Iron deficiency is the most prevalent micro-nutrient insufficiency in the world today (1). This disorder is one of the most important factors leading to higher mortality rates in deve-loping countries. Due to its high prevalence, iron deficiency anemia is one of the problems threat-ening the health of the people (2, 3). Anemia is the second cause of mortality and morbidity and leads to the death of one million people a year.
Three quarters of deaths in Africa and South Asia, and 2.4% of disability-adjusted life years (DALY) have been associated with anemia (3).
According to WHO and World Bank categor-ization, anemia is considered the third cause of DALY in women aged 15-44 years. Treatment of anemia in developing countries costs 4.4% of the Gross Domestic Product (GDP) (3, 4).
In 2005, WHO announced the spread of iron deficiency anemia 9% and 43% in developed and developing countries, respectively. One billi-on and 620 million people in the world suffer from anemia. About 293 million of them are pre-school children, and 56 million and 468 million are pregnant and non-pregnant women, respect-ively; approximately, 85% are from Africa and Asia. Of all countries, the incidence of anemia is the highest in India (3).
Pregnant women have the highest demand for iron among all. This requirement starts from 1.9 ml/1000 kcal in the daily diet of the second trimester, and gets to 2.7 ml/1000 kcal in each day of the third trimester of pregnancy. The required amount of iron is 1 ml for infants who are breastfed, 0.8 ml for teenage girls, 0.6 ml for teenage boys and non-pregnant women, 0.4 ml for the pre-school and school children, and 0.3 ml for adult men (3).
Iron plays an important role in the develop-pment of nervous system, especially during growth years. Iron deficiency leads to various health conditions such as physical, behavioral and cognitive disorders in pre-school and school children (4). Different studies in developing countries have shown that almost all pregnant women in the second half of their pregnancies, and 40% of school children suffer from iron deficiency anemia (4). In some of these count-ries, parasitic infections, malaria, AIDS, and tuberculosis are worsening the situation.
Due to the significant impact of iron on physical functional capacity, iron deficiency ane-mia reduces the capacity of the whole popula-tion and interferes with social development (4). Controlling anemia leads to a 20% increase of national production in developing countries. However, since this disease is being controlled in industrialized countries, the situation is diffe-rent in these countries. The disease is mostly controlled by the improvement of public health and health indicators, decreasing malnutrition, and controlling parasitic diseases and malaria (4).
WHO has categorized different countries, based on the prevalence of anemia. According to this categorization, countries are divided into 3 groups with low (under 20%), medium (20%-39%), and high prevalence (more than 40%) of anemia. Among developing countries, India has the highest prevalence of iron deficiency ane-mia. Fifty eight percent of pregnant women, 50% of non-pregnant women (and the women who do not breastfeed), 56% of teenage girls, 30% of male adults, and 80% of children under two years of age suffer from iron deficiency in India. Twenty percent of direct maternal deaths and 20% of indirect maternal mortality in India are due to iron deficiency anemia. Seven out of 10 children in India present with iron defici-ency; 3% and 40% have high and moderate anemia, respectively (3).
Iran, as one of the developing countries, is considered to be at the medium level (20% -39%) of anemia prevalence. A study conducted in 2009 in Iran, showed that the prevalence of anemia in school girls aged between 7 and 12 years is about 15%; its prevalence in rural areas is more than the urban regions (5). The overall estimate of anemia prevalence was %13.6 and nearly 29.1% in Iranian pregnant women and children, respectively (5-7).
In 2012, The Ministry of Health in UK reported that almost 3% of men and 8% of women have iron deficiency anemia in England. The data show that 11% of non-pregnant wom-en (aged 16 to 49 years old) have iron deficie-ncy, and that 3%-5% of the whole population suffer from iron deficiency anemia (8).
The protocols in these three countries are designed based on the general health condition of that particular country. For instance, in India, the focus is on preventive measures to control anemia together with enriching the nutrition, increasing the sanitation of drinking water and controlling malaria. The protocol regarding India includes the highest number of instruct-tions, and greatest costs and cooperation betw-een ministries and different sections. This prot-ocol was issued in 1995, and 14 ministries and governmental organizations were involved to execute the instructions. Moreover, anemia-controlling program in India is reviewed every 12 years to decrease anemia prevalence up to 50% in young girls.
In Iran, this protocol was issued in 2002, and two ministries were involved to execute the instructions. Therefore, a committee was form-ed in each province and followed the program once a month; afterwards, the number of meet-ings gradually decreased. The priority of the program was female boarding schools, and the committee presented the report of the process. The program was executed step-by-step and started from November 2002 until May 2002.
In England, anemia prevalence is at the minimum level, therefore, implementing preve-ntive measures to control this disease from childhood till the time of delivery a baby in adulthood has not been recommended. Due to the significant role of iron efficiency in physical and cognitive functions, and the universal importance of eradicating iron deficiency, this comparative review was performed regarding the situation of anemia and various iron supp-lementary programs in India, Iran, and England. This study also aimed to gain an insight into the approaches of different countries towards iron supplementation protocols.
Materials and Methods
The present study is a comparative review to examine and compare the existing protocols of iron supplementations in three countries of India, Iran and England. In order to identify the frameworks adopted in these countries, WHO/ World Bank categorization was utilized. According to this classification, countries are divided into four groups, based on the prevalence of anemia:
1. Normal countries in which the prevalence of iron deficiency anemia is less than 5% such as Canada and Italy, and some industrialized countries including Germany and France,
2. Low-prevalence countries (with 5%-19.9% iron deficiency anemia) e.g. England, United States, New Zealand, Japan, and Australia,
3. Medium-prevalence countries (with 20%-39.5% iron deficiency anemia) such as Iran, Pakistan, and countries in North Africa and parts of Central America,
4. High-prevalence countries (with more than 40% iron deficiency anemia) such as India,
Central Africa, and some countries in South America.
The reviewed countries in this study were India, Iran, and England. The main reason for selecting these three countries was to study iron deficiency anemia with three different levels of prevalence (low, medium and high). According to the latest categorization of WHO in 2008, India has the highest level of iron deficiency anemia with more than 49%, Iran is at the medium level with 20%-39%, and England with 5% - 19% has a low prevalence of iron deficien-cy anemia (3).
In order to collect the data, PubMed, WHO/ World Bank ranking, BMJ Center reports, and data distributed by health ministries were used. The countries were compared with respect to anemia prevalence, preventive protocols, and treatment strategies for the newborns, children between 1-4 years of age, teenagers, and preg-nant women. Comparative tables were provided as the basis for detecting similarities and differ-ences between the three countries.
All the mentioned countries have set long-term targets to monitor the prevalence, treat-ment and preventive protocols related to ane-mia. The implementation of the programs has being regularly examined in all these countries; for instance, examining the protocols in India is carried out every 12 years, in Iran every year, and in England every five years.
The underlying reasons for anemia in the aforementioned countries are different. In India, lack of iron-rich diets (e.g. no consumption of red meat due to religious beliefs), epidemics of parasitic diseases like malaria, and poor health indices such as unavailability of safe drinking water and low levels of hygiene (3) are the most significant risk factors for anemia in children.
In India, the reasons for iron deficiency anemia in women are: not consuming iron-rich foods; using food products containing non-heme iron-like vegetables; drinking tea and coffee; consuming calcium-rich products which prevent the absorption of iron; not using iron supplem-ents during menstruation; decrease of iron stor-age due to frequent pregnancies, deliveries, postpartum bleedings, and teenage pregnancy; losing iron because of malaria; poor health conditions; and finally unavailability of safe drinking water (3).
Since Iran is a large country, measuring the prevalence of anemia in its different regions is a difficult task. A comprehensive study in Iran showed that the highest prevalence of anemia is observed in children studying in the third grade of elementary school. The elementary school students who lived in Tehran in 2010 had the highest prevalence of anemia among 31 provin-ces of Iran (10, 11). A study conducted in 2008 showed that anemia prevalence in female school students within the age range of 7-12 years was about 15%.
The level of iron deficiency in pregnant women was different in various regions of Iran; it was between 13% and 40% in different prov-inces with different socio-economic status. Preg-nant women, 6-month to 2–year-old children, teenage girls aged 11-19 years, and pre-term newborns were the target groups of iron deficie-ncy preventive program in Iran (10). Table 1 shows the prevalence of iron deficiency anemia in high-risk groups of the reviewed countries.
In England, anemia is mostly observed in cities where the immigrant children from developing countries reside (8, 9). Anemia is generally seen in the immigrant children from Africa and South Asia who live in Birmingham. The medium prevalence of anemia was 27% in 1985, and decreased to 19% after 10 years. In England, anemia is observed in 6-month to 2-year-old children whose main source of nutria-tion is cow’s milk (4, 8). The average spread of anemia in England is estimated as 12%.
Different measures have been taken in England which have great impacts on decreasing anemia. These measures include: improving the absorption of nutrients; decreasing the consum-ption of cereals which hinder iron absorption; increasing nutrients which help with iron absor-ption such as animal-derived foods; increasing the consumption of processed iron-rich foods, especially for children; and taking supplements with high-iron absorption.
Late marriage, having the first pregnancy after the age of 25 years, taking contraceptive pills for long periods of time, and decrease in the number of pregnancies and deliveries are the effective factors in lowering the prevalence of anemia in developed countries such as England (2, 4, 8-9).
Table 2 compares the preventive and treatment protocols of anemia prevalence in high-risk groups in the studied countries; these groups include children, 10-19-year-old adolesc-ents, pregnant and lactating women, and women in their reproductive age.
There are some differences between the programs implemented in India and Iran; for instance, folic acid is less recommended for children in Iran in comparison with India (50 mcg vs. 100 mcg). Moreover, the duration of anemia preventive program for Iranian children is limited to two years; after this period, three-month examinations (in a year) are performed for six years. However, in India, it includes the whole childhood period.
It seems that in England, infant-formula feeding is more common than breastfeeding, since eating cereal which is enriched by iron is recommended for two years. In comparison with Iran, iron supplementation program for adolescents in India, not only recommends high-er doses of iron and folic acid, but is also mandatorily implemented for boys and girls. However, in Iran, iron supplementary program is optional for boys, and the family can provide them with the necessary iron. Also, the dosage of iron and folic acid is lower than the Indian program; England has no particular program designed for this population.
Using Iron supplements for pregnant wom-en in these three countries is completely differ-ent both in terms of dosage and anemia screen-ing program. India and Iran have no program for screening pregnant women, whereas in England, prescription of iron is limited to women who have a history of hemoglobinopathy, and those with ferritin lower than 30(mg/L). Unlike Engl-and, the programs of India and Iran include routine iron supplementation during pregnancy and lactating period. There is also a plan for preventing anemia in women during their reproductive age in India and Iran, while England has no plan in this regard.
Anemia is a widespread public health problem with major consequences for human health as well as social and economic development. It is the world’s second leading cause of disability and is responsible for about 1 million deaths in a year, of which three-quarters occur in Africa and Southeast Asia. Physical and cognitive losses due to iron deficiency anemia cost developing countries up to 4.05% loss in GDP per year, thereby delaying social and economic developments (10, 12). In young children, iron deficiency is a result of increased iron requirement due to rapid growth, which is almost 10 times higher (per kilogram of body weight) than that of an adult male.
Children who suffer from anemia have delayed psychomotor development and impaired performance. In addition, they experience impa-ired coordination of language and motor skills, equivalent to a 5–10 point deficit in intelligence quotient (IQ) (3, 4, 8). The consequences of anemia in women are devastating as the condi-tion adversely affects both their productive and reproductive capabilities. It is estimated that about 20% of maternal mortality is caused by anemia worldwide. Furthermore, anemia contri-butes partly to 50% of all maternal deaths (3, 4).
The present study reviewed different strate-gies implemented for the prevention and treat-ment of anemia in high-risk groups, and studies different preventive principles. By comparing the protocols, one can see the differences betw-een high-risk groups in these three countries.
The differences in the rate and risk factors of pregnant women mortality in three countries show the variations in preventive measures to control anemia. For instance, 20%- 40% of direct deaths of Indian pregnant mothers and about 20% of Iranian maternal deaths are due to anemia. Therefore, there are no filtering progra-ms in these two countries in order to identify the anemia of pregnant women, and all mothers should benefit from iron supplementary progra-ms during pregnancy, according to the recomm-ended regimens (11, 12).
India is experiencing more iron deficiency anemia due to various reasons such as not eating red meat, consuming significant amounts of milk and dairy products, and increased risk of parasitic diseases and malaria. Therefore, taking albendazole is recommended as an important anti-parasitic drug in India; this medication is used along with preventive programs in India, though it has not been recommended in Iran and England (8, 12).
According to WHO instructions, if the prevalence of parasitic diseases is higher than 30% in a country, people who are more likely to get iron deficiency anemia should benefit not only from iron supplementary but also anti-parasitic programs (3). In England, high-risk groups are not those at the age of puberty, but are children under two years of age, who are mostly the children of immigrants, low-income families, and those subsidized by the govern-ment.
Having reviewed the operational instruct-tions for controlling anemia in different countr-ies, we can conclude that:
1. Preventive programs and policies are affected by health indicators and conditions of each country e.g. safe drinking water.
2. The main purpose of these programs is to reduce the incidence of anemia, and the related consequences in risky groups.
3. In all countries especially the developed ones, the program of iron supplementation is carried out for free for the low-income people. In Iran and India, the supplementary programs have been provided for pre-school children by The Ministry of Health and Family Welfare. After the age of six, the program is provided by the schools during the academic year. In Iran this protocol is regularly executed during the first 16 weeks of the academic year. If the time of program implementation coincides with the fasting month of Ramadan, students will be educated to follow the instructions, as soon as they break their fast. In England, this program is provided for free only for the low-income families, however, in Iran and India, it is costfree for all high-risk groups.
4. The success of iron supplementary program is not only dependent on the performance of one single program, but the cooperation of all sections is also required. The collaborative attempts of the ministries of Education and Health & Family Welfare of India, and Ministry of Health and Medical Education of Iran are good examples.
5. In low-income countries, the most important and cost-effective practice is nutritional enrichment; also, the iron supplementary programs should be improved. Although in low-income countries, iron-fortified foods are more effective than iron supplementary programs, these programs are executed in developed countries. The reason seems to be the omission of some high-risk groups; for instance, no supplementary program is imple-mented for people during their pubertal age in England (14, 15).
6. Improvement of health indicators is associated with the success of anemia management. Control programs which include accessibility
to safe drinking water are considered to be of high importance (3, 10).
7. In all the studied protocols in this review, the duration of the programs was limited, between 5 to 12 years.
8. The program was free of charge for three high-risk groups of pregnant women, children under two years of age, and high school female students in developing countries of Iran and India. In England, it was free for low-income pregnant women and children under two years of age (3, 14).
Anemia is an indicator of both poor nutria-tion and poor health condition. The review of iron supplementation protocols in three countri-es of India, Iran and England showed that the protocols were different regarding the prevale-nce of anemia in the community, particularly for high-risk groups. The status of public health, availability of safe drinking water, and also prevalence of various diseases like anemia, parasitic diseases, and malaria were the major reasons for the observed differences. Program strategies focus on iron supplementation, and change according to local conditions. This study showed that in low-income countries, the most cost-effective practice is nutritional enrichment, which has already been implemented in developed countries.
Conflict of Interest
No conflict of interest exists.