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Objective This study aims to design and apply modules and flipchart about nutritional anemia and Chronic Energy Deficiency (CED) for bride in the Bugienesse Culture “mappacci”. Method this study applied a qualitative method with a case study design. The informants were selected by purposive sampling. Steps of research: (1) Fostering Atmosphere for Family Welfare Empowerment (PKK) Activist, (2) Explaining Module to community leader and flipchart to Cadres, (3) Testing media feasibility to adolescents, (4) Intervening contents of module to Master of Ceremony (MC) during Mappacci, and (5) Evaluating goals (bride). This study was analyzed by using content analysis. Results 2 modules were arranged with symbols and typical Bugienesse language for MC and community leader (Pacci giver), and 1 flipchart for PKK cadres. Teenagers understood the contents of the media and were interested in innovation of health education according to local wisdom. MC and community leader were able to explain nutritional anemia and CED information based on the module to bride. Most educated brides could identify the signs and risks of nutritional anemia and CED, as well as the importance of supplements for pregnant women. Conclusion educational innovation succeeded in giving early understanding about nutritional anemia and CED prevention to bride.

Iron deficiency anemia (IDA) continues to be major public health problem in India. It is estimated that about 20% of maternal deaths are directly related to anemia and another 50% of maternal deaths are associated with it. The question, therefore, is why, despite being the first country to launch the National Nutritional Anemia Prophylaxis Programme in 1970, the problem of IDA remains so widespread. As is to be expected, the economic implications of IDA are also massive. The issues of control of IDA in India are multiple. Inadequate dietary intake of iron, defective iron absorption, increased iron requirements due to repeated pregnancies and lactation, poor iron reserves at birth, timing of umbilical cord clamping, timing and type of complementary food introduction, frequency of infections in children, and excessive physiological blood loss during adolescence and pregnancy are some of the causes responsible for the high prevalence of anemia in India. In addition, there are other multiple programmatic and organizational issues. This review, therefore, is an attempt to examine the current burden of anemia in India, its epidemiology, and the various issues regarding its prevention and control, as well as to offer some innovative approaches to deal with this major health problem.

Previous short-term supplementation studies showed no additional hematologic benefit of multiple micronutrients (MMN) compared with iron + folic acid (IFA) in adolescent girls. This study examines whether long-term once- or twice-weekly supplementation of MMN can improve hemoglobin (Hb) and micronutrient status more than twice-weekly IFA supplementation in anemic adolescent girls in Bangladesh. Anemic girls (n = 324) aged 11-17 y attending rural schools were given once- or twice-weekly MMN or twice-weekly IFA, containing 60 mg iron/dose in both supplements, for 52 wk in a randomized double-blind trial. Blood samples were collected at baseline and 26 and 52 wk. Intent to treat analysis showed no significant difference in the Hb concentration between treatments at either 26 or 52 wk. However, after excluding girls with hemoglobinopathy and adjustment for baseline Hb, a greater increase in Hb was observed with twice-weekly MMN at 26 wk (P = 0.045). Although all 3 treatments effectively reduced iron deficiency, once-weekly MMN produced significantly lower serum ferritin concentrations than the other treatments at both 26 and 52 wk. Both once- and twice-weekly MMN significantly improved riboflavin, vitamin A, and vitamin C status compared with IFA. Overall, once-weekly MMN was less efficacious than twice-weekly MMN in improving iron, riboflavin, RBC folic acid, and vitamin A levels. Micronutrient supplementation beyond 26 wk was likely important in sustaining improved micronutrient status. These findings highlight the potential usefulness of MMN intervention in this population and have implications for programming.

Nutritional anemias are important because they are easily reversed and because their underlying causes, most often unrelated to dietary intake, require individualized assessment. Iron-deficiency anemia (IDA) usually results from iron losses accompanying chronic bleeding, including loss to intestinal parasites, or from gastric disorders or malabsorption in the elderly. Cobalamin-deficiency anemia, the only nutritional anemia with predilection for the elderly, nearly always stems from failure of intrinsic factor (IF)-related absorption. Folate-deficiency anemia, the only nutritional anemia usually caused by poor intake, has nearly disappeared in countries that fortify food with folic acid. Copper-deficiency anemia, which usually results from malabsorptive disorders or from medical or nutritional interventions that provide inadequate copper or excess zinc, is uncommon but increasingly recognized. The prevalences of nutritional anemias, which are not always distinguished from non-anemic deficiency, are uncertain. The mean corpuscular volume (MCV) provides an essential diagnostic tool leading to judicious matching of relevant biochemical changes with relevant anemia. Nutritional anemias usually feature abnormal MCV, whereas the predominant anemias in the aged, especially the anemias of chronic disease/chronic inflammation (ACD/ACI), of renal failure, and of unknown causes, are typically normocytic.

Iron deficiency is a common nutritional disorder in developing countries and contributes significantly to reduced work productivity and economic output as well as to increased morbidity and mortality. There are well established biochemical tests for assessing iron status in developed countries. However, cost and interference from infectious conditions make it difficult to assess iron status in many developing country settings. Examination of the hemoglobin distribution in the population and assessment of the hemoglobin response to supplementation are alternative approaches to defining iron status and the nature of anemia. Prevention and control of iron deficiency requires the combined approach of dietary improvement, fortification of a common staple food when feasible, and appropriate iron supplementation for infants and pregnant women. In all these intervention activities, operational research is needed to improve effectiveness. In addition, controlling iron deficiency requires coordination with other nutrition and primary health care programs as part of an integrated approach to improved health and nutrition of the population.

Nutritional adequacy is an integral part of national and social progress. Nutritional ignorance has been documented as an important contributor to malnutrition in Africa in general, and in Kenya in particular (1-4), where problems of protein energy malnutrition, nutritional anemia, and vitamin A deficiency are especially apparent. After independence was gained in 1963, the Kenya government established a nutrition policy aimed at correcting the malnutrition problems found within the country, with improvement of the nutritional status of the poor as one of its highest priorities (4). Health services were expanded to emphasize preventive and promotive health programs that gave attention to nutrition education and the training of personnel to carry out these programs (5). To implement these programs, an in-service training program was established in 1967, with the first trainees recruited from existing cadres of enrolled nurses and midwives. Upon completion of a nine month in-service course in community nutrition, the trainees were given the title of Nutrition Field Workers (NFWs) and were posted to health centers and hospitals throughout the country. They were expected to assist families by teaching them about the nutritional values and possible uses of available foods and resources. In 1983, as a result of the changing and increased demands on services of the Nutrition Field Workers, the nine month in-service training program was replaced by an expanded two year pre-service training program for high school graduates. Upon completion of the training program they are given the title of Community Nutrition Technicians (CNTs). Like the NFWs, the CNTs work in hospitals and health centers throughout the country. Together, the

Iron-deficiency anemia is one of the major problems encountered in renal transplant recipients. The aim of this retrospective study was to reevaluate the causes of anemia among 100 anemic kidney recipients. Patients with serum creatinine levels greater than 2 mg/dL were excluded from the study. Female patients were considered to be anemic if the hemoglobin was

In India large parts of the population do not have access to adequate food despite the surplus food-grain production in the country. It is noted that almost half of the children of pre-school age suffer from moderate to severe malnutrition and more than half of pregnant women and newborn babies are anemic. In this regard the 88th session of the Indian Science Congress called for urgent steps to eradicate the so-called "hidden hunger" among poor Indians caused by a lack of proper nutrition. The first strategy proposed by scientist Mahtab S. Bamji is food diversification. Bamji states that this is the best approach for long-term sustainability because its management is in the hands of the community. Evidence indicates that training of rural women as nutrition entrepreneurs and mobilizers could help a great deal. Another solution proposed by the head of the Department of Endocrinology and Metabolism N. Kochupillai was enhancing iron content of Indian pulses. To accomplish this medical and agricultural scientists would need to get together and work out a collaborative research plan to solve the medico-social problem of nutritional anemia.

Since 1949, the World Health Organization, recognizing the public health importance of nutritional anemia, has sponsored efforts directed towards its understanding and control. During this period, often as a result of the work of the Organization, advances have been made in many areas. Basic understanding of iron, folate and vitamin B12 nutrition, and the various factors which may influence the availability and requirements of these factors, has greatly increased. Surveys in a number of countries have highlighted the widespread prevalence of nutritional anemia, particularly in developing countries. The major factor responsible is a deficiency of iron, whith folate deficiency also playing a role in some population groups, especially in preganant women. There is increasing evidence that anemia adversely affects the health of individuals and may have profound socioeconomic consequences. Control of nutritional anemia is possible by providing the deficient nutrient(s) either as therapeutic supplements or by fortification of commonly used foodstuffs. Some control programs are reviewed and suggestions for further action outlined. The Organization still has an important role to play in this field, encouraging the development of control programs and providing advice and technical assistance ot member countries.

Anemia is a problem in all countries of the English-speaking Caribbean where data are available. It affects mostly preschool age children and pregnant and lactating women. The most common cause is a deficiency of iron. This is probably due to an inadequate intake with a low absorption. A deficiency of folate is also probably a responsible factor in the pathogenesis of some of the anemias. Anemias associated with parasitic infestations such as hookworm and whipworm and hemoglobinopathies such as sickle cell anemia are also noted. Am J C/in Nuir 1982:35: 327-337.

The causes of megaloblastic anemia were studied in a survey of patients admitted to six Israeli hospitals over a period of 15 yr. Among the 203 patients identified, 69% had pernicious anemia, 12% had gastrointestinal disease, 9% had primary nutritional deficiency of whom only 1% were associated with pregnancy, and 7% had selective vitamin B12 malabsorption with albuminuria. Comparison with previously published surveys showed, that in contrast with earlier studies where primary nutritional deficiency was the cause of megaloblastic anemia in about 70% of cases and pernicious anemia in only 20%, in more recent studies the proportion of cases with primary nutritional anemia in general and those associated with pregnancy in particular was much lower. This is most probably the result of improved standards of living and a national program of preventive folate supplementation at maternity clinics. A potential hazard of such preventive programs is the aggravation of neurological complications in patients with undiagnosed vitamin B12 deficiency. Early recognition of pernicious anemia and other forms of selective B12 malabsorption is a new challenge created by the changing pattern of megaloblastic anemias.

Relative bioavailability of two iron fortificants, electrolytic Fe and ferric orthophosphate, was related to that of the reference ferrous sulfate with in vitro and rat model depletion-repletion methods in four laboratories to compare values directly with those obtained in a parallel human study. In vitro testing was performed on Fe compounds with both solubility and dialysis in a simulated in vitro gastrointestinal digestion system. Two depletion-repletion techniques, hemoglobin-regeneration efficiency (HRE) and an official method of the Association of Official Analytical Chemists (AOAC), were examined. AOAC relative biological values (RBV) of electrolytic Fe were 0.66 and 0.78 and of FePO4 were 0.25 and 0.34. HRE values were 0.78 and 0.58 for electrolytic Fe and FePO4, respectively. When compared with FeSO4 in a radiolabeled farina-based meal fed to humans, the RBV of FePO4 was 0.25 and electrolytic Fe 0.75. Results obtained with the AOAC method serve as the most reliable prediction of Fe bioavailability in the human although in vitro dialysis is a promising screening technique.

Ferritin, iron status, and hematological parameters--Hb, hematocrit--were determined in 172 mature women at screening visits in first aid medical care units located in Senegal. Of the subjects 36.6, 39.5, 34.9% had Hb, hematocrit, and ferritin levels below accepted norms (i.e., Hb less than 11 g/dl, hematocrit less than 33%, serum ferritin less than 10 ng/ml). Serum iron level was normal (greater than 50 micrograms/dl) in 94.2% of the subjects, but 48.3% had marginal levels (51 to 100 micrograms/dl). The distribution curves of Hb level in the population indicates that about 58% of the women had Hb less than 12 g/dl. Furthermore, the very low serum ferritin levels (less than 20 ng/ml) encountered in 75.6% of subjects, demonstrate the small size of their iron stores. This precarious iron balance indicates that these women are at a high risk of nutritional anemia. Numerous factors such as pregnancy or parasitical infestation can dramatically modify this iron balance and increase the prevalence of anemia in this population.

A survey was carried out in Guyana to determine the prevalence and the etiology of the nutritional anemias among both sexes, in various age groups, and in pregnant and lactating women. The sample consisted of 590 subjects drawn from 103 households selected by multistage cluster sampling. Anthropometric and hematological measurements and stool investigations for intestinal parasites were carried out in each subject. Socioeconomic and other demographic data were obtained for each household. High prevalences of anemia, although of a relatively mild degree, were found among all age groups especially among pregnant and lactating women. The major factors related to Hb levels were found to be inadequate consumption of food rich in the erythropoietic nutrients, iron deficiency, age, sex, pregnancy, household income, and percentage of household income spent on food. A number of socioeconomic and other demographic variables were associated with anemia. More anemia was found in urban than in rural areas.

The prevalence and type of nutritional anemia was investigated in 344 children aged 1 to 16 years of mixed race and living in a poor urban setting. Iron deficiency anemia was common in 1-year-old children (23%) as was biochemical evidence of iron deficiency (53%). Anemia rates were minimal in older children and the prevalence of iron deficiency decreased with age. Folate deficiency did not appear to contribute to the etiology of anemia, and nutritional vitamin B12 deficiency was not present. No-relationship could be found between a number of familial variables and hematological nutritional status. It is suggested that to identify families whose children are at risk for nutritional anemia new approaches will be needed to define their characteristics.

Summary The subject of nutritional anemiain infancy and childhood is reviewed, with emphasis on the etiology, the pathogenesis, and the mechanisms of iron metabolism involved. In twenty infants and children with severe nutritional anemia, satisfactory therapeutic results were obtained when oral iron was administered. Every other patient in this series received large doses of ascrobic acid additionally which improved the response to iron therapy. The observations were critically analyzed and evaluated. The hemoglobin values were restored rapidly to a normal range in all cases. The average daily hemoglobin response in the group treated with oral iron alone was 0.205 Gm. The average daily hemoglobin response in the group treated with oral iron and ascorbic acid amounted to 0.347 Gm. The average length of treatment in the first group was twenty-one days, while the same was achieved after seventeen days of therapy in the second group. It is concluded that the oral administration of iron in nutritional anemia of infancy and childhood is equally efficacious as other types of treatment. Apparently ascorbic acid increases the absorption and to some extent may aid the utilization of orally given iron.

IT IS a well known fact that many pullets become thin, pale, and develop general or specific diseases after they have been in production for a time. Dukes and Schwarte (1932) found no significant correlation between spring egg production and hemoglobin level of the blood. Cook and Harmon (1933), on the other hand, reported that egg production caused a marked drop in hemoglobin level and that it rose again soon after production stopped. If egg production does cause a drop in hemoglobin level of the blood, it would result in abnormal cell activities and predispose the birds to disease. Some feedstuffs and mineral preparations are being advocated by commercial firms as supplements for laying rations to increase their iron content and thus prevent a possible nutritional anemia. The purpose of this paper is to add to and possibly aid in clarifying the existing data on the influence of egg production . . .

Summary The diagnosis of those anemias of early infancy which occur during the first four to six weeks of life was considered. This embraces the newborn period when adjustment to extrauterine life takes place. During this time profound alterations occur in various systems, including that of hematopoiesis. A satisfactory evaluation of the blood picture may be obscured by these changes as well as by the changes incident to growth and development. The evidence presented in this paper points to the remarkable adaptation and integration of physiologic processes by which sudden and drastic shifts in blood levels are kept in check in the early newborn period. Recent studies reveal, for instance, that the hemoglobin level is usually sustained or shows only a gradual decline during this period. Similarly, the type of nutritional anemia which depends on maternal iron deficiency is of infrequent occurrence during the first days of life. Adjustments in hematopoiesis may take place at varying rates of speed, and protective mechanisms may be upset. To facilitate the interpretation of the blood disorders of this period, normal blood formation and the forces which control hematopoietic equilibrium during fetal life and in the newborn period have been reviewed. In the light of accumulating information, it is possible to relate some of the manifestations of the anemias of this period to deficiencies of one or more hematopoietic factors. Some of the features of erythroblastosis fetalis and of hemorrhagic disease may be explained on this basis. Retarded elaboration of essential hematopoietic principles by the young infant probably contributes to the pathogenesis of a blood disorder. In addition to its other functions, transfusion may serve as an accelerating influence in the production of these elements by newborn infants. Since erythroblastic or Cooley's anemia, familial hemolytic jaundice and hypoplastic anemia may make their initial appearance during the latter part of the newborn period, it is important to look for certain hematologic features by which these conditions may be recognized.

The results of this study indicate clearly that iron fortification of an infant formula, offered to premature infants from the newborn period, affords effective prophylaxis against iron deficiency. Acquisition of hemoglobin iron keeps pace with the rapid growth of these infants. Hematologic observations from the tenth week of life are indistinguishable from those of healthy term infants receiving optimal nutritional care. On the other hand, the majority of premature infants who derive iron solely from iron-fortified and iron-containing solid foods, even when these foods are fed from an early age, develop true iron deficiency anemia. This nutritional anemia can be corrected effectively by the addition to the diet of a formula containing 12 mg. of elemental iron per quart.

Summary Laboratory rats have been fed a diet of raw whole milk supplementedwith 20 per cent of honey. Rats receiving milk to which 16 per cent sucrose was added served as controls. Rats which received a milk-dark honey mixture ad libitum showedan increase in the hemoglobin content of their blood, while the hemoglobin content of rats fed light honey or sucrose supplement in their milk gradually decreased, The gain in weight as well as the food consumption in the first group was also greater. In paired feeding experiments, it was demonstrated that rats receiving a dark honey supplement were able to maintain their hemoglobin at almost the initial level, while the hemoglobin content of rats fed a light honey supplement declined to a level only about 30 per cent of normal, where it remained almost constant. The hemoglobin content of the blood of the control animals receiving a sucrose supplement fell steadily. When the hemoglobin content of the blood of young rats was reduced by a whole milk diet to 6 or 4 Gm. per 100 c.c. level, the addition of 20 per cent dark honey to the milk caused a gradual increase in the hemoglobin, while the addition of 20 per cent light honey permitted a gradual further decline in the hemoglobin until a level of about 3 Gm. per 100 c.c. was reached. It is concluded that the dark honey can play a role in the preventionand cure of nutritional anemia in rats, while light honey is less effective as a source of the blood-forming mineral elements.

I T 15 hoped that Perspectives in Nutrition will review the literature selectively, interpret it moderately and present a spectrum of ideas that will serve as a continual stimulation to nutritional research applied to medical problems.

ACROCYTIC anemia is widespread in deM veloping countries where malnutrition is a problem. Many workers in this field agree that in this type of anemia the hematologic response to folic acid, vitamin BIZ and iron is unsatisfactory. * The response of megaloblastic anemia in protein-calorie malnutrition to cr-tocopherol,2 and of macrocytic anemia in children to the coenzyme Q-l chr~manol,~ was first described in man in 1963 from this laboratory. The predominant type of anemia in infants and children admitted to our hospital is macrocytic The iron deficiency type of anemia is rarely seen. Since this anemia is a nutritional anemia, multiple deficiencies are expected and the complete characterization of the various factors involved awaits further study. It is the purpose of this paper to present the interrelationship between vitamin E and folic acid, vitamin BIZ, vitamin C and iron. The data presented herein will also help in clarifying to some extent the natural history of the disease, which is important in trying to assess both response and interrelationship.

One hundred twelve pregnant women at 26 ± 2 weeks of gestation and with hemoglobin levels of less than 11 g/100 ml were investigated for level of hematocrit, serum iron, iron-binding capacity, serum vitamin B12, and serum folates. They were randomly divided into eight groups receiving as follows: I, placebo; II, iron; III, vitamin B12; IV, folic acid; V, iron + vitamin B12; VI, iron + folic acid; VII, vitamin B12 + folic acid; and VIII, iron, vitamin B12, and folic acid. The treatment was given for a period of 4 weeks. The women receiving iron singly or in combination showed a significant rise in hemoglobin. Vitamin B12 and/or folic acid did not enhance the effect of iron supplementation. The response to therapy was not related to initial level of serum iron, vitamin B12, or folic acid. The study clearly demonstrates that iron deficiency is the most important factor in causation of anemia in these women.

A dietary deficiency was inadequate to explain the severe folate or iron deficiency frequently found among Punjabi villagers. In 18 such patients 13 had subclinical steatorrhea D-xylose malabsorption and abnormalities of jejunal mucosal biopsies. Nutritional anemia would otehrwise have been the diagnosis. Classical tropical sprue was diagnosed in 27 patients. Subclinical malabsorption was thought to be the cause for the marginal nutritional deficiency and for overt deficiency states in pregnant women and preschool children. Severe folate deficiency was found in 60 of 100 women in the last trimester of pregnancy and in 73% of 140 women within 12 hours of a full-term delivery. In another village among 1173 nonpregnant adults only 4 gave a history of attacks of diarrhea. Of 185 who gave 24-hour stool specimens 67 had steatorrhea excreting an average of 13 gm of fat daily. The incidence of steatorrhea was greater in the upper and middle socioeconomic groups than in the lower class. A very high incidence of steatorrhea and of D-xylose malabsorption was found in 100 women after delivery. Jejunal biopsy done on every 5th subject with steatorrhea and on 5 subjects without steatorrhea showed only minor inflammatory changes. In a current study fat and nitrogen balances are being investigated. A high incidence of steatorrhea has been found in 31 nonpregnant females and 29 males aged 16-65 years. Of these 60 subjects 32 excreted over 6 gm of fat daily. few had any symptoms. In 10 from whom jejunal biopsies were obtained findings were normal. Anemia was uncommon. Only 2 were severely anemic. Both had hookworm infestation. Neither had steatorrhea. Parasitic infestation was found in half of the subjects studied. No relationship was found between the incidence of steatorrhea and fat intake level of hemoglobin folate level or parasitic infestation.(PR FFF: Ludhiana)