SPECIAL ARTICLE
Year : 2020 | Volume
: 64 | Issue : 3 | Page : 236--241
Evaluation of promotion of iron-rich foods for the prevention of nutritional anemia in India
Davendra K Taneja1, Sanjay K Rai2, Kapil Yadav3,
1 Ex Director Professor, Department of Community Medicine, Maulana Azad Medical College, New Delhi, India
2 Professor, Centre for Community Medicine, AIIMS, New Delhi, India
3 Additional Professor, Centre for Community Medicine, AIIMS, New Delhi, India
Correspondence Address:
Davendra K Taneja
Flat No. 1103, Tower 6, The Close North, Nirvana Country, Sector 50, Gurugram - 122 018, Haryana
India
Abstract
Background: Nutritional anemia due to iron deficiency is the most common cause of anemia in India. The average diet in India is low in iron and mostly of vegetable origin. This can be improved by increasing awareness of foodstuffs that are rich in iron and ensuring their availability. Objective: The objective of the study was to assess the quality of information available on iron-rich foods and to assess their production and consumption in India. Methods: This was a review of common textbooks for medical, nursing, and home science students; related policy and program documents; and government publications on production and consumption of various foodstuffs in India. Results: Details of specific foods that are rich in iron have not been provided. Instead, food groups such as pulses, cereals, nuts, and green leafy vegetables (GLVs) have been mentioned that are good sources of non-heme iron. This is in spite of the fact that all the foodstuffs in these groups are not uniformly iron rich. Among cereals and pulses, rice and red gram dal (arhar) are the most commonly produced and consumed, though they have the lowest iron content. Spinach and mustard leaves believed to be iron rich and commonly consumed are among those GLVs having lowest iron content. Conclusion: Details of 5–10 foodstuffs which have the highest iron content within each food group should be available in relevant books and documents meant for education, production, and consumption data.
How to cite this article:
Taneja DK, Rai SK, Yadav K. Evaluation of promotion of iron-rich foods for the prevention of nutritional anemia in India.Indian J Public Health 2020;64:236-241
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How to cite this URL:
Taneja DK, Rai SK, Yadav K. Evaluation of promotion of iron-rich foods for the prevention of nutritional anemia in India. Indian J Public Health [serial online] 2020 [cited 2023 Mar 22 ];64:236-241
Available from: https://www.ijph.in/text.asp?2020/64/3/236/295798 |
Full Text
Introduction
Anemia is a global public health problem in both developed and developing nations, affecting more than one-third of the World's total population.[1] It affects people from all age groups, geographies, and socioeconomic status. However, children and pregnant women from poor socioeconomic status are more vulnerable to it.[2] In India, more than 50% of children (58.6%), women of reproductive age (53.2%), and pregnant women (50.4%) are anemic.[3]
Anemia has several consequences on an individual's health as well as socioeconomic development of a nation. Nutritional anemia due to iron deficiency is the most common cause of anemia, although several other conditions such as nutritional deficiencies of folate, Vitamin B12 and Vitamin A, chronic inflammation, parasitic infections, fluorosis, and hemoglobinopathies significantly contribute to its prevalence. In its severe form, anemia is associated with fatigue, weakness, dizziness, and drowsiness.[2] Iron-deficiency anemia (IDA) impairs the cognitive performance, behavior, physical growth, immunity against infections as well as physical capacity and work performance.
Various strategies have been adopted to combat nutritional anemia in India which includes dietary diversification, food fortification, weekly iron and folic acid supplementation, improving infant and young child feeding practices, and promoting safe water, hygiene, and sanitation (WASH). Food diversification approach designed to increase micronutrient intake through diet represents the most desirable and sustainable method for preventing micronutrient malnutrition.[4],[5] Although heme iron derived from animal sources is better absorbed than non-heme iron derived from plant sources, whole cereals, whole pulses, and vegetables, particularly green leafy vegetables (GLVs), contribute to a significant intake of dietary iron in Indian diets.[6]
The objectives of the current study were (1) to assess the quality of information being provided with regard to the promotion of iron-rich foodstuffs among cereals, pulses, and GLVs and (2) to assess the availability and consumption of iron-rich foodstuffs in India.
Materials and Methods
It was planned to review information on iron-rich foodstuffs in (1) currently available common textbooks of community medicine and pediatrics for medical and nursing students and textbooks of nutrition and dietetics for home science students, (2) ICMR publications on dietary guidelines and requirements for Indians, and (3) policy and program documents.
Information on production and consumption of iron-rich foods was collected from published documents of National Sample Survey Office, Ministry of Agriculture and Ministry of Food and Civil supplies.
The information given in textbooks, policy, and program documents was then compared with information in Indian Food Composition Tables (ICMR 2017) about iron content in foodstuffs that are considered to be main sources of dietary iron in vegetarian diets consumed in relatively large quantities, for example, cereals, pulses, and GLVs.
For evaluating promotion of iron-rich foods, eight different textbooks[6],[7],[8],[9],[10],[11],[12],[13] and Indian Council Of Medical Research (ICMR) publication “Dietary Guidelines for Indians-A Manual. National Institute of Nutrition (2010)” were reviewed.
Policy and program documents
The following policy and program documents were reviewed for information about iron-rich foodstuffs for prevention of anemia – Anemia Mukt Bharat (AMB) Operational Guidelines (2018), National Health Policy (2017), National Nutrition Policy (1993), National Nutrition Strategy (2017), National Iron Plus Initiative (NIPI) Guidelines (2013), and National Plan of Action (2016).
Information on production and consumption
Information about production and consumption of iron-rich foodstuffs was collected from publications of National Sample Survey Office, Ministry of Statistics and Programme Implementation; Agricultural Statistics Division, Ministry of Agriculture; Indian Institute of Soybean Research; and Directorate of Pulses Development, Ministry of Agriculture and Farmers Welfare, Government of India.
Observations
Description in the text books
Textbooks for medical and nursing students: Park's Textbooks of Preventive and Social Medicine and Textbook of Community Medicine by Rajvir Bhalwar have mentioned food groups (dark GLVs, cereals, pulses, nuts and dry fruits) as main sources of non-heme iron in the diets along with factors which enhance and inhibit iron absorption in the body.[6],[7]
IAPSM's Textbook of Community Medicine by A. M. Kadri gives only tables of nutritive values of foodstuffs based on food composition tables by ICMR.[8]
Textbook of Preventive and Social Medicine by Gupta and Mahajan mentions intake of iron-rich foods such as GLVs. Besides, it suggests intake of foods that enhance bioavailability of iron and leavening of flour by yeast to reduce phytate in the food consumed, as it interferes with absorption of iron.[9]
None of these books specify iron-rich foodstuffs.
In the textbooks of Ghai's Essential Pediatrics and Review of Preventive and Social Medicine by Vivek Jain, there is no mention of the dietary sources of iron.[10],[11]
Textbooks for home science students: Food Science by B Sri Laxmi, mention only about GLVs as rich source of iron and specifies some of them.[12]
Nothing specific on iron-rich foods has been described in the Textbook of Nutrition in the Community by Arvind Wadhwa.[13]
Dietary Guidelines for Indians (2010) specify some of the GLVs like amaranth, Bengal gram leaves, cauliflower greens, and radish leaves besides legumes, dried fruits, meat, fish, and poultry. Some of the foodstuffs that enhance absorption of iron and those which inhibit its absorption have also been described.[14]
Description in policy and program documents
Most of the policy and program documents have mentioned the use of IFA supplementation, food fortification, deworming, early screening and detection, improving infant and young child feeding practices, and dietary diversification as potential strategies for combating nutritional anemia. However, only a few of them have provided some detail of iron-rich foodstuffs.
The National Nutrition Policy (1993) does not specify anything on consumption of iron rich foods. However, it does lay emphasis on increasing production of GLVs, guava and gooseberry.[15] The National Nutrition Strategy (2017) suggests an increased intake of dark GLVs and foods rich in Vitamin C.[16]
In the National Health Policy (2017), there is only a brief mention of dietary diversification and the use of micronutrient sprinklers for combating nutritional anemia. It lacks specific details on the consumption of iron- and Vitamin C-rich food items.[17]Policy on Control of Nutritional Anemia describes iron-rich foods as GLVs, cereals such as wheat, ragi, jowar and bajra, and pulses, especially sprouted pulses and gur (jaggery).[18]
NIPI Guidelines (2013) emphasizes the increased consumption of GLVs, lentils, whole pulses, jaggery, fruits, groundnuts, ragi, whole grains, milk, nuts, germinated seeds, and fermented products. It describes iron-rich foodstuffs such as chick pea, spinach, amaranth, onion stocks, mustard leaves, fenugreek leaves, mint leaves, colocasia leaves, lentils, black gram whole, soybean, gingelly seeds, red gram dal, green plantain, black gram dal, watermelon, pumpkin, and mutton. Besides this, it mentions foodstuffs that inhibit or facilitate iron absorption.[19]
In National Plan of Action (2016), iron- and folic acid-rich foodstuffs have not been specified.[20]
In AMB Operational Guidelines (2018), all the resource materials available on the AMB dashboard (such as posters, recipe booklet, pamphlets, and box playing cards, etc.) for different vulnerable groups visually depict various food items rich in iron as GLVs, whole and sprouted pulses, jaggery, egg, fish, meat, etc., and those rich in Vitamin C. At one place, fenugreek and amaranth leaves have been specifically mentioned. One resource material also depicts various food items that inhibit iron absorption and recommends their avoidance with main meals.[21]
Nutritive values of various cereals, pulses, and green leafy vegetables
As shown in [Table 1] and [Table 2], different cereals and pulses (except for soybean) provide calories and protein in similar quantities within their group with minor variations. Bajra, ragi, rice flakes (poha) wheat flour, and jowar provide a higher amount of iron than maize and rice. Rice has the lowest iron content.[22]{Table 1}{Table 2}
Horse gram dal, soybean, and moth beans provide as much as twice the iron in comparison to green gram dal and red gram dal. Top five pulses with respect to iron content are horse gram dal, soybean, moth beans, lentil (whole), and Bengal gram (whole).[22]
GLVs are considered to be rich sources of iron and calcium. As shown in [Table 3], beet greens, fenugreek leaves, pumpkin leaves, parsley leaves, and amaranth leaves have the highest iron content among GLVs.[22]{Table 3}
Other vegetables, fruits, condiments and spices, nuts, oilseeds, and sugar
Among the fresh spices and condiments, leaves such as curry (8.7 mg/100 g), mint (8.6 mg), parsley (5.5 mg), coriander (5.5 mg), and drumstick (4.6 mg) have high-iron content. Most of the fruits and vegetables, except lotus stem (3.3 mg iron/100 g), are a poor source of iron. Some of the nuts and oilseeds such as gingelly seeds (14.9 mg), mustard seeds (13.5 mg), cashew nuts (5.9 mg) and almond (4.5 mg), and jaggery (4.6 mg/100 g) are fairly rich sources of dietary iron.[22]
Heme sources of iron
Boiled egg yolk is rich in iron (4.9) as compared to egg white. Among poultry, chicken liver is the richest source of iron (9.9 mg/100 g) followed by duck meat (4.3 mg/100 g). Animal meat, particularly liver and spleen, is very rich source of iron. Fish on the contrary are not a very good source of iron.[22]
Food consumption patterns in India
Cereals and grains
Overall, rice accounted for about half of the cereals consumed in rural as well as urban areas, followed by wheat flour. The consumption of lesser cereals, namely jowar, bajra, and maize was low, being <10% of the total cereal consumption.[23]
Pulses and legumes
Per capita per day consumption of pulses was 26 g and 30 g in rural and urban areas, respectively. Consumption of four pulses, namely arhar, moong, masur, and urad accounted for more than 60% consumption of all the pulses. Of all the pulses, red gram dal (arhar) had the highest share of consumption in both rural (27%) and urban (33%) areas followed by masur (14%) in rural areas and moong (13%) in urban areas.[23]
Green leafy vegetables and other vegetables
The National Sample Survey Office provides consumption pattern of 17 vegetables including some of the GLVs clubbed under palak/others. However, separate figures for different GLVs are not available.[23]
Heme sources
Per capita consumption of heme sources of iron was higher in urban areas than in rural areas. Per capita consumption of egg was 0.45 and 0.74 per week, while for fish, mutton, beef, and chicken it was 18 g/day and 21 g/day in rural and urban areas, respectively.[23]
Fruits
Data on consumption of specific food items rich in Vitamin A and Vitamin C are not given in the NSS report. However, most commonly consumed fruits, nuts, and oil seeds both in rural and urban areas were apples, bananas, coconuts, and mangoes. Per capita consumption of fairly rich sources of Vitamin C such as orange/mausami and papaya was very less as compared to other fruits.[23]
Food production
Cereals and grains
As shown in [Table 4], rice and wheat accounted for most of the cereal production in India (44% and 39%, respectively) followed by maize (10.6%). Production of other cereals and millets such as jowar (1.4%), bajra (3.2%), ragi (0.4%), small millets (1.3%), and barley (0.6%) was very less.[24]{Table 4}
Pulses
As observed in the table, chickpea (safed chana), arhar, urad, and moong account for more than 80% production of pulses. Production of horse gram, moth, peas, and beans and lentils is low.[25] However, soybean production was estimated to be 11.39 million tonnes in 2017–2018.[26]
Green leafy vegetables
Separate figures for production of different GLVs are not available.
Discussion
Iron deficiency and associated anemia is a major public health problem in India. The program for its prevention and control is based on iron folic acid prophylaxis, treatment, deworming, and encouraging consumption of iron-rich foodstuffs which is the most desirable and sustainable method for preventing micronutrient malnutrition. Foods of vegetable origin are the main source of iron in diets of majority of Indian people.
Lack of description or description of broad food groups rather than specific foodstuffs that are rich in iron in the textbooks for medical, nursing, and home science students[6],[7],[8],[9],[10],[11],[12],[13] as well as policy and program documents[15],[16],[17],[20] could be an obstacle to dissemination of desired information to people by health and home science personnel, thereby affecting the consumption of iron-rich foods. Documents that provide incomplete details[14],[18],[21] also pose similar problem.
Although NIPI Guidelines[19] are the only one to provide details of foods rich in iron, some of the foodstuffs mentioned such as spinach, mustard leaves, watermelon, pumpkin, plantain (green), and red gram dal do not have high-iron content as per the ICMR food composition tables.[22]
On the positive side, poor bioavailability of iron from non-heme sources (such as cereals, pulses, and GLVs) and increased bioavailability from heme sources (such as egg, meat, and poultry) have been specified in most of the places. Some documents also highlight the role of iron enhancing and iron inhibiting food items to be consumed or restricted along with iron-rich food.
Rice which is a poor source of iron as compared to other cereals[22] accounts for nearly half of the total cereal consumption in India. On the contrary, consumption of coarse cereals, which are iron rich, is much less in spite of their availability as per the production data.[23] High nutrition benefits of coarse cereals point to the need for an increase in their consumption and even higher production.
Although from the perspective of dietary source of proteins, pulses are treated as one group with a narrow range of variation; however, iron content among them is quite variable. Pulses such as horse gram dal, soybean, moth, lentils, Bengal gram (whole and dal), rajmah, dry peas, black gram, and cow pea have much higher iron content than other pulses. Soybean has twice the iron compared to red gram dal (arhar). Arhar and moong, though lowest in iron content, account for more than a third of pulse production and consumption in the country.[22] Arhar dal which has the lowest iron content among the pulses is the one which is most commonly consumed and produced in the country.[23],[25]
Among the GLVs, those with very high-iron content, for example, beet greens, pumpkin leaves, colocasia leaves, and radish leaves are usually not consumed by people and rather used to feed cattle or discarded as waste. There are others such as curry leaves, mint leaves, parsley, coriander leaves, amaranth leaves, and drumstick leaves, though high in iron content,[22] are consumed either less frequently or in small quantities. Greens like spinach, mustard leaves, and bathua leaves though popular in Indian homes are those with the least iron content.[22] Separate figures for production and consumption of different GLVs are also not available.
Thus, there is a need to provide details of specific cereals, pulses, GLVs, and other rich sources of dietary iron such as nuts and oilseeds in textbooks for medical, nursing, and home science students as well as policy and program documents and other related health education and information materials. Health education with regard to those items that are not usually consumed in different population groups will require area-specific approach considering their availability. Behavior change will also need demonstration of recipes for items not being usually consumed but are fed to cattle or are discarded. One practical approach will be to provide a menu for home-cooked lunch with one iron-rich food on each of the school days, for example, Monday to Saturday to the students. This is likely to have a positive effect on the family dietary practices too.
Jaggery, though rich in iron (4.6 mg iron per 100 g),[22] is usually consumed in small amounts. Promoting traditional Indian snacks like gur chana or tilbugga prepared from jaggery and Bengal gram or gingelly seeds can contribute to significantly higher intake of jaggery and thus iron.
To ensure adequate availability of individual iron-rich cereals, pulses, and GLVs and Vitamin C rich fruits and vegetables, it is essential that data for cereals, pulses, GLVs, and fruits may be collected for individual foodstuffs in these groups at the state and national levels and policies and programs directed for greater production of those with higher iron content. Greens like mint, parsley, coriander, and curry leaves can be easily grown in the kitchen gardens. These efforts along with other measures will help in the long run toward the reduction of problem of iron deficiency and associated anemia.
Promotion of individual iron-rich cereals, pulses, or GLVs does not compromise on calories, protein, or calcium intake, thus allowing for selective promotion of iron-rich foods within these entities.
Conclusion
Encouraging consumption of iron-rich foods is the most desirable and sustainable method of prevention of IDA. A review of common textbooks for medical, nursing, and home science students and various policy and program documents and those pertaining to food production and consumption in India mention the broad food groups and usually do not describe specific foodstuffs rich in iron. In this context, some of the foodstuffs which are relatively poor in iron in their groups like milled rice, red gram (arhar), green gram, spinach, and mustard leaves are commonly consumed in the country and some with fairly good iron content like beet greens, radish, pumpkin, and colocasia leaves are either used to feed cattle or are discarded as waste. Thus, iron-rich foodstuff-wise description in all relevant documents is essential to ensure their adequate availability and consumption.
Acknowledgment
The authors would like to thank Dr. Gomathi Ramaswami, Senior Research Officer, and Ms Kashish Vohra, Research Officer, who helped in literature search and review.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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