In this study, researchers compare sachet count or self-reporting forms to electronic devices for measuring adherence to daily home fortification with micronutrient powders (MNP) and measure the association between each adherence assessment method and change in hemoglobin concentration. To measure MNP use among young Kenyan children, parents were given a medication event monitoring system (MEMS), a self-reporting form, and were also instructed to keep empty sachets. Researchers found that self-reporting and sachet count were associated with over-reporting compared to monitoring using MEMS. When adherence was measured with MEMS, children with high adherence had higher hemoglobin at the end of the intervention compared to those with low adherence. However, this association was not seen when adherence was measured by self-report or sachet count, suggesting assessment by the electronic device is more reliable.
Anemia Resource Review
The Anemia Resource Review is a selection of materials that will help you keep on top of research and developments related to strengthening multisectoral approaches to preventing and controlling anemia. To see materials from earlier editions, or to view resources from across SPRING's technical areas, visit the Resource Review.
Researchers evaluated the accuracy of anemia diagnosis using HemoCue Hb 201+ wicking and gravity blood sampling methods and a noninvasive device. Venous blood samples taken from Rwandan children 6-59 months of age compared these three methods against a standard reference measured with a hematology analyzer. Results showed that the HemoCue gravity method was the most accurate. However, use of the HemoCue gravity method in low-resource settings is limited, while the use of the noninvasive method requires less training of health workers and can increase patient and caregiver acceptability, reduce the risk of infection, and reduce the burden on supply, making the non-invasive method promising for use in low-resource settings.
This study assessed IFA supplementation programs in seven countries to better understand barriers and enablers for improved coverage and utilization of IFA supplements during pregnancy. Researchers conducted focus-group discussions and interviews with women, health care providers, and social influencers to analyze knowledge, attitudes, and practices associated with IFA supplementation. Authors concluded that there is a need to strengthen demand for antenatal care, especially during the first trimester, and to create an environment where IFA supplementation adherence is normalized. In addition, improved delivery of IFA supplementation (including the use of community-based delivery and counseling) and supply chain management are necessary for reducing systemic barriers.
Hepcidin is a liver-derived hormone discovered in the late 2000s, considered to be the master regulator of iron. The article describes the interaction of hepcidin and ferroportin (a cellular iron exporter) and highlights that prolonged inflammation reduces bioavailable iron and makes supplemented iron less effectively absorbed, potentially causing iron deficiency and anemia. Prior to this discovery, most research focused on dietary factors leading to iron deficiency and anemia. With the new understanding of the role of hepcidin, researchers acknowledge the importance of infection and inflammation, providing better evidence for effective preventative and therapeutic interventions to address iron deficiency and anemia.
This study compared the accuracy of HemoCue Hb301 versus XT-1800i, Mindray BC-3000Plus, or both automated analyzers combined. Researchers collected capillary and venous blood from Laotian children ages 6-23 months to compare hemoglobin measurement across methods. Authors concluded that HemoCue showed bias toward high hemoglobin concentration compared to the automated analyzers, meaning use of HemoCue resulted in a significantly lower prevalence of anemia. Because HemoCue is commonly used in field settings, further research is needed to better train phlebotomists and implement appropriate standardized practices to ensure accurate hemoglobin assessment.
This study examined three food fortification programs in Latin America to identify lessons learned for the design and implementation of successful fortification programming. Researchers gathered data on the history of food fortification programs in each country and information on factors that contributed to successes and challenges the programs faced. Authors found that the highly centralized milling industry in each country and willing industry buy-in were factors that supported program success. In addition, the presence of institutions with good research capacity and champions of fortification were important for program success. The study concluded that fortification programs should consider these contextual factors, develop private/public partnerships, and ensure appropriate contextual program design and comprehensive monitoring and evaluation.
The WHO recommends exclusive breastfeeding of infants for six months after birth. Breastmilk contains all the nutrients an infant needs in the first six months of life but is low in iron. This cross-sectional study sought to determine if the duration of exclusive breastfeeding is associated with anemia and iron deficiency in Kenyan infants. Researchers tested for hemoglobin, plasma ferritin, sTfR, and C-reactive protein in 134 infants, and collected data on age, gender, duration of exclusive breastfeeding, weaning foods, and level of income. Months of exclusive breastfeeding was significantly correlated with both hemoglobin (positively correlated) and sTfR (negatively correlated), suggesting that in infants in rural Kenya, longer exclusive breastfeeding is associated with better iron status.
This study assessed anthropometric measurements and developmental and laboratory outcomes in children born to women who received daily iron and folic acid (IFA) supplementation, twice weekly IFA, or twice weekly multiple micronutrient (MMN) supplementation (all with 60 mg of elemental iron) during pregnancy. At 36 months of age, children of mothers provided with low-dose iron supplementation during pregnancy (twice weekly IFA or MMN) had lower heights, lower height-for-age z-scores, and lower motor composite scores at 36 months than children of mother provided with daily IFA. Authors concluded that daily IFA has beneficial effects on child growth at 36 months of age in comparison with low-dose supplementation.
Researchers conducted a systematic review and meta-analysis to assess the effect of vitamin A supplementation (VAS) on iron status biomarkers and anemia in children, teenagers, and pregnant or lactating women. Results showed that VAS was significantly associated with a reduced risk of anemia and increased levels of hemoglobin. However, no association was observed between VAS and prevalence of iron deficiency, despite increased levels of ferritin. Authors concluded that VAS may reduce the risk of anemia by improving levels of hemoglobin and ferritin in individuals with low serum retinol levels.
This study evaluated the effects of adjusting prevalence of iron deficiency and iron deficiency anemia (IDA) for inflammation alone versus inflammation and malaria during low and high malaria transmission seasons. Venous blood samples were collected from Zambian children during the low malaria and high malaria seasons, respectively. Researchers found that, at a population-level, correcting for malaria and inflammation accounted for statistically significant changes in the estimated prevalence of iron deficiency and IDA, suggesting that by adjusting for both factors, the reliability of iron deficiency and IDA prevalence estimates within and across malaria seasons can be improved.
Current hemoglobin thresholds used to define anemia were originally proposed by the WHO in 1968. Informed by data from studies of predominantly white European and North American populations, these thresholds failed to account for variations such as the method of measurement, geography, race, and age. Recognizing the critical impact these guidelines have in both clinical and public health practice, a group of anemia experts from low-, middle-, and high-income countries convened to assess hemoglobin measurement and anemia definition guidelines. The group aims to develop new guidelines that ensure appropriate standardization of hemoglobin measurements across a range of methods and consider physiological, environmental, and genetic factors in determining appropriate thresholds.
This study evaluated sensitivity of a point-of-care (POC) immunoassay (Sickle SCAN) to diagnose sickle cell disease and a first generation POC color-based assay to detect anemia, in comparison to their respective laboratory-based gold standards. Researchers collected blood samples from Tanzanian children 21 years of age or younger who were at risk for sickle cell disease or anemia. They compared the POC sickle cell assay to hemoglobin electrophoresis results and the POC anemia assay to automated hematology analyzer results. Even when used by providers who were unfamiliar with the assay, the sickle cell disease POC assay provided excellent sensitivity. The hemoglobin POC assay (measuring anemia) was less accurate than the sickle cell assay. However, its specificity was still more effective than using clinical signs to diagnose anemia.
Reports, Tools, and Other Related Materials
Globally, vitamin A deficiency impacts an estimated 250 million preschool-age children, yet tools to enable early diagnosis are often not available in low resource settings. Cornell engineers and researchers recently developed a low-cost rapid test to measure inflammation and iron and vitamin A deficiencies at point of care, with a test duration of 15 minutes. The team’s work was published in December in the Proceedings of the National Academy of Sciences.
Despite steps taken to address the global burden of nutrition, malnutrition and food insecurity remain critical issues, especially among women and children. The 2017 Global Nutrition Report highlights core areas of the Sustainable Development Goals that nutrition can both contribute to and benefit from, including sustainable food production, infrastructure, health systems, equity and inclusion, and peace and stability. The report sets a global agenda for addressing food security and malnutrition, including anemia among women of reproductive age, and establishes targets and indicators for monitoring progress to guide global efforts.
GAIN Executive Director Lawrence Haddad eloquently summarizes the key issues related to operationalizing micronutrient powders (MNP), drawing on information from SPRING’s report on a global technical consultation on operationalizing MNP, published in the journal Maternal and Child Nutrition, and GAIN’s systematic review on MNP adherence, published in Current Developments in Nutrition. He notes that MNPs are still a complex programming challenge, and the inherent difficulties in designing and implementing effective programs are exacerbated by lack of feedback data from program evaluations.
On the African continent, one in five people is chronically undernourished. This report reviews the current global situation and policy agenda, highlighting challenges to addressing malnutrition in Africa, and consolidates lessons learned from successful interventions and country programming. The report also notes the importance of exploring innovative approaches to addressing factors that undermine progress, including climate change, conflict, and infectious disease.
The WHO released new global guidelines on the use of preventive chemotherapy to decrease soil-transmitted helminth infection in children, adolescent girls, women of reproductive age, and pregnant women in endemic areas. Recommendations are intended to support policymakers and technical and program staff in designing, implementing, or scaling up programming.
HarvestPlus developed a new strategic plan detailing key activities and resources needed for scaling up biofortification over the next five years. The strategy was informed by an evidence-based analysis that identified 30 priority countries and 13 crops for biofortification with vitamin A, iron, and/or zinc. With these renewed efforts, HarvestPlus aims to reach 1 billion consumers with renewed efforts by 2030.
This book, which is free to download at the link below, examines the first 1,000 days and the impact of exposure to malnutrition, environmental enteropathies, and hormonal and other environmental stressors on long-term health outcomes. In the chapter “Requirements and Recommendations for Mineral Intakes During Pregnancy,” the author specifically discusses iron deficiency and anemia during pregnancy. The book also details interventions across disciplines for addressing poor conditions during this critical life stage.
This study explored the impact of providing salt fortified with iron and iodine to Indian children in second grade on anemia and cognition. Baseline and endline data were collected from children in the intervention and control groups, and fortified salt was delivered through the school feeding program to the intervention group over three months. Researchers found that children who received fortified salt were less likely to suffer from anemia and had higher school attendance. Reading and math outcomes were statistically insignificant; however, both were positively influenced by higher school attendance.
The Nutrition 2018 conference engages researchers, practitioners, global and public health professionals, policymakers, and advocacy leaders in sharing the latest research in nutrition. This year’s themes include physiological, clinical, and global/public health nutrition, population science, and food science and systems.
This symposium brings together stakeholders, including UN organizations, policymakers, researchers, health professionals, NGOs, and civil society organizations, to strengthen efforts to address the double burden of malnutrition. Participants will share research findings and experiences implementing policies and programs to identify necessary actions, new assessment tools, and important considerations for policies and planning. The symposium will cover five topics: epidemiology, biology, assessment, interventions, and policy implications.
The Food and Agriculture Organization (FAO) of the United Nations and the WHO recently released a web-based database to help fill the global gap in evidence on individual quantitative food consumption. On December 5, 2017, the Accelerated Reduction Efforts on Anaemia (AREA) Community of Practice (COP) hosted a webinar focusing on iron deficiency anemia (IDA), exploring how the tool can provide support for programmatic decision-making with food-based approaches to addressing IDA. In the recorded webinar, Victoria Padula de Quadros and Catherine Laclercq of FAO introduced the tool and shared examples of how it provides estimates of iron intake for children and women of reproductive age.
The 2018 SBCC Summit highlights the essential role SBCC plays in catalyzing change and making progress toward the Sustainable Development Goals. This year, the conference will be hosted in Bali, Indonesia from April 16-20th, and focuses on the theme “Shifting Norms, Changing Behavior, Amplifying Voice: What Works?” Participants at this conference will learn and share ways SBCC can support efforts to address some of the most persistent development challenges the world faces today. SPRING’s anemia team will present on their experiences with social behavior change communications piloted in conjunction with micronutrient powder distribution among children 6-23 months of age in rural Uganda.
The 28th World Nutrition Congress will focus on the theme “Promulgating Improved Innovations in Nutrition.” The conference, hosted in Manila, Philippines from August 9-10, 2018, will feature keynote presentations, plenary sessions, young researcher talks, poster presentations, nutrition workshops, and public healthcare sessions. Participants are encouraged to join this opportunity to discuss the most prominent challenges in nutrition and dietetics facing the world today.
Online Community Corner
The Accelerated Reduction Effort on Anaemia (AREA) Community of Practice (COP), facilitated by the United Nations System Standing Committee on Nutrition (UNSCN) and moderated by the U.S. Agency for International Development's (USAID’s) SPRING project, was launched in June 2015. The AREA COP provides a unique opportunity to connect with other professionals and stay abreast of the latest developments in anemia-related research, policy, and implementation. Since the AREA COP’s creation in May 2015, it has grown to more than 800 members from over 70 countries. The COP webinar series presents cutting-edge and timely topics to members based on their feedback and the latest happenings in the field.
On April 11, 2018, the COP will host its eighth webinar, entitled ”Changing the way we think about the cost-effectiveness of addressing childhood anemia.” Dr. Steve Vosti and Emily Baker will present on a costing study conducted in rural Uganda which explored two methods of micronutrient powder distribution for addressing iron deficiency anemia in children ages 6-23 months. Presenters will review key reasons why nutrition interventions should consider cost, important costs to consider, and what emerged from the nine-month pilot in Uganda. The webinar recording and slides will be made available online for those unable to attend.
In addition to hosting webinars, the COP disseminates anemia-related vacancies, training opportunities, conference announcements, recent publications, and reports, many of which are then discussed among members. On average, the COP circulates five discussion topics per month, which aim to keep members abreast of the science and programming behind multi-sectoral anemia control. In the last six months, the following are some of the topics that were shared among the group:
- An informative discussion was held on a shared article detailing evidence on iron safety.
- The COP hosted a webinar on using the FAO/WHO Global Individual Food Consumption Data Tool to understand and plan programs to combat iron deficiency-related anemia.
- Members engaged in a discussion on how to address high variability in HemoCue hemoglobin concentration measurement.
- An informative debate was held among members on the effectiveness and relevance of current vitamin A supplementation programs, which ultimately play a role in anemia control.
If you are not already a member, please join us by clicking the link below. You can also reach out on Twitter: @AREAnaemia
Websites to Watch
Feed the Future works across sectors and levels to improve incomes and nutrition, with a stated goal of reducing by 20% each the prevalence of poverty and the prevalence of stunted children in the areas in which they work.
FAQR, a USAID-funded project hosted at Tufts University, provides actionable recommendations on ways to improve nutrition among vulnerable people for whom the direct distribution of food aid can make a significant impact.
Working at country and global levels, FANTA provides comprehensive technical support to USAID and its partners. FANTA supports the design and implementation of programs in focus countries and strengthens the evidence base, methods, and global standards for food security and nutrition programming.
FFI is a multi-sector partnership helping countries plan, implement, and monitor grain fortification programs. FFI aims to use industrial food fortification to prevent neural tube defects and anemia caused by nutritional deficiencies.
GAIN is an alliance driven by the vision of a world without malnutrition and a mission to reduce malnutrition through sustainable strategies aimed at improving the health and nutrition of populations at risk.
The Global Atlas of Helminth Infections (GAHI) shows the geographical distribution of neglected tropical diseases transmitted by worms: soil-transmitted helminthiasis, schistosomiasis, and lymphatic filariasis. All GAHI resources are available on an open access basis.
HKI is a partner on SPRING and has a long history of working in anemia control as part of their larger portfolio in reduction of malnutrition.
Established by CDC in 2000, the International Micronutrient Malnutrition Prevention and Control (IMMPaCt) program works with global partners to contribute CDC skills and resources to eliminate micronutrient deficiencies (especially iron, vitamin A, iodine, folate, and zinc deficiencies) among vulnerable populations throughout the world.
MCSP advocates for greater attention to major and neglected barriers to optimal maternal and young child nutrition. Through different sectors and influential community members, MCSP works to identify new channels to increase the reach and scale-up of nutrition interventions within countries.
The Knowledge for Health (K4Health) Project aims to improve family planning and reproductive health services in low- and middle-income countries by working to change the way family planning knowledge is accessed, shared, and used. This toolkit recommends an integrated package of services to control the three major causes of anemia and provides background information related to these causes and guidance about implementing programs to address them. The toolkit also discusses maternal and child health programs that contribute to anemia.
The Micronutrient Initiative is the leading organization working exclusively to eliminate vitamin and mineral deficiencies in the world´s most vulnerable populations.
PMI is a key component of the U.S. Government's Global Health Initiative and strives to reduce the intolerable burden of malaria and help relieve poverty on the African continent.
REFINE is a knowledge-sharing mechanism that aims to improve food aid interventions. This repository houses ongoing and published studies on food aid products, programs, and processes.
Scaling Up Nutrition (SUN) is a movement bringing together governments, civil society, the United Nations, donors, businesses, and researchers around the principle that all people have a right to food and good nutrition. The SUN approach is strongly multisectoral and features country-level resources on nutrition-specific and -sensitive programs.
HF-TAG is a multisectoral community of stakeholders involved in home fortification with a vision of a world without malnourished children.
TMG is a partner on SPRING and has developed (in consultation with a Steering Committee of World Bank, WHO, and UNICEF) and advocacy strategy and materials to help convince people to tackle the problem of iron deficiency.
This website features the U.S. Government’s major investments in global health, including hallmarks like The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), The President’s Malaria Initiative (PMI), and Feed the Future (FTF).
UNICEF is a leading humanitarian and development agency working globally for the rights of every child. UNICEF believes all children have a right to survive, thrive, and fulfill their potential – to the benefit of a better world.
The United Nations System Standing Committee on Nutrition (UNSCN) is the food and nutrition policy harmonization forum of the United Nations. The mandate of the UNSCN is to promote cooperation among UN agencies and partner organizations in support of community, national, regional, and international efforts to end malnutrition in all of its forms in this generation. It aims to do so by refining the direction, increasing the scale, and strengthening the coherence and impact of efforts against global malnutrition.
Since at least the 1970’s, USAID has been involved in global efforts to address iron deficiency and anemia.
The WASHplus project supports healthy households and communities by creating and delivering interventions that lead to significant improvements in access, practices, and health outcomes related to water supply, sanitation, and hygiene (WASH) and household air pollution (HAP).