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Eating right to fight anaemia

As India aims to reduce anaemia prevalence by 3% every year among children, adolescents and women, nutritional poverty remains an area of concern

Eating right to fight anaemia
In India, a typical day begins with tea or soaked almonds. Almonds are rich in iron but if had with tea the absorption of iron gets reduced. Experts suggest a gap of a minimum of one hour between vitamin C-rich foods and others which interfere with iron absorption.

You are what you eat, goes the old saying. It has been estimated that more than 2 billion people in the world are overweight or obese, and over 800 million people do not get enough calories or nutrition. In short, unhealthy or poor diets are contributing to health deficiencies and deaths around the world.

This is particularly true for anaemia, which is an outcome of iron deficiency. A blood disorder in which the blood has a reduced ability to carry oxygen due to a lower-than-normal number of red blood cells, or a reduction in the amount of haemoglobin, anaemia normally comes with symptoms such as tiredness, weakness, shortness of breath, headaches and a reduced ability to exercise. When anaemia is acute, symptoms may include confusion, feeling like one is going to pass out, loss of consciousness and increased thirst, etc.

Eating iron-rich foods is one of the ways to improve haemoglobin levels naturally. However, this is not happening as nutritional poverty still remains a health emergency in India and many other countries globally. Southeast Asia has some of the highest rates of iron-deficiency anaemia. In India, more than half of the female population are anaemic.

The current State of Inequality in India report by Institute for Competitiveness lists all the concentrated efforts to strengthen the rural health infrastructure, but nutritional deficiency remains an area of concern. In India, the percentage of anaemic children under 5 years of age (6-59 months) has increased from 58.6% in 2015-16 to 67.1% in 2019-21. Gujarat has reported more than the national figure, with 79.7% of children having anaemia, which increased from 62.6% in 2015-16. Ladakh has recorded 92.5% of children with anaemia among the Union Territories. A similar trend is visible, with an increasing prevalence rate of anaemia among adolescent girls (59.1% from 54.1%) and women of reproductive age (57.2% from 53.2%). In comparison to women, adolescent boys (31.1%) and men (25%) have reported lower rates of anaemia.

“Causes include malnutrition or not having an adequate diet, along with high fibre levels in vegetables, which can also lead to decreased absorption. Also, fortification of food has not happened for a long time, and we have deviated from traditional habits of eating and cooking food in iron utensils, which used to be the source of iron in older days,” says Dr Rahul Bhargava, principal director, hematology, Fortis Memorial Research Institute, Gurugram, who feels that eradication of anaemia requires a multi-dimensional approach and community participation.

According to Swati Bathwal, public health nutritionist, dietitian and author, anaemia is not always caused due to iron deficiency, but from inherited disorders. “In urban cities, availability of fast foods (which are low in nutrients), increased intake of coffee or foods which reduce iron absorption, packaged foods, low vegetable intake and unhealthy lifestyle are some of the reasons. In rural areas, low income, lack of awareness and ignorance, shortage of food supply, climate change (which is impacting the quality of food), infectious diseases like malaria and food hygiene are some contributory factors,” says Bathwal.

Hidden hunger

‘Hidden hunger’ is one of the health epidemics that have caught the attention of food experts across the world, which essentially is a deficiency of micronutrients. According to UNICEF’s 2019 report ‘Adolescents, Diets and Nutrition: Growing Well in a Changing World’, over 80% adolescents suffer from hidden hunger in India.

“It’s called hidden as they may not necessarily be hungry or undernourished in the physical sense but have all the signs of malnourishment like anaemia, low energy, fatigue, amenorrhea, etc, which strikes at the core of their health and vitality. Hidden hunger or anaemia can be caused by two extremes—one due to overall insufficient food intake that we often see in the poverty-stricken population and the other due to the rich and affluent suffering from micro-nutrient deficiencies. With growing incomes and increased spending on food, people are moving away from traditional diets to a lifestyle majorly consisting of ultra-processed foods—high in calories and low in micronutrients. As a country we face a triple threat: undernourishment, micronutrient deficiencies, and obesity, all of which can result in anaemia,” shares Mumbai-based Munmun Ganeriwal, a nutritionist and gut microbiome specialist.

The pandemic has shifted normal routines, especially related to parenting. A new Abbott-Momspresso survey has brought several concerns that Indian parents continue to face. The survey, conducted online earlier this year with over 2,500 mothers across India, highlights changes in eating habits and physical activity—two key lifestyle functions impacting healthy growth in children. Up to 68% feel that their child has become fussier with food choices; 84% feel that the pandemic has led to reduced physical activity and increased use of digital technologies; 70% feel that their child’s immunity is not strong enough to be safe in external environments.

Crisis control

Be it shortage of food grains or lack of awareness in rural areas, nutritional poverty is increasing and adding to the cases of anaemia every year. Bihar continues to have the highest population of nutritionally vulnerable children, with as many as 41% of children below 5 years being underweight and 42.9% having stunted growth. Maharashtra has 25.6% of children as wasted and 10.9% as severely wasted—the highest in the country as per the State of Inequality in India report.

While recent news reports suggest a huge jump in the enrolment of students in government schools in the second pandemic year (2021-22), an estimated 4.88 lakh children—or about 27% of the total enrolment—were left out of the midday meal scheme in Delhi “due to shortage of foodgrains”, according to the Union government.

To encourage healthy and holistic growth in kids, pharma major Abbott has launched its Grow Right 2.0 charter introducing guidelines for good practices in ‘Measuring growth, Eating, Activity, Nurturing and Sleep (MEANS)’. The charter—backed by health and nutrition experts—can help address parents’ concerns by providing tips to encourage healthy lifestyle habits.

Another pharma company, Emcure Pharmaceuticals, has started a website called www.anemiafreeindia.com to answer queries related to nutrition in women and anaemia at different life stages. It has installed smart kiosks displaying QR codes in the waiting areas of hospitals and clinics to educate patients with guided augmented reality (AR) videos and frequently asked questions. “We have launched a chatbot on the website to assess one’s health and find if there’s a risk of anemia. It answers queries related to nutrition too,” says Pratin Vete, president-India sales and marketing, Emcure Pharmaceuticals.

The central government has also given high priority to the issue of malnutrition and has implemented various schemes like anganwadi services, scheme for adolescent girls and Pradhan Mantri Matru Vandana Yojana (PMMVY) under the umbrella Integrated Child Development Scheme (ICDS). The services under ICDS are provided through anganwadi workers (AWWs) and anganwadi helpers (AWHs) at all local ICDS (or anganwadi) centres.

Also Read: Climate change is adversely affecting health. Are people aware?

Diet chart

In India, a typical day begins with tea or soaked almonds. Almonds are rich in iron but if had with tea the absorption of iron gets reduced. Experts suggest a gap of a minimum of one hour between vitamin C-rich foods and others which interfere with iron absorption.

One can add herbs in food like mint or coriander leaves, chutney with meals or squeeze lemon juice on dal or chutneys to increase iron absorption. In rural India, the combination of green chillies with meals assists in iron absorption but availability of iron-rich meals due to low income is a concern. In case of pernicious anaemia —caused due to vitamin B12 and very common in India—appropriate supplements should be provided.

Eating in proportions is important and consuming more carbohydrates as compared to vegetables can result in an imbalance of nutrients. “We require dietary diversity. A monotonous cereal diet that lacks diversity is the issue. Millets are carbohydrates but are rich in micronutrients like iron, B12, etc. Sugar is bad when it is refined. Jaggery is a rich source of dietary iron. The need of the hour is not to eliminate any food group but to address the issue of hidden hunger through dietary diversification of micronutrient-rich produce,” says Ganeriwal.

While multiple strategies have been devised to give iron tablets to fight anaemia, Dr Bhargava feels they have not prescribed in a proper way. “Before and after two hours of iron tablets, one must avoid milk, tea, green leafy vegetables and calcium tablets. In the rural hinterlands, you will see that an iron tablet is given along with food,” he adds.

A balanced diet depending on your dietary preferences will not cause anaemia. “Carbohydrates and vegetables will impact iron deficiencies only when there is a wrong combination of food or lack of protein intake. In urban cities, we consume packaged foods, which are low in vitamin C. Vitamin C is heat sensitive and gets lost during storage and transport. In cities, we consume plenty of coffee and tea. It’s not the caffeine but the tannins, a compound in these drinks which reduce iron absorption. Calcium from milk doesn’t assist in iron absorption either. So, it is better to combine the foods appropriately. A stressful life increases acidity or bloating or alters our gut flora, which further reduces vitamin B12 and low vitamin B12 also causes anaemia,” feels Bathwal.

Both being overweight and underweight can result in malnutrition. A person who is obese or overweight can be anaemic due to less intake of vegetables or fruits. “Unhealthy foods which impair the gut lining are on the rise. One could eat a burger or pizza and still be in the appropriate weight range but will not have the right nutrients. Increased carbohydrate intake and lack of protein sources are also one of the contributory factors. A vegetarian diet low in iron is a myth,” adds Bathwal.

Iron deficiency is like a silent assassin that slowly but surely messes up health from the inside, and its prolonged deficiency can prove to be extremely debilitating. “In food, iron is present in two different forms: heme iron and non-heme iron. The way our body absorbs these two types of iron is different. Heme iron, found in eggs, meat, fish and poultry, is easily absorbed and used by our body. Non-heme iron, on the other hand, is found in vegetarian sources like tofu, beans and legumes, fruits and vegetables, dark leafy greens—mainly spinach and kale—and iron-fortified cereals and supplements. Non-heme iron is more difficult to absorb. This is one reason why vegetarians, even if their diet includes dairy and eggs, are at a higher risk of developing iron deficiency,” says nutritionist Kavita Devgan in her book The Immunity Diet.

Devgan recommends foods like whole grains, soy, nuts, spinach, beets and legumes that can decrease the amount of non-heme iron absorbed from the food. “Pair these with foods that enhance non-heme absorption. For example, dress your greens with a homemade, orange or lemon juice based dressing to enhance non-heme absorption, as vitamin C found in oranges and lemons helps boost the absorption. Or throw in some tomatoes or other vitamin C-rich foods like broccoli, bell pepper, strawberries, citrus fruits, papaya, cauliflower or amla (gooseberry) for better iron absorption.

Growing concern

  • In India, the percentage of anaemic children under 5 years has risen from 58.6% in 2015-16 to 67.1% in 2019-21
  • Gujarat has more than the national figure, with 79.7% of kids having anaemia, which increased from 62.6% in 2015-16
  • Ladakh recorded 92.5% of children with anaemia among the Union Territories

Natural Recourse

  • Sapota (chikoo), guava and several other fruits are rich in vitamin C, which is essential to absorbing iron
  • Traditional fruits like phalsa, black plums and green plantains (raw banana) should be included more often
  • Iron-rich meals include nuts and edible seeds, lentils and pulses of all varieties, chicken and some forms of red meat for non-vegetarians. A wrong combination will, however, reduce the absorption of iron

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