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WhyarethewomenofMeghalayaso
anaemic?
PUBLIC|THURSDAY,JUNE16,2016

BySandraAlbert

The prevalence of anaemia among women is often used as an indicator of nutritional

wellbeing of society. Meghalaya state has some of the poorest nutritional indicatorsin
the northeast region. The most recent district level family health survey (DLHS4,2013)
reports theprevalence ofanaemia as 71% in children (659 months), 42% inadolescents
(1519years),54%inwomen(1549years)and64%ofpregnantwomen.Thusmorethan
half our women are anaemic. Initially anaemia can be asymptomatic (no overt
manifestation) or it can cause weakness, easy fatigue, pallor, breathlessness, palpitations
and headaches. Iron deficiency anaemia is detrimental to the growth and mental
development of children.Amongpregnant women there isadefiniteassociationbetween
anaemia and poor maternal outcomes such as increased risk for heavy blood loss after
deliveryandlowbirthweightamongnewborns.

Iron is required for the production of hemoglobin, a protein present in red blood cells,
responsible for carrying oxygen from our lungs to every cell in ourbody. Intheabsence
of iron the body fails to make enough hemoglobin or red blood cells, resulting in iron
deficiency anaemia. Although anaemia can result from other causes, the majority are
related to iron deficiency. Anaemia can also result from deficiency of other
micronutrients like vitamin B12 and folate and from genetic factors (haemolytic
anaemias). All of these alternate causes are prevalent in Meghalaya but we do not know
to what extent. But iron deficiency remains the most frequent cause of anaemia in our
state. Iron deficiency results from lowdietary intake, low absorption or from conditions
thatcausechronicbloodloss(eg.wormsorulcers).

Were Meghalayaspeoplehealthierintimespast?Itappearssoifonereferstotheearliest
anthropological records of the Khasis, where they are described as a short statured but
wellnourished tribe. Of note with regards to the subject of anaemiais PRT Gurdons
(1914) observation that Khasis used pots madeofironforcookingvegetables.Theuseof

iron vessels in the past was not surprising as iron smelting was once a thriving local
industry. A research article in Current Science, that used radiocarbon dating and other
techniques to asses ancientiron slagfromtheKhasihillsreportedevidenceofcontinuous
iron smelting in theKhasi Hills spanning 2000 years.Like a remnant of this ancient art,
untila few years ago, one could observe afew blacksmithworkshopsalongtheMylliem
highway but suddenly they seem to have all disappeared! Over the years consumption
patterns have changed as have cooking processes. In the present day iron vessels have
largely beenreplacedbytheubiquitousaluminiumvessels.ObservationofKhasikitchens
and jadoh shops demonstrates a fondness for aluminium utensils which Khasi women
take pride in keeping ashine. Thus almost insidiously a potentially superior indigenous
practicegotreplacedbysomethingshinyandwhite.

Do cooking patterns and utensils matter?Aclue to this canbeseeninastudyamongthe

!Kungbushmen of Botswana, Southern Africa who used iron cooking vessels in their
normal cooking practices. Investigators reported low prevalence of iron, folate, and
vitamin B12 deficiency among this group, when compared with more economically
advanced populations. This despite some of them having parasites such as hookworms
(that often contribute to anaemia through chronic blood loss). The absence of anaemia
among the !Kungwas attributed to the dietary iron intake being supplemented by iron
derived fromtheircookingpots.AdownsidewasdocumentedamongtheBantutribewho
inappropriately used these vessels for brewing alcoholic beverages, where it proved
harmfulasitcontributedtoironoverload.

The governments health departmentshave been trying to amelioratethehighprevalence

of anaemia amongst our people through two measures one to give iron supplements
(pills) to all pregnant women and more recently the newly introduced weekly iron
supplementation scheme among adolescents and children. When a person is iron
deficient, it certainly warrants some form of urgent amelioration such as providingiron
supplements. But can or should this be a long term strategy? Questions of public health
relevance should ideallybe addressed onthe basis of welldesignedstudies that produce
good quality evidence that is relevant locally and within contexts. Sadly this is not
something we as a nation pays sufficient attention to, our health research budgets are
miniscule to say the least. But on the topic of iron supplementation and anaemiathere is
someemergingevidencethatquestionsoldacceptednotions.

In a handful of controlledstudies from Africa, investigators have found that dietaryiron

fortification resulted in a significant increase in diseasecausing gut bacteria that cause
diarrhoea in children supplemented withironascomparedwiththosewithoutdietaryiron
supplementation. Those given iron were found to have increased markers for intestinal
inflammation. This isnoteworthy as one of themost commonly given anecdotal reasons

for noncompliancewith iron supplementation in pregnancy in Meghalaya is intestinal

irritation and stomach upsets. In other words iron supplementation is not asharmless as
once assumed, it can alter the normal profile of gut microbes and promote potentially
disease causing microbial flora. Recentlyanotherinteresting association was reported by
researchers in Karnataka pregnant women who were not anemic but who took the
routinely recommended iron supplementation gave birth to lowbirth weightbabies. The
authors conclude that rather thana uniform approach, anindividualised approach to iron
supplementationinpregnancymaybewarranted.

There isanadditionalsidethatneedstobeconsidered,itisnotjustthepresenceofironin
the diet butalso the ability of thebody to absorb itas a nutrient. For instance onesdiet
may have sufficient iron but its absorption (bioavailability) can be hampered by the
immediate drinking oftea withameal.Teainparticularinterfereswithabsorptionofiron
from vegetable sources. On the other hand simple measures like squeezinglemon juice
(ascorbic acid) or consuming othervitamin Crich itemsalongwith ameal can improve
ironabsorptionfromthefoodbeingconsumed.

The Food & AgricultureOrganizationoftheUNreiteratesthatanutritiousdietisthebest

approach to combat all forms of malnutrition. While food supplements can be used for
specific dietary deficiencies in the short term, interventions that are food based and
involve dietary diversification are proposed as better alternatives. A few NGOs in
Maharashtra have demonstrated how anaemia can be improved through home kitchen
gardens. Through this intervention, anaemiaamongnotjustwomenbutothermembersof
families improved considerably, average consumption of vegetables increased and
medical bills reduced. Sustained alternative efforts such as improving dietary diversity
through kitchen gardens, wild edibles, delaying teadrinking after a meal, and awareness
raising measures need to be made in parallel to current efforts so that long term
sustainablesolutionscanbefound.
(TheauthoristheDirector,IndianInstituteofPublicHealthShillong,PHFI)
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