Dr. Zulfiqar Bhutta: Women’s wellbeing is at the center of improving anemia

Anemia among women of reproductive age is a complex global health challenge – and progress against the condition has stagnated over the past decade.

The consequences of anemia for both pregnant women and newborns can be devastating. Since anemia prevents blood from carrying enough oxygen to the body’s tissues it increases both the risk of maternal mortality and jeopardizes fetal development.

To try to accelerate progress against this complex condition, Exemplars in Global Health (EGH) studied five low- and low middle-income countries – the Philippines, Uganda, Pakistan, Senegal, and Mexico – that have shown signs of improvement in anemia among women of reproductive age (between 15 and 49 years of age) that were greater than what could be expected from economic gains alone, along with other factors such as etiological diversity and regional representation. The research examined factors at the national, community, household, and individual levels that contributed to substantial progress in reducing anemia among these women in the countries.

In this first installment of an interview with Dr. Zulfiqar Bhutta ahead of this year’s Micronutrient Forum Global Conference starting Oct. 16, Exemplars News spoke with the Robert Harding Inaugural Chair in Global Child Health and co-director of the Centre for Global Child Health at the Hospital for Sick Children in Toronto about the findings of the new research, which he helped develop and lead. The EGH program and Dr. Bhutta, who is also founding director of the Centre of Excellence in Women and Child Health and the Institute for Global Health and Development at Aga Khan University, will be presenting their findings at this year's Micronutrient Forum conference.

Could you give us an overview of global progress in reducing the prevalence of anemia among women of reproductive age?

Dr. Bhutta: It's a glass half full with global anemia gains. While there has been progress since 2000, progress has been slow, with stagnation over the past decade. Additionally, anemia has a wide range of causes that vary by regional access to nutrition, family planning and pregnancy-related healthcare services, and epidemiology of both genetic and infectious disease. One of the big challenges we have with something like anemia is that, despite all the effort and programs, we still don't have a good enough measurement at a global level of progress on nutritional anemia versus progress on all other causes of anemia.

Anemia is a manifestation of more than just nutritional deficiency. There's a component that is clearly nutritional, but as mentioned before, there are many other causes, including genetic disorders, infectious disease, environmental factors, and chronic inflammation. So, I'm not too surprised there hasn't been much reduction in anemia worldwide, at least to the extent we expected, partly because we've primarily been focused on nutritional anemia among women of reproductive age – and more specifically focused on iron deficiency alone.

What are the main challenges in reducing the prevalence of anemia among women of reproductive age, particularly given stagnating prevalence rates over the past decade?

Dr. Bhutta: One primary challenge across countries and contexts is that the etiology of anemia has not been well known. A detailed understanding of the causes of anemia in country-specific contexts is crucial to understand what sectors to engage and what to target with interventions, policies, and programs. This also enables a better understanding of the ‘limiting factors’ that potentially impede progress towards anemia reduction.

Our solution for reducing the global anemia burden has been largely iron and folic acid supplementation programs to address iron deficiency anemia. However, many countries have not been able to make much progress using this strategy alone. Hence our approach to look at countries that have been able to shift the curve of iron deficiency anemia; countries that have been able to eliminate severe iron deficiency and also reduce moderate anemia rates.

I believe we should address this challenge of understanding drivers and solutions for anemia like we did with stunting – starting at the base. Start with the drivers and social determinants of anemia. Then move on to what percentage of anemia can be realistically targeted through supplementation programs. And then also ask if supplementation programs should be the only thing in our arsenal. Many people will say you just cannot reach enough women with supplementation programs because they require high levels of access, coverage, and compliance, which may be difficult. Perhaps we could have done better with fortification programs, but we haven't yet and need to. And finally, I would say that what appears to be anemia and iron deficiency in many populations is, in my opinion, probably also a consequence of multiple micronutrient deficiencies or even non-nutrition-related causes as previously discussed, such as infectious diseases (and) genetic disorders, among others.

How much of the anemia burden among women of reproductive age can be addressed through nutrition- specific interventions versus non-nutrition interventions?

Dr. Bhutta: The World Health Organization (WHO) and other modeled estimates say that about half of all anemia has nutritional causes, including iron deficiency. Based on our research and understanding of anemia, I believe this estimate may be higher than reality – I think the reality on the ground is that probably about one third to 40% of anemia is probably nutritional. And within the nutritional anemia, not all of it is iron deficiency, it could also be inflammatory conditions.

How did the Anemia Exemplars research program examine the challenges in reducing anemia among women of reproductive age across countries and contexts?

Dr. Bhutta: To help accelerate progress against the stagnating and complex condition of anemia, we conducted research in five countries – the Philippines, Uganda, Pakistan, Senegal, and Mexico. We selected countries based on improvement in anemia among WRA (women of reproductive age) that outpaced economic development, in addition to other critical considerations including etiological diversity, regional representation, and feasibility of study. By studying countries across regions and contexts, we accounted for regional variation on the different etiologies of anemia, including nutritional (e.g., iron deficiency), infection (e.g., malaria), genetic (e.g., sickle cell disease), and causes related to pregnancy.

What key themes emerged across Anemia Exemplar countries in terms of interventions, policies and programs, and delivery platforms that enabled exemplary performance in reducing anemia among women of reproductive age?

Dr. Bhutta: This has been one of the best projects I've been involved in because it's been so educational. We had absolutely no a priori hypothesis as to what would have changed anemia in countries.

Here's what we found after several years of study and inquiry. First, many of the drivers that change anemia are the same as the drivers changing maternal nutrition and childhood stunting. So, investing in improving nutrition, health, and the wellbeing of women holistically is very important.

Secondly, we found that in malaria endemic areas it makes a lot of sense to effectively prevent, treat, and control malaria as that emerged as a consistent driver. Anemia rates are higher in these populations because if you don't have good malaria programs, you will have increased risk for anemia.

Family planning interventions also help reduce unintended and high-risk pregnancies and associated risk of anemia. Iron deficiency related to anemia is seen in women with a higher number of pregnancies, as diets usually do not compensate for the increase demands of iron during gestation. Multiple pregnancies also put women at higher risk of hemorrhage and cause nutritional depletion, which can lead to anemia. Therefore, ensuring access to family planning methods and counseling – particularly for adolescents – is a big driver for controlling anemia. Working to address investments in women's education, wellbeing, empowerment, and reducing teenage pregnancies is critically important.

Across everything mentioned, what’s emerging from many of the Anemia Exemplars is the need for countries to invest in improving social safety nets and to invest in women in a fundamental way, by empowering them with education and access to family planning and good quality antenatal care and maternal care programs. Also, it's important to target populations at greater risk – either greater risk of malaria or other diseases – and improve investments in the environment such as in sanitation hygiene. Bottom line, you need to invest across direct and indirect nutrition strategies, across health and non- health sectors, and across social determinants, and you need to do so smartly – and improvements in anemia will follow.

What lessons can be learned from Anemia Exemplar countries to help drive progress in reducing anemia among WRA across low- and middle-income countries?

Dr. Bhutta: The biggest lesson is that anemia reduction is possible and it's possible in any country in the world. The global health community must move away from lamenting the lack of progress every few years to much more concerted and targeted strategies to assess national and subnational trends and program quality and for effective and timely course correction. This strategy can be largely informed by the findings from these exemplar countries and will be key to improve the health and wellbeing of women of reproductive.

Another lesson is that reducing anemia will require paying attention to some of the social determinants and drivers of undernutrition and maternal wellbeing, particularly for family planning access and counseling, and poverty reduction via social protection programs.

The final thing I'd say is that, despite all of this work, we're cognizant of how much we don't know and how much work still needs to be done in terms of understanding the entire spectrum of anemia, improving tools for diagnosis and management.

Based on your findings from the Anemia Exemplars research, what do you believe is next in terms of anemia-related research and strategies to reduce anemia globally?

Dr. Bhutta: First is the fact that we're looking at maternal nutrition and outcomes, which was a natural consequence of this work. I also think countries need to begin thinking about childhood and adolescent anemia. As I mentioned, maternal anemia has its antecedents in childhood and we haven't quite looked at what causes childhood anemia as they may not be the same factors as maternal anemia. We need to better understand drivers of maternal nutrition and fetal and newborn outcomes to be reasonably confident that we've got our head around the spectrum.

This interview was edited for length and clarity.