Several public health experts and activists have expressed concern over the suggestion that India should abandon WHO standards on haemoglobin levels to define anaemia and instead adopt locally determined standards. Such a change could help India show very low prevalence of anaemia just by changing the benchmark.
According to an article co-authored by Sanjeev Sanyal, a member of the PM’s Economic Advisory Council, with a change in the way samples are drawn and tested and with lower benchmarks, the prevalence of anaemia could come down from 67% among under-5 children and from 59% among girls aged 15-19 years to about 15% for both age groups. Sanyal’s article was based on a study published in the Lancet, which was based on data from the Comprehensive National Nutrition Survey (CNNS) 2019. The CNNS indicated that the haemoglobin cut-off could be reduced from 11 gm per decilitre to about 9.5 gm/dL for India. .
“It sounds like a miracle achieved with no effort except their ability to re-define a normal population,” said a statement issued by several public health experts as part of a signature campaign against such lowering of the haemoglobin cut-off. It added that the proposed lower benchmark was calculated from a data set from CNNS 2019, which was not meant to generate any kind of standards or benchmarks and which was from just one country, India.
The objective of the CNNS was to collect a comprehensive set of data on nutritional status of Indian children from 0–19 years of age and to provide robust data on the shifting conditions of both undernutrition and overweight and obesity. “Standards must be generated from a study of populations who have no constraints to growth, have access to good quality food including iron rich foods, education, and all other socio economic attributes which go to support a healthy population. This population should be identified using clearly defined inclusion and exclusion criteria. Instead, the authors of the Lancet study use a subset of over 8,000 individuals drawn from the overall CNNS sample of more than 49,000 individuals. A sub-sample of 8,000 from such a survey cannot be used to argue for re-examination of WHO haemoglobin cut-offs to define anaemia or to set standards for India,” argued the experts.
It is reliably learnt that a committee has been set up to advise the government on the suitability of using the new lower benchmark for tracking anaemia prevalence. The Lancet article stated that the data from the CNNS survey also showed that anaemia prevalence would come down if blood samples were drawn from the vein and tested in a lab instead of using a point-of-care instrument to test blood samples from a finger prick. It stated that the gold standard in testing for anaemia was to use blood samples from the vein.
Since the age group in the Lancet study included girls aged 15-19, which could include many who would bear children, it worries clinicians that lowering the cut-off could endanger the lives of many pregnant women. “In my 20 years of obstetric practice in a rural area of Mysore I have seen plenty of tragedies due to low haemoglobin i.e. less than 11 gm/d. Our pregnant and labouring mothers are not able to tolerate even a little more than average blood loss and could go into haemodynamic shock. Since we have started maintaining a baseline of 11 gm/dL we have seen that such things have almost disappeared. So I strongly reject this proposal to lower the Hb cut-off for anaemia to 9.5 gm/dL,” said Dr Rita Lobo, a rural obstetrician.
According to an article co-authored by Sanjeev Sanyal, a member of the PM’s Economic Advisory Council, with a change in the way samples are drawn and tested and with lower benchmarks, the prevalence of anaemia could come down from 67% among under-5 children and from 59% among girls aged 15-19 years to about 15% for both age groups. Sanyal’s article was based on a study published in the Lancet, which was based on data from the Comprehensive National Nutrition Survey (CNNS) 2019. The CNNS indicated that the haemoglobin cut-off could be reduced from 11 gm per decilitre to about 9.5 gm/dL for India. .
“It sounds like a miracle achieved with no effort except their ability to re-define a normal population,” said a statement issued by several public health experts as part of a signature campaign against such lowering of the haemoglobin cut-off. It added that the proposed lower benchmark was calculated from a data set from CNNS 2019, which was not meant to generate any kind of standards or benchmarks and which was from just one country, India.
The objective of the CNNS was to collect a comprehensive set of data on nutritional status of Indian children from 0–19 years of age and to provide robust data on the shifting conditions of both undernutrition and overweight and obesity. “Standards must be generated from a study of populations who have no constraints to growth, have access to good quality food including iron rich foods, education, and all other socio economic attributes which go to support a healthy population. This population should be identified using clearly defined inclusion and exclusion criteria. Instead, the authors of the Lancet study use a subset of over 8,000 individuals drawn from the overall CNNS sample of more than 49,000 individuals. A sub-sample of 8,000 from such a survey cannot be used to argue for re-examination of WHO haemoglobin cut-offs to define anaemia or to set standards for India,” argued the experts.
It is reliably learnt that a committee has been set up to advise the government on the suitability of using the new lower benchmark for tracking anaemia prevalence. The Lancet article stated that the data from the CNNS survey also showed that anaemia prevalence would come down if blood samples were drawn from the vein and tested in a lab instead of using a point-of-care instrument to test blood samples from a finger prick. It stated that the gold standard in testing for anaemia was to use blood samples from the vein.
Since the age group in the Lancet study included girls aged 15-19, which could include many who would bear children, it worries clinicians that lowering the cut-off could endanger the lives of many pregnant women. “In my 20 years of obstetric practice in a rural area of Mysore I have seen plenty of tragedies due to low haemoglobin i.e. less than 11 gm/d. Our pregnant and labouring mothers are not able to tolerate even a little more than average blood loss and could go into haemodynamic shock. Since we have started maintaining a baseline of 11 gm/dL we have seen that such things have almost disappeared. So I strongly reject this proposal to lower the Hb cut-off for anaemia to 9.5 gm/dL,” said Dr Rita Lobo, a rural obstetrician.
