Anemia remains stubbornly common for women and children

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PAULINE CHIOU: Welcome to another episode of Global Health Insights, a video podcast on the pressing health issues. The world is facing today. I'm Pauline Chiou in media relations at the Institute for Health Metrics and Evaluation, also known as IHME. Today, we are talking about anemia. A new study shows that it impacts one in four people around the world, primarily impacting women of childbearing age and also children under the age of five.

And this study is published in the Lancet Haematology journal. And we are fortunate that the research team is here. We have Dr. Nick Kassebaum, who's senior author of the paper, head of IHME's neonatal and child health team, as well as professor of anesthesia and pain management at the University of Washington. And also joining us is Will Gardner, lead author of the paper and a researcher at IHME, as well as Dr. Theresa McHugh, a scientific writer at IHME who focuses on neonatal and children's health. Thank you for being with us to talk about this very important issue and your new study that's been published. Great to see you having us here. Dr. Kassebaum, let me start with you. Your team looked at 30 years of global anemia data from 1990 to 2021.

What are the most important findings that you feel should be addressed now?

DR. NICK KASSEBAUM: So one of the biggest is that the progress in anemia and reducing anemia burden has really been much slower than the progress in reducing other problematic health conditions. Neonatal mortality has gone down a lot. Maternal mortality has gone down. All other problems of nutrition, like child stunting, wasting and underweight have gone down significantly.

Anemia is really a bit of an outlier and how persistent and stagnant the story has been about how many people are anemic.

PAULINE CHIOU: And why is that? Why is it an outlier? I know it's a nuanced, complex situation.

DR. NICK KASSEBAUM: I think in some ways it anemia can be thought of as a as a common manifestation of when lots of things go wrong.

You know, if we have bad infections or inflammation in the body, you will get anemic. We lose blood due to gastrointestinal or gynecologic problems or menstrual disorders. We'll get anemic if you develop chronic conditions like kidney disease or inflammatory bowel disease, you your body with herbalism changes and you end up being weak. So there's lots and lots of different reasons why people can be anemic.

So it's not as amenable to simple one off intervention funds or simple strategies in the same way that some other conditions are. There's no vaccine for itself.

It has to be a whole lot more holistic and a whole lot more comprehensive to really just shift the needle.

PAULINE CHIOU: And Will, in terms of shifting the needle, you've mentioned in the paper that the focus on eradicating anemia has been existing for several decades now.

Yet the cases persist, especially among women of childbearing age and children. But it's declining among men. And the paper has an interesting statistic for the last year of the study, just to highlight this in 2021, when you look at that age group, 15 to 49. 33.7% of women had anemia versus 11.3% of men. So why are we seeing this difference in success stories?

WILL GARDNER: Yeah. So I think, like Nick said, there are a lot of different and multifactorial causes that can go into a person developing anemia, something that we focus on in the paper and hypothesized in this group in particular. Some of this might reflect unmet needs for family planning services and contraception. There are certain gynecologic and maternal disorders that contribute to anemia in women of reproductive age and other things like menstrual education and prevention and screening among women and adolescents that have maybe not always been the focus.

And in some cases, these groups may not have access to some of the existing prevention services or for whatever reason, are not getting those services as they're being delivered. So I think those are, you know, a reason why this has been such a focus in international target setting, because this is a group that both has a high level of burden and there could be significant consequences for anemia in this group.

PAULINE CHIOU: And Dr. McHugh, when we look at the regions, we know that sub-Saharan Africa and South Asia are at high risk. And speaking of some of these issues that will brought up, is it an issue of asking policymakers and decision makers to fund these educational services and to narrow that knowledge gap? Or are there other recommendations that you have?

DR. THERESA McHUGH: Yeah, great point, Pauline. I would say that anemia generally can be considered an indicator of the nutritional status of a population. And so areas like sub-Saharan Africa and Southeast Asia are more prone to anemia because of malnutrition. And like both Will and Nick have mentioned previously, the approach needs to be multifaceted. I would say that important areas of focus should be increasing access to nutritionally valuable foods, especially those that are high in iron content like green leafy vegetables, tofu, red meat, dates, raisins.

And also improving access to health care has been important just simply for identifying a case of anemia.

Those are important areas for focus.

PAULINE CHIOU: And if we wanted to drill down on the impact of anemia, especially on women or children, I mean, what's the health impact and the socioeconomic impact?

DR. THERESA McHUGH: Well, the health impacts can be great.

And so symptoms of anemia include things like breathlessness, heart palpitations, headache, dizziness, memory issues, inability to focus, inability, ability to perform work. And so those impact the socioeconomic status of an individual in terms of being able to go out and achieve gainful employment. They can also have an impact on the mental well-being of an individual in terms of just being able to do the activities that are desired in life.

And so we see in anemic individuals, there's their increased rates of anxiety and depression.

PAULINE CHIOU: Dr. Kassebaum, could you flesh that out as well? The impacts, but also the underlying causes or conditions of anemia, giving a dietary iron supplement often is just not enough because of the underlying picture of a patient's health. So can you flesh that out for us?

DR. NICK KASSEBAUM: Certainly. So under the consequences of anemia and so so anemia is both the result of certain diseases and we also suspect is a risk factor for the development of other diseases. So one of the areas of ongoing research that we're working hard on right now is so very carefully try to understand the links between being anemic and developing other problems.

So for there is some suggestion, as Dr. McHugh was mentioning, that the anemia is a risk factor for the development of depression, anemia may be a risk factor for maternal hemorrhage. For maternal mortality, just being anemic makes it more likely that someone as a life threatening pregnancy complication and a number of other problems and all of those taken together depending on what we find, where we analyzes data, may suggest that the burden of anemia is even much, much larger than what we're estimating right now.

The only burden we're including now, which is already massive, is just an assessment of the disability experienced by the person who is anemic right now without consideration of all of the other downstream consequences, as are the causes.

You know, it's this tricky middle spot where if anemia leads to diseases, it's also the result of diseases. Part of the focus on nutrition for anemia is because nutrition is comparatively easy not to say that it's easy everywhere in every circumstance, but if anybody who's anemic, if you give them iron, if you give them folic acid, if you give them other micronutrients and you give them enough calories, their anemia will likely improve.

But if they have ongoing blood loss or they have an ongoing inflammation or they have a persistent infection or things like hookworm, for example, or other intestinal parasites, then all you're going to be doing at that point is providing them just enough to keep up with their ongoing losses so they might not fall further behind, but they're not actually going to catch up.

So if you're going to catch up, you actually have to figure out what is the underlying problem, treat the underlying problem and give a chance for all of that replenishment and all of those nutrients to get in the body and help the person's body catch up and then prevent that disease from coming back. So it's not again, go back to the vaccine analogy.

There's not a simple vaccine for treating anemia really is about saying what is the individual circumstance of the person once they become anemic, What is the problem where they have to treat the problem and then prevent its recurrence at the population level? It's about what are the big issues that lead to anemia? How can we prevent them holistically with policies and population level interventions, and how can we effectively and efficiently identify those who are anemic and then help each of those people get back to a state of health?

PAULINE CHIOU: You're painting a very effective picture of how complex and layered the situation is. Well, with that in mind, let's take a look at just the geographical disparities here. When we look at some areas, we see that the highest some burden of anemia is in Mali, Zambia, Togo, where each country has more than 50% of the population that's anemic.

But then the low burden countries are Iceland, Norway and Monaco, where each country has less than 5%. So. So what can we learn from just that snapshot about anemia?

WILL GARDNER: Yeah, absolutely. I think these examples are great instances where this idea of the underlying cause profile and the different things that contribute to anemia really manifest in the overall burden.

So we see that there are certain places, say, in West Africa, where malaria is very high and that's a large contributor of anemia. And we find that in our study, places where HIV burden is very high, have a lot of anemia due to HIV. And so when you look at this distribution of underlying causes, that is, you know, a large driver of anemia in some places and geographies.

And so, you know, we keep going back to this idea that it's not just, you know, iron supplementation or some of the approaches that have been taken before anything that doesn't kind of take account of those different underlying causes that could either reduce the efficacy of supplementation or that just are not helped by supplementation that anemia due to those causes will be persistent over time and will not fall as much.

And so places that maybe have less of those or have a cause profile that is more amenable to supplementing them to begin with may have more success in those kinds of programs. So I think it really speaks to the use case and what is a real strength of this analysis is the ability to take these results at a local level and design interventions that are actually reflective of the underlying epidemiology of anemia in a specific community or country.

PAULINE CHIOU: And that's why it's so important to really break it down by region. So policymakers and decision makers can have a localized use, a treatment plan. This is such an important conversation. Will Gardner, Dr. Theresa McHugh, Dr. Nick Kassebaum, thank you so much for joining us. And if our listeners want to learn more, they can read your study in The Lancet Hematology.

We really appreciate it.