Anemia in women of reproductive age (15-49 years) in low- and middle-income countries (LMICs) continues to be an intractable problem of ‘hidden hunger’, illustrating health inequalities between the sexes and a shameful loss of human capital. The low concentration of hemoglobin in the blood that defines anemia occurs long after tissue iron stores have been depleted to levels associated with suboptimal function. A major cause of anemia, this iron deficiency results in decreased oxygen carrying capacity in red blood cells, which in turn decreases energy efficiency, work capacity and productivity.¹. In addition, severe anemia during pregnancy is consistently linked to maternal mortality.². Anemia in women of reproductive age is concentrated in LMICs and requires urgent and immediate attention. In this issue of Natural medicine, Kinyoki and colleagues set out to model the prevalence and burden of mild, moderate, and severe anemia in LMICs over the past two decades.³.

The study examines data from several databases in 82 PRFIs, comprising 218 georeferenced household surveys conducted between 2000 and 2018 and including more than three million women. Based on their analysis, the authors estimate that half a billion women were living with anemia in LMICs in 2018. Over the period 2000 to 2018, they see limited decreases in the prevalence of LICI. anemia (35.6% to 31.6%) and an increase in the number of years. lived with a disability, due to population growth. They reveal widespread subnational disparities and predict that a large majority of countries will not meet the World Health Organization’s global nutrition target of a 50% reduction in anemia prevalence by 2030 Although limited by gaps in the quality and quantity of data, this new analysis provides an opportunity to shed light, once again, on an important public health problem and the failure of public policies.

Losses in physical productivity due to iron deficiency have been linked to gross domestic product and can result in losses of billions of dollars per year⁴ (although stronger and more complete estimates are needed). A recent analysis estimated the gains of 2.28 million school years and US $ 8.25 billion in lifetime income associated with stepping up prenatal iron and folic acid supplementation⁵. An argument on economic and human capital is therefore well justified to convey the urgent need for programmatic action to political decision-makers and economic planners. India, with its high prevalence rate of 50%, has the highest number of women of reproductive age with anemia (181.3 million) and is home to two-thirds of LMIC cases³; obviously this could generate a huge economic benefit in tackling this problem. 87 million anemic women live in China, Pakistan and Nigeria.

Tackling this massive problem has been difficult due to issues such as gender inequality, program failure, and reliance on economic development (and dietary change), all of which stem from part of a general lack of political will. Etiologies such as malaria, soil-transmitted helminth infections and chronic inflammation exist and may explain part of the geographic heterogeneity; however, iron deficiency and other nutritional causes of anemia predominate in women³ and may be linked to gender inequality in terms of access to quality food and, in particular, iron-rich food sources⁶. Highly bioavailable sources of heme (meat, eggs and liver) are needed to meet the daily iron requirement, which in women is set at 18 mg. A three-ounce (85-gram) serving of red meat provides 2.6 mg of iron, an average egg provides 0.6 mg of iron, and a poorly absorbed plant source such as a cup (30 grams) of spinach does. than 0.8 mg of iron. Consuming the three daily servings will only reach 22% of the recommended daily iron intake; the quality of the diet of women in LMICs is much worse than that, and the requirements are higher during pregnancy. Also, the recommended intakes would be insufficient to correct the deficiency, especially in a context where 40 to 50% of the population is anemic. Linear programming has demonstrated that strategies based on diet alone may not be sufficient to meet the dietary needs of women, instead calling for fortification and supplementation approaches.⁷.

Antenatal iron-folic acid supplementation is an evidence-based, highly affordable ($ 1 per pregnancy) and recommended intervention. Nonetheless, large-scale programs have failed to achieve adequate coverage due to supply chain failures and low uptake. Political will and global momentum for maternal nutrition is lacking, with limited spending on maternal and child health interventions⁸. In addition, income growth is dependent on widely accepted factors of change in the prevalence of anemia, such as women’s education, improved nutrition, water, sanitation and hygiene. .⁹. However, anemia rates are only falling a quarter as fast as income is increasing.^ten. In addition, there is a lack of data showing that behavior change approaches for dietary diversification are working, and there is evidence that interventions in the areas of water, sanitation and hygiene do not work. ‘not affect anemia.¹¹ (although both seem appropriate to do in the long run, and for their own good). The slow decline in the prevalence of anemia in women³ therefore calls for a different approach and a substantial commitment.

The analysis by Kinyoki et al.³ can help guide the future course of action. The type of resolved data generated, if used to create mapping and tracking tools, could be a powerful means of geographic targeting, resource allocation, deployment of interventions, and tracking of progress. In addition, a multi-level approach across the lifespan (Fig. 1) can help tackle this problem. For the general population, a strong food fortification effort is needed and has been shown to be effective in reducing anemia in women of childbearing age.¹². When the prevalence of anemia is high, fortification can be increased by intermittent (weekly) iron supplementation as recommended by the World Health Organization. During pregnancy, iron plus folic acid or, better yet, multiple micronutrient supplementation should be enhanced through antenatal care and other platforms, along with the context-specific use of deworming and intermittent preventive therapy. malaria during pregnancy. Antenatal hemoglobin screening, recommended but poorly implemented, can be used in the treatment of the most severe anemia with short infusions of iron given by the intravenous route, as is practiced in high-income countries. If each level of this strategy is effective, then the next level will be smaller, because prevention is the goal.

There is an urgent need for field diagnostics and point-of-care systems that are more accurate than the hemoglobinometers currently in use. Non-invasive technologies, including pulse oximetry, are promising and more acceptable, but their diagnostic performance needs to be improved. Point-of-care systems to identify underlying causes (iron deficiency, inflammation, and hemoglobinopathy) are also needed as the field moves towards more specific public health prevention and treatment strategies. Much needed work on redefining hemoglobin thresholds for anemia appears to be underway, and treatment protocols also need to be updated. Treatment regimens with intravenous administration of low molecular weight iron products such as ferric carboxy maltose and ferric derisomaltose are promising but will require “affordability” for the context of PRFIs. The COVID-19 pandemic has exacerbated food and nutrition insecurity in LMICs and has done so disproportionately for women and children. Maternal anemia is a scourge that cannot exist in such proportions and calls for immediate, large-scale, equity-based and economically justified action.