Sri Lanka is mired in a financial meltdown. Import restrictions have been imposed on many essential food items as foreign reserves reached rock bottom. The public has to bear the brunt of food shortage as well as skyrocketing food prices. If people become food insecure, they will inevitably face nutrient insecurity too which should not be overlooked. Hidden hunger or nutrient deficiencies can have disastrous outcomes.
Among other important nutrient deficiencies, Iron deficiency can be cataclysmic if occurs. Iron is one of the major micronutrients in the diet that should not be omitted. Iron helps maintain healthy blood. It is an essential element for important functions such as oxygen transport, DNA synthesis and muscle metabolism. The main cause of anaemia is insufficient of iron in the blood.
This is the most prevalent nutrient deficiency in the world affecting people of all ages. Children, pregnant women, women of menstruating age, vegetarians (if the meals are not planned) and people receiving kidney dialysis are at high risk of iron-deficiency anaemia. As per the reports of the World Health Organization, 33 percent of non-pregnant women, 40 percent of pregnant women, and 42 percent of children are anaemic worldwide.
“Estimates indicate that one in three children and one in four adults in Sri Lanka suffer from iron deficiency anemia making it the most critical micronutrient related deficiency in the country” (Ministry of Health, Sri Lanka). Over 35 percent of pregnant women in Sri Lanka are anaemic (World Health Organization, Global Health Observatory Data Repository/World Health Statistics,2018)
However, with the onslaught of unprecedented coronavirus disease, and subsequent disruption of food distribution, the number of children and adults who are affected with iron deficiency anemia may be higher by today. This amount may rise drastically on par with the economic crisis and food shortage in the country.
IDA
Iron is required to form myoglobin, a protein in muscle cells. Myoglobin is essential for certain enzymes without which the body’s chemical reactions fail to occur. Myoglobin also carries and stores oxygen specifically in muscle tissues. Iron is a major component of hemoglobin too, a type of protein in red blood cells that carries oxygen from the lungs to all parts of the body. Red blood cells become smaller than normal and contain less hemoglobin if iron levels are low. Without a sufficient amount of iron, there would not be enough red blood cells to transport oxygen, which causes fatigue.(Harvard Medical School)
The good news, however, is that iron deficiency does not occur abruptly. As per research, iron deficiency occurs in four stages. At the first stage, iron stores in the body begins to decrease due to the absence of iron in the diet or due to excessive bleeding. If necessary interventions are not made, this situation then leads to the depletion of iron stores and result in the drop in red blood cells. Prolonged occurrence of this leads to Iron Deficiency Anemia or IDA (Powers JM, Buchanan GR. Disorders of Iron Metabolism: New Diagnostic and Treatment Approaches to Iron Deficiency. Hematology/Oncology Clinics. 2019 Jun 1;33(3):393-408)
Fatigue, lightheadedness, weakness, loss of concentration, pale skin, confusion (and sometimes psychological illnesses), sensitivity to cold, shortness of breath, rapid heartbeat, loss of hair are the symptoms of IDA.
Infants and children require iron in high amounts due to rapid growth. Iron is essential in the brain development of infants and children. Anaemic children cannot excel in education due to difficulty in concentration, loss of memory which may occur in some cases and fatigue. They are weak and less active by nature. Active participation in academic as well extra-curricular activities cannot be expected from anaemic children.
As per the National Institutes of Health Office of Dietary Supplements USA, during pregnancy, women require a considerably high amount of iron as greater amounts of red blood cells are produced for the foetus. If the pregnant mother become iron deficient and anaemic, it can lead to premature birth or low birth weight.
Women of menstruating age is another vulnerable group for IDA. Women require more iron than men, due to monthly blood loss caused by menstruation.
Vegetarians, endurance athletes, people with chronic kidney failures and elderly are also at a risk of IDA.
Vulnerable groups should be constantly monitored for IDA and timely intervention can prevent them from being anaemic and to increase the productivity of working population as fatigue, tiredness and mood swings may affect efficiency and productivity.
RDA
Although the Sri Lankan population as a whole is not anaemic, the country’s food insecurity may lead to the rise in the number of people who are iron-deficient. Non-affordability and non-availability of iron-rich foods can worsen the situation. To prevent people from being iron deficient, they are required to incorporate a certain amount of iron on a daily basis. This amount is scientifically known as the Recommended Dietary Allowance (RDA). The RDA for iron is as follows;
“For adults, 19-50 years is 8 mg daily for men, 18 mg for women, 27 mg for pregnancy, and 9 mg for lactation. Pregnant and non-pregnant women require a high amount of iron due to blood loss through menstruation and because of the rapid growth of the fetus that requires extra blood circulation during pregnancy.
Adolescents, 14-18 years actively growing also need higher iron: 11 mg for boys, 15 mg for girls. The RDA for women 51 years and above drops to 8 mg with the assumption that cessation of menstruation has occurred with menopause. It may be noted that menopause occurs later for some women, so they should continue to follow the RDA for younger women until menopause is confirmed”(Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium, and Zinc: a Report of the Panel on Micronutrients. Washington, DC: National Academy Press; 2001)
If someone exceeds the RDA of iron, it can have detrimental impact over time because iron does not excrete from the body. When a person takes sufficient iron from his diet and also takes iron supplements without the consultation of a medical doctor, iron stores can build up over time and become toxic in some cases. Hence, it is advisable to speak to a doctor, prior to taking iron supplements as insurance against iron deficiency, if sufficient iron is taken through the diet.
If someone wants to know if he is iron-deficient or iron-loaded, laboratory evaluation can be helpful. The ferritin level in the blood is evaluated in such tests. Ferritin is a protein that can be found in small amounts in the blood. If ferritin levels in the blood are low, that means the person is iron-deficient. If someone’s iron intake is high, his ferritin levels in the blood are high. In both these scenarios, medical intervention is required.
Meal planning
Iron is obtained through the food we eat. Some iron is not easily absorbed. The easily absorbed form of iron is known as heme iron. Heme iron is attached to hemoglobin protein. Easily absorbable heme irons are found abundantly in red meat, poultry and seafood.
Non-heme iron is found in plant-sourced foods. Leafy greens, whole grains, nuts, seeds and legumes contain non heme iron. The body doesn’t absorb non-heme iron that we obtain from fruits, vegetables, beans, and leafy greens as easily as it absorbs heme iron.
In simple terms, iron found in meat and seafood are easily absorbed into the body than iron found in vegetables. Hence, vegetarians may run a risk of iron deficiency. Vegetarians must seek to fulfill iron requirements from leafy greens, spinach, legumes such as lentils, whole grains, seeds, soybeans, mushrooms, and other plant foods that contain iron along with sufficient vitamin C in the same diet to absorb iron well. Tea and calcium-rich foods may deter the absorption of iron.
A large portion of Sri Lankan population is not affordable to incorporate meat, poultry and seafood regularly into their diets. Due to the economic crisis, the prices of poultry, red meat and seafood such as fresh fish, dried fish and sardines have gone up. When prices go up, people tend to avoid buying them, despite the fact that such food contain the essential nutrients and their deprivation may be detrimental. People go for cheaper food options which may not contain the essential nutrients.
Their consumption of whole grains, nuts and seeds is also less. Foods made of refined wheat flour such as bread and roti become their regular staples. Due to ignorance and sometimes, unavailability, consumption of iron-rich food may not be possible. This can lead to iron deficiency in the population.
However, if animal-based heme iron is not sufficiently obtained through meals, a good amount of vitamin C is required to be added to the same meal which contains non-heme iron from plant sources.
Affordable meal
Since rice is the staple in Sri Lanka and traditional brown rice varieties contain a good amount of iron, regular brown rice consumers may not be seriously affected by iron deficiency.
Brown rice, spinach and Dhal curry, Pol Sambolaya, (made by adding lime juice and tomato as sources of Vitamin C to better absorb non heme iron in brown rice) and dry fish curry such as Karawala or Halmassan is an affordable meal for many. However, hike in prices may still discourage people from incorporating animal-sourced iron. Brown rice with vitamin C-rich Pol Sambolaya (by adding lime juice and tomato) that contains iron is an affordable meal for many.
Kurakkan is also a good source of iron and is affordable. Kurakkan Thalapa, pittu and roti can also be incorporated into the diet. When preparing curry as an accompaniment to foods, adding lime juice, tomato, or garcinia can increase the absorption of iron in Kurakkan.
Leafy greens or Pala Melluma is a popular and affordable food in Sri Lankan cuisine. Leafy greens or Pala are a good source of plant based non heme iron. Sri Lankans are accustomed to add lime juice or tomato in the preparation of salad or Sambolaya with leafy greens. Lime juice is also added when preparing Melluma. The wisdom of adding lime juice is that vitamin C in lime juice can help better absorption of non heme iron found in leafy greens. The most affordable sources of iron from leafy greens are spinach, Gotu Kola, Sarana, Thampala, Moringa leaves, Keran Koku, Miyana Dalu and other types of Pala found near paddy fields, in the wild and in home gardens.
Gotu Kola Sambolaya is a delectable addition to any meal. Make sure to add sufficient lime juice when preparing the leafy green salad and regular consumption of leafy greens can fight iron deficiency to a certain extent. A delicious, healthy and iron-rich drink can be made by juicing Gotukola and mixing orange or tomato juice in it.
Iron absorption
Spinach or Nivithi may not be very popular vegetable among Sri Lankans. Most housewives prefer adding spinach in Dhal curry. Red lentils also contain a good amount of iron. When preparing spinach with dhal curry, adding tomato or lime juice can improve the iron absorption. When preparing spinach curry, adding a sufficient amount of Goraka (garcinia) is helpful in absorbing non heme iron found in the vegetable. Spinach can also be juiced. It is advisable to add orange or lime juice into spinach drink.
Soybeans are also a good source of iron. Yet, commercially produced Soya Meat which is also affordable and abundant, cannot be recommended as a good source of iron as they may not contain soybean extract.
Boiled chickpeas is a popular food in Sri Lanka. Eating vitamin C-rich fruits along with chickpeas can help better absorption of iron in them. Currying chickpea by adding a good amount of vitamin C sources such as garcinia or lime juice is advisable.
Vegetable and fruits such as Beetroot and water melon contain iron too.
Dr. Naveen De Soysa is the Assistant Secretary of the Government Medical Officers’ Association and the Senior Registrar in Community Medicine at the National Institute of Health Sciences. Panchamee Hewavissenti is a culinary researcher and recipe creator