify for groups in need, not everyone, using better-absorbed iron forms.
3. Invest in causes: Fund diagnostics, deworming, sanitation and affordable diverse foods.

Conclusion

Anaemia in India has many causes, so a salt additive cannot solve it and may divert effort from diagnosis and sanitation. The test is whether district evidence comes before any national scale-up of a fortified product.

Matching Previous Year Question

“[2023] Consider the following statements in the context of interventions being undertaken under Anaemia Mukt Bharat Strategy: 1. It provides prophylactic calcium supplementation for pre-school children, adolescents and pregnant women. 2. It runs a compaign for delayed cord clamping at the time of child-birth. 3. It provides for periodic deworming to children and adolescents. 4. It addresses non-nutritional causes of anaemia in endemic pockets with special focus on malaria, hemoglobinopathies and fluorosis. How many of the statements given above are correct? (a) Only one (b) Only two (c) Only three (d) All four ANSWER: (c)”