Anemia and iron deficiency in rural Bangladeshi pregnant women living in areas of high and low iron in groundwater

The geo-spatial perspective of biological, social and environmental determinants of early pregnancy anaemia in rural Sri Lanka: Need for context-specific approaches on prevention

We provide a novel approach to understanding the multiple causations of maternal anaemia in a geospatial context, highlighting how genetics, environment and socioeconomic disparities at the micro-geographical level lead to the inequitable distribution of anaemia. All first-trimester pregnant women registered for the antenatal care programme in Anuradhapura District, Sri Lanka from July to September 2019 were invited to the Rajarata Pregnancy Cohort (RaPCo), which assessed the prevalence of anaemia in early pregnancy. The combination of the prevalence of anaemia and minor haemoglobinopathy-related anaemia (MHA) with the poverty headcount index of the 22 health divisions in the district was investigated using GeoDa spatial K-means clustering. Sociodemographic and economic data at the divisional level were compared between identified clusters. Combining the analysis with the geographical and environmental characteristics of the region, further hypotheses regarding anaemia in this community were formulated. The study included data from 3,137 pregnant women in early pregnancy. The anaemia and MHA prevalence varied from 13.6 to 21.7% and from 2.6% to 5%, respectively. We identified four distinct spatial clusters. The cluster with the highest anaemia prevalence also included high poverty and the highest prevalence of MHA. The clusters had significant differences with regard to ethnic distribution, access to water, sanitation and dietary patterns. Areas supplied by major irrigation projects had significantly low levels of anaemia, probably attributable to internal migration and improved livelihood. It was evident that genetic, socioeconomic and environmental risk factors were grouped at the divisional level, and that their complex interactions make controlling anaemia with blanket interventions unsuccessful. Analysis of the distribution of heterogeneous risk factors at the micro-geospatial level helped identify context-specific approaches to tackle anaemia in pregnancy.

Ideal Dose of Iron in Multiple Micronutrient Supplement: A Narrative Review of Evidence

Anemia is a significant public health problem in low- and middle-income countries (LMICs). The co-existence of other micronutrient deficiencies and iron deficiency among pregnant women may be the reason for the inability to control anemia through iron and folic acid (IFA) supplementation. Multiple micronutrient supplementation (MMS) in pregnancy may help to overcome this problem. However, the recent World Health Organization (WHO) guidelines on MMS supplementation in pregnancy raised concerns regarding the adequacy of a 30mg iron dose in the MMS supplements in LMICs. The review summarized the literature to answer this question. Though most studies showed a comparable effect of MMS with 30mg iron and IFA with 60mg iron on maternal anemia outcomes, anemia persisted in the third trimester in both groups. There is a need to consider the use of a higher iron dose in MMS, especially in LMICs, to combat the problem of anemia, alongside correcting other micronutrient deficiencies.

Prevalence and Risk Factors of Vitamin B12 Deficiency among Pregnant Women in Rural Bangladesh

Vitamin B12 deficiency is associated with an increased risk of pregnancy complications and adverse birth outcomes. However, data on vitamin B12 deficiency in pregnant Bangladeshi women are limited. This study examines vitamin B12 deficiency and marginal deficiency in rural Bangladeshi women during early and late pregnancies. Some 522 women whose gestational age was <20 weeks were recruited. Serum vitamin B12 concentrations were measured at baseline and after 14 weeks of iron-folate supplementation. Logistic regression analysis examined the association of various socio-demographic, dietary, and pregnancy-related factors with vitamin B12 deficiency and marginal deficiency. Overall, 19% of the women during early pregnancy had vitamin B12 deficiency (serum vitamin B12 concentration < 203 pg/mL) and nearly 40% had marginal deficiency (serum vitamin B12 concentration 203 to <300 pg/mL). Vitamin B12 deficiency doubled to 38% during late pregnancy, while marginal deficiency slightly increased to 41.7%. The pregnant women with a gestational age of ≥27 weeks had a higher risk of developing vitamin B12 deficiency (OR = 2.61; 95% CI = 1.096−6.214) than those of a gestational age of <27 weeks. Vitamin B12 deficiency was significantly higher in pregnant women in rented accommodation (OR = 13.32; 95% CI = 1.55−114.25) than in those living in their own house. Vitamin B12 deficiency was significantly higher among women who consumed red or organ meat <3 times a week than in those who consumed it more often (OR = 2.327, 95% CI = 1.194−4.536). None of these factors were significantly associated with marginal vitamin B12 deficiency. In conclusion, vitamin B12 deficiency and marginal deficiency among pregnant rural Bangladeshi women increased as their pregnancies progressed. Increasing gestational age, living in a rented house, and the consumption of red or organ meat <3 times a week were identified as the independent risk factors of vitamin B12 deficiency in this population. Further research with more in-depth assessments of dietary vitamin B12 intakes is needed to develop an intervention program preventing vitamin B12 deficiency in this population.

Consumption of animal source foods, especially fish, is associated with better nutritional status among women of reproductive age in rural Bangladesh

In rural Bangladesh, intake of nutrient-rich foods, such as animal source foods (ASFs), is generally suboptimal. Diets low in nutrients and lacking in diversity put women of reproductive age (WRA) at risk of malnutrition as well as adverse birth outcomes. The objective of this study was to assess the relationship between maternal dietary diversity, consumption of specific food groups and markers of nutritional status, including underweight [body mass index (BMI) < 18.5 kg/m² ], overweight (BMI ≥ 23 kg/m² ) and anaemia (haemoglobin < 120 g/dl) among WRA in Bangladesh. This analysis used data from the third round of a longitudinal observational study, collected from February through May of 2017. Dietary data were collected with a questionnaire, and Women's Dietary Diversity Score (WDDS) was calculated. Associations between WDDS, food group consumption and markers of nutritional status were assessed with separate adjusted logistic regression models. Among WRA, the prevalence of underweight, overweight and anaemia was 13.38%, 40.94% and 39.99%, respectively. Women who consumed dark green leafy vegetables (DGLV) or eggs were less likely to be anaemic or underweight, respectively, and women who consumed ASFs, particularly fish, were less likely to be underweight compared with women who did not consume these foods. WDDS did not show any consistent relationship with WRA outcomes. Interventions that focus on promoting optimal nutritional status among WRA in Bangladesh should emphasise increasing consumption of specific nutrient-rich foods, including ASFs, DGLV and eggs, rather than solely focusing on improving diet diversity in general.

Iron content of drinking water is associated with anaemia status among children in high groundwater iron areas in Bangladesh

OBJECTIVE

Iron in groundwater provides a good source of absorbable iron for humans and can contribute to optimal iron and haemoglobin (Hb) status among populations. We aimed to examine the relationship between the iron content of groundwater and anaemia status among 12- to 23-month-old children in a rural area of Bangladesh.

METHOD

A cross-sectional study was conducted in 80 randomly selected unions (the lowest administrative unit) in Sylhet and Moulvibazar districts of Bangladesh. A total of 800 children aged 12-23 months were selected via a systematic random sampling method. The child's age, sex, stunting status, consumption of iron-rich or iron-fortified food, maternal age and maternal body mass index (BMI) and the type of terrain were subjected to multiple logistic regression analysis to observe the independent relationships between groundwater iron content and anaemia in children.

RESULTS

In total, 50.4% of children were anaemic. The odds of children being anaemic were 1.51-fold higher [OR: 1.51 (95% CI: 1.09, 2.09)] among households consuming water with an iron content <2 mg/L than in households consuming water with an iron content ≥2 mg/L. Childhood stunting, child's sex, child's age and the type of terrain were also significantly associated with anaemia among children.

CONCLUSION

Groundwater with a high iron concentration was significantly associated with a decreased risk of childhood anaemia. This study provides evidence of the importance of groundwater iron to protect impoverished young children from anaemia.

Anemia among pregnant women in internally displaced camps in Mogadishu, Somalia: a cross-sectional study on prevalence, severity and associated risk factors

BACKGROUND

Anemia in pregnancy is a serious global public health problem in most developing countries and a major cause of maternal morbidity and mortality. Somalia which already had very high maternal mortality ratio of 829 per 100,000 live births, pregnant women in internally displaced camps (IDPs) remain at most exposed. The aim of the study was to determine the prevalence, severity and associated risk factors of anemia among pregnant women in internally displaced camps in Mogadishu, Somalia.

METHODS

A community based cross-sectional study was conducted among 383 households in the most IDP settled districts in Mogadishu. Every pregnant mother in these sampled households who was voluntarily consented was targeted. A sample of blood was also taken by pricking the fingertip and inserted into hemoglobin meter. Those with Hb < 11 g/dl from hemoglobin meter had been taken another sample of 3 cc blood and put into EDTA tube for CBC analysis to identify the type of anemia. Data on risk factors were collected using structured pretested questionnaire via an interview. Collected data was coded and entered in SPSS- Version 22 for analysis. Descriptive analysis, bivariate chi-square and multivariate logistic regression were done.

RESULTS

The overall prevalence of anemia among study participants was 44.4% (95%CI: 39.5-49.3%), where severe and moderate anemia were 11.8 and 47.0% respectively. In addition all anaemic cases were microcytic hypochromic anemia. Young maternal age, low Family income, fewer/zero parity, being at third or second trimesters, lack of ANC attendance during pregnancy, lack of iron supplementation during pregnancy, taking tea immediately after meal during pregnancy, lower/zero frequency of daily meat and vegetables consumption during pregnancy were associated risk factors of anemia.

CONCLUSION

The anemia prevalence from this study was severe public health problem. Several factors were found to be associated with anemia during pregnancy. Measures has to be taken to curb the problem by including them mass iron supplementation and health education towards identified risk factors.

Social support, nutrition and health among women in rural Bangladesh: complex tradeoffs in allocare, kin proximity and support network size

Malnutrition among women of reproductive age is a significant public health concern in low- and middle-income countries. Of particular concern are undernutrition from underweight and iron deficiency, along with overweight and obesity, all of which have negative health consequences for mothers and children. Accumulating evidence suggests that risk for poor nutritional outcomes may be mitigated by social support, yet how social support is measured varies tremendously and its effects likely vary by age, kinship and reproductive status. We examine the effects of different measures of social support on weight and iron nutrition among 677 randomly sampled women from rural Bangladesh. While we find that total support network size mitigates risk for underweight, other results point to a potential tradeoff in the effects of kin proximity, with nearby adult children associated with both lower risk for underweight and obesity and higher risk for iron deficiency and anaemia. Social support from kin may then enhance energy balance but not diet quality. Results also suggest that a woman's network of caregivers might reflect their greater need for help, as those who received more help with childcare and housework had worse iron nutrition. Overall, although some findings support the hypothesis that social support can be protective, others emphasize that social relationships often have neutral or negative effects, illustrating the kinds of tradeoffs expected from an evolutionary perspective. The complexities of these effects deserve attention in future work, particularly within public health, where what is defined as 'social support' is often assumed to be positive. This article is part of the theme issue 'Multidisciplinary perspectives on social support and maternal-child health'.

Anemia among Women Who Visit Bost Hospital for Delivery in Helmand Province, Afghanistan

Background

Anemia is a global public health problem that affects a large number of pregnant women worldwide. In developed and developing countries, the number of pregnant women who become anemic ranges between 18% and 56%, respectively. The aim of this study was to determine the prevalence of anemia and factors associated with anemia among pregnant women who visit Bost Hospital for delivery in Helmand province, Afghanistan.

Methods

This was a hospital-based cross-sectional study that included 787 pregnant women who visited Bost Hospital for delivery services from January to June 2019. Data was collected in a self-structured questionnaire, which included sociodemographic, obstetrics, and laboratory information. Data was analyzed using SPSS 21.00 Statistical software. The prevalence of anemia was presented as a percentage. Bivariate analysis and binary logistic regression were used to identify the predictors of anemia among pregnant women.

Results

The overall prevalence of anemia in this study was 51% (95% CI = 48.7%–54.7%). The mean hemoglobin concentration among the study participants was 10.8 (±1.8) g/dL. On bivariate analysis, age group 30 years and above, rural residency and unemployment/housewives, multiparity, and no previous use of contraceptive were found to be associated with anemia. Binary logistic regression showed that multiparity (AOR = 3.09, 95% CI = 1.81–5.29) and no contraceptive use (AOR = 1.53, 95% CI = 1.08–2.16) were the independent predictors of increased anemia among pregnant women.

Conclusion

Anemia was found to be a severe public health problem in the study area. Policymakers in Afghanistan must accelerate interventions to promote family planning. The need for prospective studies is also suggested to identify other factors associated with anemia among pregnant women.

Assessing the influence of land use on groundwater pollution based on coefficient of variation weight method: a case study of Shuangliao City

In this study, the quality of groundwater was tested in 95 sampling wells in Shuangliao City. Based on the results, the coefficient of variation method was used to calculate the comprehensively evaluated value F, and the grade of groundwater quality, in accordance with the actual scenario in the study area, was classified according to the results of the evaluation. The spatial distribution of groundwater quality types in the study area was classified. In addition, the influence of human activity on each groundwater subsystem was assessed. Combined with the land use types in the study area, the Circle model was used to extract the land use types in the circular buffer zone with a radius of 500 m, and the Kendall rank correlation test was used to analyze the influence of the land use types on the spatial distribution of groundwater pollution. Based on the coefficient of variation, the groundwater quality standard was divided into four sections considering the actual scenario: ≤ 0.92 (I), 0.92~≤ 1.75 (II), 1.75~≤ 2.40 (III), and > 2.40 (IV). Water from class II was considered the main type for groundwater quality. NO₃^-, TFe, and Mn were deemed the main indexes of groundwater pollution. Further, land use type was found to have a great influence on the spatial distribution of groundwater pollution; specifically, dry land, paddy field, areas with dense traffic, and residential areas are the main land types that affect the groundwater environment.

Effect of Micronutrient Powder (MNP) with a Low-Dose of Iron on Hemoglobin and Iron Biomarkers, and Its Effect on Morbidities in Rural Bangladeshi Children Drinking Groundwater with a High-Level of Iron: A Randomized Controlled Trial

Micronutrient Powder (MNP) is beneficial to control anemia, but some iron-related side-effects are common. A high level of iron in the groundwater used for drinking may exacerbate the side-effects among MNP users. We conducted a randomized controlled trial examining the effect of a low-dose iron MNP compared with the standard MNP in children aged 2–5 years residing in a high-groundwater-iron area in rural Bangladesh. We randomized 327 children, who were drinking from the “high-iron” wells (≥2 mg/L), to receive either standard (12.5 mg iron) or low-dose iron (5.0 mg iron) MNP, one sachet per day for two months. Iron parameters were measured both at baseline and end-point. The children were monitored weekly for morbidities. A generalized linear model was used to determine the treatment effect of the low-dose iron MNP. Poisson regressions were used to determine the incidence rate ratios of the morbidities. The trial was registered at ISRCTN60058115. Changes in the prevalence of anemia (defined as a hemoglobin level < 11.0 g/dL) were 5.4% (baseline) to 1.0% (end-point) in the standard MNP; and 5.8% (baseline) to 2.5% (end-point) in the low-dose iron MNP groups. The low-dose iron MNP was non-inferior to the standard MNP on hemoglobin outcome (β = −0.14, 95% CI: −0.30, 0.013; p = 0.07). It resulted in a lower incidence of diarrhea (IRR = 0.29, p = 0.01, 95% CI: 0.11–0.77), nausea (IRR = 0.24, p = 0.002, 95% CI: 0.09–0.59) and fever (IRR = 0.26, p < 0.001, 95% CI: 0.15–0.43) compared to the standard MNP. Low-dose iron MNP was non-inferior to the standard MNP in preventing anemia yet demonstrated an added advantage of lowering the key side-effects.

Dietary Factors Moderate the Relation between Groundwater Iron and Anemia in Women and Children in Rural Bangladesh

BACKGROUND

Anemia affects ∼1.6 billion people worldwide, often owing to iron deficiency. In Bangladesh, high levels of anemia have been observed alongside little iron deficiency. Elevated concentrations of groundwater iron could constitute a significant source of dietary iron.

OBJECTIVE

We aimed to quantify the effect of groundwater iron on anemia in nonpregnant women and young children in Bangladesh, taking into account dietary factors that may affect iron absorption.

METHODS

We analyzed data on 1871 nonpregnant women and 987 children (6-37 mo) from the 2015 baseline survey of the Food and Agricultural Approaches to Reducing Malnutrition cluster-randomized trial in Sylhet, Bangladesh. We used logistic regression with robust standard errors to assess effects of self-reported groundwater iron, dietary intake, and sociodemographic characteristics on anemia, considering interactions between groundwater iron and dietary factors.

RESULTS

Groundwater iron presence was associated with less anemia in women (OR: 0.74; 95% CI: 0.60, 0.90) and children (OR: 0.58; 95% CI: 0.44, 0.76). This effect was modified by dietary factors. In women, the effect of groundwater iron on anemia was stronger if no vitamin C-rich or heme-iron foods were consumed, and there was a clear dose-response relation. In children, intake of vitamin C-rich foods strengthened the effect of groundwater iron on anemia, and there was no evidence for interaction by intake of iron-rich foods.

CONCLUSIONS

Heme-iron and vitamin C consumption reduced the effect of groundwater iron on anemia among women but not children in Bangladesh, which may be due to higher levels of iron deficiency and lower levels of iron intake among children. Vitamin C consumption appears to enhance iron absorption from groundwater in children and they may thus benefit from consuming more vitamin C-rich fruits and vegetables. Even among women and children consuming heme-iron or vitamin C-rich foods and groundwater iron, anemia prevalence remained elevated, pointing to additional causes of anemia beyond iron deficiency.This trial was registered at clinicaltrials.gov as NCT02505711.

Effect of routine iron-folic acid supplementation among rural pregnant women living in low- and high-groundwater-iron areas in Bangladesh

OBJECTIVE

The present study investigated the risks and benefits of routine Fe-folic acid (IFA) supplementation in pregnant women living in low- and high-groundwater-Fe areas in Bangladesh.

DESIGN

A case-controlled prospective longitudinal study design was used to compare the effect of daily Fe (60 mg) and folic acid (400 μg) supplementation for 3·5 months.

SETTING

A rural community in Bangladesh.

PARTICIPANTS

Pregnant women living in low-groundwater-Fe areas (n 260) and high-groundwater-Fe areas (n 262).

RESULTS

Mean Hb and serum ferritin concentrations at baseline were significantly higher in pregnant women in the high-groundwater-Fe areas. After supplementation, the mean change in Hb concentration in the women in the low-groundwater-Fe areas (0·10 g/dl) was higher than that in the pregnant women in the high-groundwater-Fe areas (-0·08 g/dl; P = 0·052). No significant changes in the prevalence of anaemia or Fe deficiency (ID) in either group were observed after IFA supplementation; however, the prevalence of Fe-deficiency anaemia (IDA) decreased significantly in the women in the low-groundwater-Fe areas. The risk of anaemia, ID and IDA after supplementation did not differ significantly between the groups. None of the participants had Fe overload. However, a significant proportion of the women in the high- and low-groundwater-Fe areas remained anaemic and Fe-deficient after supplementation.

CONCLUSION

IFA supplementation significantly increased the Hb concentration in pregnant women living in the low-groundwater-Fe areas. Routine supplementation with 60 mg Fe and 400 μg folic acid does not pose any significant risk of haemoconcentration or Fe overload. Further research to identify other nutritional and non-nutritional contributors to anaemia is warranted to prevent and treat anaemia.

Modulatory Effect of the Supplemented Copper Ion on In Vitro Activity of Bovine Lactoferrin to Murine Splenocytes and RAW264.7 Macrophages

Bovine lactoferrin (LF) was supplemented with Cu²⁺ at three contents of 0.16, 0.32, and 0.64 mg/g LF, respectively. After then, LF and Cu-supplemented LF products were assessed for immuno-modulation in murine splenocytes and RAW264.7 macrophages, using dose levels of 10-40 μg/mL and four evaluation reflectors including stimulation index of splenocytes, T lymphocyte subpopulations, macrophage phagocytosis, and cytokine secretion. The results indicated that LF and Cu-supplemented LF products had suppression on splenocytes as well as concanavalin A (ConA)- or lipopolysaccharide-stimulated splenocytes; however, using lower Cu-supplementation content (i.e., 0.16 mg/g LF) and lower dose level (10 μg/mL) alleviated this suppression significantly (P &lt; 0.05). Compared to LF, Cu-supplemented LF product of lower Cu-supplementation content at lower dose level yielded slightly enhanced macrophage stimulation, increased CD4⁺/CD8⁺ ratio of T lymphocyte subpopulations in ConA-stimulated splenocytes, and significant secretion enhancement for interleukin-2 (IL-2), IL-4, interferon-γ (in splenocytes), IL-1β, and tumor necrosis factor-α (in macrophages) (P &lt; 0.05). Furthermore, Cu-supplemented LF product of higher Cu-supplementation content (i.e., 0.64 mg/g LF) at higher dose level mostly showed opposite effects in the cells, in comparison with its counterpart at lower dose level. It is concluded that Cu-supplementation of LF can alleviate or increase LF's effects on the two immune cells, and moreover, Cu content of supplemented LF is a key factor that modulates these effects.

Maximising benefits and minimising adverse effects of micronutrient interventions in low- and middle-income countries

Micronutrient deficiencies are widespread and disproportionately affect women and children in low- and middle-income countries (LMIC). Among various interventions, food fortification and supplementation with micronutrients have been proven to be cost-effective. The aim of the present paper is to review existing literature to assess risks of excessive intake in LMIC to then highlight programmatic changes required to maximise benefits of micronutrient interventions while minimising risks of adverse effects. While very few LMIC have national food consumption surveys that can inform fortification programmes, many more are implementing mandatory fortification programmes. The risks of inadequate micronutrient intakes were common, but risks of excessive intakes were also present for iodine, vitamin A, folic acid and iron. Excessive salt consumption, high concentrations of iodine in ground-water and excessive levels of iodisation were linked with excessive iodine intake. For vitamin A, overlapping interventions were the main risk for excessive intake; whereas for iron, contamination with iron from soil and screw-wares of millers and high iron concentration in drinking-water increased the risk of excessive intake, which could be further exacerbated with fortification. Before implementing micronutrient interventions, adherence to the basic principles of documenting evidence confirming that the deficiency in question exists and that fortification will correct this deficiency is needed. This can be supported with dietary intake assessments and biochemical screening that help diagnose nutrient deficiencies. Targeting micronutrient interventions, although programmatically challenging, should be considered whenever possible. Moreover, closer monitoring of appropriate fortification of foods and overlapping interventions is needed.