1. Nutritional Anemia in Bangladesh:
Problems and Solutions
Dr Tahmeed Ahmed
Director
Centre for Nutrition & Food Security
ICDDR,B
Professor, Public Health Nutrition
James P. Grant School of Public
Health, BRAC University

2. Anemia
A condition in which the Hb
concentration in the blood is below
a defined level, resulting in a
reduced oxygen-carrying capacity
of red blood cells

3. Definition of Anemia at Sea Level
Stoltzfus & Dreyfuss; INACG/UNICEF/WHO 1998

4. Consequences of Anemia
• Poor immune function and increased morbidity
from infection
• Fatigue and lower physical work capacity
• Poor physical growth
• Impaired learning and school achievement
Brabin BJ 2001
Grantham-McGregor S 2001

5. Consequences of Anemia in Pregnancy
• Increased risk of complications during
delivery, including prolonged labor, preterm
delivery, LBW and maternal and neonatal
deaths
• Infants of mothers with iron deficiency anemia
are more likely to have low iron stores and to
become anemic
Brabin BJ 2001
Grantham-McGregor S 2001

6. Anemia causes huge economic loss
• Results in productivity loss
• Economic cost of anemia in Bangladesh is
estimated to be 7.9% of GDP
Christian P 2005
UN/SCN 2004

7. What are the causes of anemia?
• Iron deficiency – dietary deficiency, loss of iron
• Hookworm
• Vitamin deficiencies, eg vitamin B12, folic acid
• Malaria
• Hemoglobinopathies, eg thalassemia
• Chronic infections, such as TB, HIV

8. Iron Deficiency Anemia
• Iron deficiency is the most important cause of
anemia
• 60% of all anemia is due to iron deficiency
Stoltzfus R 1998, Black RE 2008

9. Review of Anemia Control Program
• Review of literature, survey reports
• Meta analyses
• Communication with stake holders from
public, private and research sectors
• 22 interviews - NNP, DGFP, IPHN, IEDCR,
CMSD, NIPORT, EDCL, UNICEF, MI, BRAC,
ICDDR,B
• Informal round table discussion at ICDDR,B

12. Prevalence of Anemia in Bangladesh
Age Year Settings Sample Size %
Infants 20041 Rural 1227 U-5 92
(6-11 mo) 20032 Urban 93 83.9
20032 CHT 51 90
20013 Rural 1148 U-5 74.1
19994 Urban 183 92.3
NSP 20041 , Anemia prevalence survey
UNICEF/BBS 20032, NSP 20023 , NSP 20004

13. Prevalence of Anemia in Bangladesh
Age Year Settings Sample Size %
Infants 20041 Rural 1227 U-5 92
(6-11 mo) 20032 Urban 93 83.9
20032 CHT 51 90
20013 Rural 1148 U-5 74.1
19994 Urban 183 92.3
•Demand for iron is high
•Complementary feeding is inappropriate
•No program for anemia control in infants
NSP 20041 , Anemia prevalence survey
UNICEF/BBS 20032, NSP 20023 , NSP 20004

14. Complementary Foods Provide little
Micronutrients to Bangladeshi Infants
 Breast milk contributes to 75% of total energy intake
 Small amounts of CF offered
 Vitamin B6 50% of RNI
 Vitamin A 48% of RNI
 Zinc 45% of RNI
 Iron 9% of RNI
 Increase in CF will not substantially increase MN
intake
Kimmons J, 2006

15. Pre-school Children and Adolescent Girls
Age Year Settings Sample Size %
Pre-school 20041 Rural 1227 68
(6-59 mo) 20032 Urban 861 55.7
20013 Rural 1148 48.3
Adolescent 20041 Rural 661 39.7
(13-19 yr) 20032 Urban 1341 23.4
20013 Rural 237 30
NSP 20041 , Anemia prevalence survey
UNICEF/BBS 20032, NSP 20023

16. Anemia Prevalence Trends in Bangladesh
Infant Pre school
Adolescent NPNL women
Pregnant Women Lactating Women
100
92
90
80 74.1
67.9
70
60 48.3 46
50
46.7 46
40 39.7
P
n
c
e
r
t
30 35
33 38.8
20 30
10
0
2001 2003 2004
NSP 2004, Anemia prevalence survey UNICEF/BBS
2003, NSP 2002, WHO global database on anemia

17. Strategies for Anemia Prevention
and Control
• Micronutrient supplementation
• Dietary improvement
• Parasitic disease control
• Food fortification
• Family planning and safe motherhood
National Strategy for Anemia Prevention and Control
in Bangladesh, MOHFW 2007

18. Existing Programs on Iron Supplementation
Age group Department
Infants, children No national program
Adolescents DGFP
PLW DGFP, DGHS, NGOs
NPW DGFP

19. Dose of Iron-folic Acid Tablets
Target group Doses
Adolescent girls 2 tablets/week
Newly wed women 2 tablets/week
Pregnant women 2 tablets daily up to delivery
(NGOs 1 tab daily)
Lactating mother 1 tablet daily for 90-120 d

20. Iron-folic Acid Tablets

21. Dispensing IFA Tablets
DGFP Given in a polythene bag Spoilage ?
DGHS Wrapped in paper Spoilage ?
BRAC Now giving tablets in Tk 14 for 100 tab vs
blister pack Tk 12 for 100 open tabs

22. Iron Coverage among Pregnant Women
HFSNA 2009

23. IFA Tablet Coverage during Pregnancy in
BINP Areas
Indicator Survey Area
BINP (%) Comparison (%) All (%)
IFA intake
Regular 25.4 16 19.5
Irregular 9.9 9.5 9.6
None 64.7 74.5 70.9
Total (n) 2193 3785 5979
NNP Baseline Survey 2004

24. Reasons for Not Taking IFA Tablets
Regularly
Reasons N=1741 pregnant
women, %
Side effects (diarrhea, etc) 25.5
Forget to take 19.5
Did not consider necessary 16.3
Lack of supply 12.0
Do not receive enough tablets 6.1
Economic constrains 4.5
Objection of family members 1.9
Lost tablets 0.2
Others 7.8
NNP Baseline Survey 2004

25. Multiple Micronutrient Powder
1 RDA of
•Iron
•Folic acid
•Vitamin A
•Vitamin C
•Zinc

27. No color
No taste of its own
No odor

28. Children with the following conditions are excluded:
•Any acute illness
•Severe cough
•Breathlessness
•Severe visible wasting

29. What can we do to control anemia?

30. Comprehensive Nutrition Actions Required
• Increase exclusive breastfeeding rates
• Improve complementary feeding practices by
using various foods rich in iron
• Consider home-based fortification of CF using
multiple micronutrient powder
• Coordination of efforts of different agencies and
the private sector in control of anemia

31. • Promote factors that will increase coverage of
IFA supplementation among adolescent girls,
pregnant & lactating women
– Effective counseling
– Sustained supply
– Appropriate packaging
– Mass media coverage
– Trained workforce