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Combating childhood iron deficiency: 

Are national policies and efforts anaemic?

by Channa R. Jayasekera

United Nations World Food Programme

Stuck in traffic near the Castle Street Hospital for Women one would not fail to notice a large advertisement of an iron/folate-fortified milk powder for pregnant women.

"Helps proper development of your baby's brain" reads the catchy, if ominous slogan. As piercing as this advertisement would be to any would-be mother, it seems highly effective in delivering the message that iron (and folate) deficiency has serious repercussions.

For the past thirty years, Sri Lanka has been embroiled in a serious public health battle against iron deficiency. Particularly, this has focused on controlling Iron Deficiency Anemia (IDA) - a consequence of serious iron deficiency that effects brain development, immune function and hinders the body's ability to supply oxygen to its cells.

IDA the most prevalent of all nutritional deficiency disorders in Sri Lanka, affects around 45% percent of pre-school children, 45 percent of non-pregnant women and 58 percent of pregnant women today. Further 18 percent of babies have low birth weights (less than 2.5kg or 5.5lbs) - an indication of iron deficiency in mothers.

(N.B The levels of IDA in the Northeast have not yet been determined conclusively). This figures are grossly in excess of the approximately 5 percent that is considered a 'latent' prevalence for a given population.

Given this current magnitude of the problem, we can infer that three decades of efforts have yielded pallid results. Further our efforts have been predominantly targeted towards pregnant women and not adequately toward young children.

As highlighted in the most recent policy document - Controlling Anemia in Sri Lanka: Issues and Options published by the government's Nutrition Coordination Division, it is certainly time to innovate combat strategies and rethinking existing ones targeting children.

Children who suffer from IDA demonstrate poor academic achievement, cognitive development, psychomotor functions, physical stamina and eventual hindering of their economic productivity.

It is also important to understand that IDA can stand alone, and be present whether or not a child appears otherwise well-nourished.

Iron deficiency, for this reason is deemed a 'hidden hunger'.

The predominant cause of IDA among Sri Lankan children is poor dietary iron intake, though it can also result from the loss of iron due to intestinal parasite (i.e. worm) infections and infestations like Malaria.

These are also the predominant causes of IDA in adults, in particular during pregnancy when bodily iron requirements are high. Poor dietary iron intake is, of course, poverty and food insecurity - driven and strongly associated with inadequate nutrition knowledge in the population.

A lack of dietary diversity underpins the inadequate quantity or poor equality of iron-rich foods consumed.

For example, much of the IDA-afflicted population consumes too little readily bioavailable (i.e. absorbed) 'haem' iron, derived from animal products. The main source of dietary iron is therefore of plant origin, or 'non-haem' iron, which is significantly less bioavailable.

Further behaviours like drinking tea with or immediately after meals exacerbate the low bioavailable of dietary iron.

Policy and existing interventions

The main government strategies to directly combat IDA have been to increase iron consumption by distributing iron in tablet-form to pregnant mothers, and iron-fortitude food supplements (Thriposha) to undernourished children and pregnant lactating women.

Additionally, to combat iron loses, anti-helminthic (worm) and malaria chemoprophylactic treatments are administered. Nutritional education, in the form of Information, Education and Communication (IEC) to enhance healthy practices and compliance also feature prominently in all these efforts.

Delving further, we determine that it is only the administration of Thriposha and anti-helminthics that directly targets improving the iron status of pre-school children.

UN agencies like the World Health Organisation (WHO), United Nations Children's Fund (UNICEF) and the World Food Programme (WFP) support some of the aforementioned projects. Significant among these assistance programmes are collaboration on IEC, UNICEF's provision of iron tablets.

WHO's capacity-building and funding of government interventions, and WFP's distribution of a Thriposha-like fortified supplementary food, Com-Soya Blend (CSB) to all children and pregnant lactating women in specific districts identified as most vulnerable.

Due to the recency of the CSB programme however, the impact on the iron status of child beneficiaries is yet to be determined.

Non-governmental interventions against IDA are modulated by government policy and by collaboration with various government bodies. Simultaneously, these interventions are modulated by the needs of the target population, conveyed through health/nutrition statistics and field-level monitoring. Hence whether actions planned must fit within the confines of government policy in order to be approved.

Establishing Recommended Daily Allowances (RDS's) is one of the vital policies that guide efforts against IDA, RDA's are put forward by government expert committees as the appropriate nutrient intake guidelines for Sri Lankans of difference ages, sexes, lifestyles and life stage.

Policy also leaves room for (and rationalises) dietary supplementation, for example via fortified foods like Thriposha or CSB, tablets/capsules etc, so as to attempt meeting, but not exceeding the RDS's of various critical nutrients. Hence, the RDAs are critical consideration when formulating supplementary feeding programme so undernourished children.

Policy and Intervention Shortcomings

It is apparent that the impact of government efforts on childhood IDA is inadequate, despite their existence for decades. In fact the unacceptable prevalence of IDA in the country bear testament to this. The following is a brief examination of the policy and existing efforts.

National supplementary feeding (Thriposha) programme: the Thriposha Programme was a pioneering initiative in South Asia to provide a cereal-based, vitamin and mineral-fortified supplementary food to undernourished children and pregnant/lactating women.

However, the programme has had its resources stretched so much over the past thirty years that it is now speculated to serve only around 60% of the deserving child population, and that too at nutritionally inadequate ration quantities.

The Thriposha Programme's ineffectiveness in improving the iron status of children is clear when one sees that IDS levels in beneficiary children are not significantly different from non-beneficiary children.

This is most likely due to the fact that eligible children are rationed only 50 grams of Thriposha per day (distributed on a monthly basis).

Further the Thriposha Programme is capable of targeting only those children under-five who are clinically determined to be undernourished (based on their weight and age), despite ID's prevalence even in otherwise better-nourished children.

This means that a significant proportion of IDA-affected children are left out of Thriposha. The programme's implementation in the former conflict affected areas, where IDA is perceived to be in higher prevalence, is also irregular due to logistical issues.

Efforts to curb childhood helminthic infections:

Administering anti-helminthics to children also suffers the same financial and logistical constraints, though it should ideally be proved to all under

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