A major health problem in Assam

Dr. Dharmakanta Kumbhakar

(The writer can be reached at drkdharmakanta@yahoo.com)

A good health depends to a large extent on balanced diet which maintains the nutritional status. Most of the poor people of Assam are deprived of a balanced diet. Moreover, in today's age, time has become more valuable than nutrition. We eat on the run, we grab a bite; pizzas and burgers are becoming lunch options and a hastily put together junk recipe is replacing a traditional balanced meal. Adding to this poisonous fare, pollution and adulteration are depleting the nutritive value of all food sources. The result of these factors is an avalanche in the prevalence of nutritional deficiencies, the chief among which is nutritional anaemia.

In Assam, nutritional anaemia is recognised as a major health problem as it is widespread among children, adolescent girls and boys, women of reproductive age, pregnant women and lactating mothers in different districts of the State, mirroring overall high rates of undernutrition. As per the Fourth National Family Health Survey (NFHS-4) 2015-16, an estimated 35.7% of 6 to 59-months-old children in Assam are anaemic. Approximately 46.0% of all 15 to 49-years-old adult women in Assam are anaemic. In rural areas, the situation is marginally worse (46.3%). The NFHS-4 records that 46.1% non-pregnant woman of reproductive age (15-49 years) and 44.8% of pregnant women are anaemic in Assam. Almost all of them suffer from nutritional anaemia. The NFHS-4 also records that 25.4% of 15 to 49-years-old adult men suffer from nutritional anaemia in Assam. These figures are high in all the districts of Assam which have tea gardens. It indicates that the problem of nutritional anaemia is worse among the tea garden population of Assam than others. The latest data as per NFHS-5, 2019-20 is yet to be published.

The most common type of nutritional anaemia in Assam is iron deficiency anaemia (IDA) and less frequently folic acid and vitamin B12 deficiency anaemia due to low dietary intake of iron and folic acid (IFA) and vitamin B12, improper absorption of IFA and vitamin B12, increased demand of IFA during pregnancy and lactation and other related causes such as hook-worm infestation. IDA occurs when iron stores in the body get depleted and haemoglobin synthesis is inhibited. Folic acid or vitamin B12 deficiency is implicated in the aetiology of nutritional anaemia as these are needed for the formation and growth of red blood cells.

Anaemia is a reduction in the oxygen-transporting capacity of blood from lungs to different tissues and organs of the body due to reduction of haemoglobin concentration in the red blood cell mass to below-normal amounts. Anaemia can lead to reduced productivity, increased susceptibility to infections and slow recovery from illnesses. Nutritional anaemia has detrimental effects on the health of children, adolescent girls, women of reproductive age, pregnant women and lactating mothers. Nutritional anaemia in children can result in impaired cognitive performance, behavioural and locomotor development, coordination, language development and scholastic achievement thereby severely implicating human development besides increasing morbidity from infectious diseases. Adolescent girls need extra IFA for physiological and biological changes associated with age to prepare them for childbearing in due course of time and, in the longer term to reduce nutritional anaemia in older women of reproductive age. Incidence of nutritional anaemia in adolescent girls and women can result in weakness, diminished physical and mental capacity and increased morbidity from infectious diseases. In pregnant women, nutritional anaemia may become the underlying cause of maternal mortality and perinatal mortality. Forty per cent of all maternal and perinatal deaths in Assam are linked to nutritional anaemia especially IDA. IDA also results in an increased risk of premature delivery, low birth weights and infant mortality. Iron deficiency in late pregnancy results in poor foetal iron stores, which may alter brain iron content and neurotransmitters irreversibly in foetal life and postnatal babies.

Most of the children, adolescent girls and boys, women of reproductive age, pregnant women and lactating mothers of Assam are vulnerable for these adverse consequences of nutritional anaemia as it is most prevalent in the State. Nutritional anaemia in adult men decreases the productivity and per capita income of the State.

The Assam Government is providing free IFA supplement to all pregnant women, lactating mothers, adolescent girls and children to prevent nutritional anaemia and its adverse consequences under the National Anaemia Control Programme for the last two decades. They often run some special drives to make Assam nutritional anaemia-free. Despite the measures taken, there is very slow decline in the prevalence and adverse consequences of nutritional anaemia in Assam and till date it is a major health problem in the State.

The coverage under IFA supplementation is low in Assam as majority of pregnant women don't receive IFA tablets always, only one-third of those who receive the tablets take them regularly, less than 10% take more than 90 tablets of IFA during pregnancy. The free distribution of IFA tablet amongst school children of the State is also poor. There has been poor access and intake of IFA syrup by children, inadequate training of frontline health workers and inadequate counselling of mothers.

Therefore, redressing nutritional anaemia among the vulnerable groups in the State requires an urgent attention. The anaemia control programme needs to be implemented more efficiently in Assam. New innovative strategies are the need of the hour to make IFA readily available as well as the mechanism to motivate the vulnerable groups to regularly take IFA supplements. The low compliance of IFA supplementation is particularly due to the side effects associated with IFA preparations. Taking IFA preparations on empty stomach can cause gastritis, abdominal cramp, vomiting and passage of black stool. The good news is that combined food and IFA supplementation can reduce the side effects associated with IFA preparations. The combined food and IFA supplementation programme would be most effective to address nutritional anaemia in Assam.

Of course, only free combined food and IFA supplementation programme cannot iron out nutritional anaemia from Assam. It is the time to collectively iron out nutritional anaemia from the State with awareness, balanced diet and proper supplementation. Some important steps along with combined food and IFA supplementation to deal with this major public health problem may be dietary diversification ensuring inclusion of iron-folate-vitamin B12 rich food, inclusion of food items that promote iron absorption, food fortification with IFA, screening for early detection of nutritional anemia among vulnerable groups and appropriate management of nutritional anaemia. The Government should provide nutritional support to meet the recommended dietary allowances for vulnerable groups through Aanganwadi programmes. There must be proper implementation of integrated programme for hookworm eradication, proper sanitation, etc. The nutritional anaemia amongst the adult male population in Assam must be corrected to increase productivity and per capita income; so that the families get nutritious food and Assam becomes nutritional anaemia-free.