Social Determinants of Anaemia: SpeakAre Policymakers Listening?

The World Health Organization (WHO) defines social determinants of health (SDH) as “non-medical factors that influence health outcomes.” SDH account for 30%–55% of health outcomes (WHO 2024c). Access to education, contraception, nutrition, sanitation, the internet, better living and working conditions, etc, improve health outcomes for families and communities. Policymaking should transcend politics, caste, gender, religion, class, mythology, bias, conflict of interest, etc, and be grounded in evidence. This paper examines anaemia in India—its prevalence, its effects, possible solutions and gaps in policymaking with a particular focus on its social determinants.

What Is Nutritional Anaemia?

Iron deficiency is estimated to be responsible for half of all anaemia globally and most of this is due to insufficient dietary intake. Other causes of anaemia include genetic conditions, infections, inflammation, gynaecologic and obstetric conditions, chronic or sudden blood loss, altered metabolism, etc. The quality of red blood cells (RBC) can worsen due to medications, long-term chronic disease, bone marrow disease, etc.

In India, low consumption of iron-rich foods as well as the presence of inhibitors such as tannins and phytates/phytins in predominantly cereal-based diets is an important cause of iron deficiency anaemia. Iron in food is available in two forms: heme from animal sources and non-heme from both plant and animal sources.

Although whole grains, millets, legumes, nuts, vegetables and green leafy vegetables have fair amounts of iron, the absorption is usually low. Unlike ruminants, humans lack the enzyme phytase that digests phytin, which is an inhibitor of absorption in plant-source foods. 

The absorption of non-heme iron from plant food is around 2%–10% depending on the presence of inhibitors and enhancers, while approximately 25% iron in meat-containing foods is absorbed (Gopalan et al 2021; Piskin et al 2022). The absorption of non-heme iron is enhanced by ascorbic acid, meat, fermented vegetables, soya sauce and inhibited by phytates (in bran, oats, unpolished rice, cocoa, peas), iron-binding phenolic compounds (tea, coffee, red wines, cocoa, etc), calcium (milk, cheese) and soya protein (FAO 2001). Vitamin C or ascorbic acid, present in citrus fruits, guava, amla, etc, enhances the absorption of iron from foods and increases the mobilisation of iron from stores (Piskin et al 2022). 

Studies have shown that meat, poultry and organ meat contain highly bioavailable heme iron and also increase the absorption of non-heme iron from vegetarian meals. In addition to the more bioavailable heme iron, beef contains superior-quality proteins, fatty acids and several other nutrients essential for haemoglobin synthesis (Natekar et al 2022; Lynch et al 1989). Vegetarians need 1.8 times more iron than meat eaters. Women require more because of menstrual blood loss (WHO 2023).

Apart from iron deficiency, anaemia can be caused by deficiencies of other nutrients such as folate or folic acid, vitamin B12 (cobalamine), vitamins A, B2 (riboflavin), B6 (pyridoxine), C, D and E, and copper (WHO 2017; Kraemer and Zimmermann 2007; Powers 2003; Santoro et al 2015; Sharif et al 2023).

Vitamin B12, also called cobalamin, is widely present in animal food such as liver, eggs, milk, meat and fish. The absorption of this vitamin requires the presence of protein in the diet and its deficiency can prevent maturation of the RBCs. Vegans and vegetarians are at particularly high risk of B12 deficiency. Its deficiency is common in areas where intake of meat, milk and dairy is low. Vitamin B12 levels increase progressively from vegans to lacto-ovo-vegetarians, to those who consume fish or some meat, to omnivores (Allen 2009). 

Vitamin A is present in a more bioavailable form in foods from animal sources such as whole milk, curd, egg, fish, meat, and especially liver. Plant sources in the form of β-carotene are green leafy vegetables and orange/yellow-coloured vegetables like carrots, yellow pumpkin, tomatoes, mango, papaya, etc. The conversion of β-carotene to vitamin A in the intestine requires the presence of fat content in the meal, which may not always be the case in the diets of poor communities. The absorption of vitamin A is reduced in children with worms or respiratory or gastrointestinal infections. 

Anaemia can cause a range of non-specific symptoms such as fatigue, light-headedness, drowsiness, reduced concentration, irritability, loss of appetite, pica,1 and shortness of breath on exertion. These are classical symptoms often unfortunately dismissed or “managed” symptomatically by clinicians, with the generic advice to “eat properly.” Anaemic mothers are 30%–40% less likely to have favourable pregnancy outcomes and their infants are less likely to have normal iron reserves (WHO 2024a). In pregnancy, it can contribute to cardiac failure during labour, haemorrhage during and after delivery, slower healing times and increased risk of infection (Suryanarayana et al 2017).

Anaemia can contribute to preventable causes of child mortality such as low birth weights and premature births. Children with anaemia, especially from marginalised communities, can often get labelled as slow learners attributed more to their social backgrounds than their health. 

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