Diagnosing and treating anemia in rural Guatemala

In regions of the world where populations are at greatest risk for iron deficiency anemia (IDA), barriers make screening particularly challenging. Even though noninvasive field-tested methods provide an inexpensive approach for determining iron status, it can be difficult to gain access to rural, secluded communities. Therefore, the prevalence of IDA in these regions remains largely unknown. Researchers examining the most current representative data regarding the prevalence of IDA in Latin American countries that Costa Rica, Chile, Argentina and Mexico (4.0%, 40%, 7.6% and 19.9%, respectively) had the lowest prevalence rates. Countries with moderate to high prevalence rates, which ranged from 21.4% to 45.5%, included Guatemala, Brazil, the Dominican Republic, Bolivia, Panama, and Haiti. Our data supports this finding in terms of IDA prevalence rates. Although prevalency rates have been estimated, very few studies have assessed treatment efficacy.

During Phase 1 of our medical mission, we assessed iron status in 4 rural, impoverished regions of Guatemala; each listed below:

1. Pueblo Modelo – This is one of the poorest cities in Guatemala. Due to mudslides and earthquakes, an entire community was resettled to this region without any existing infrastructure. Water is delivered on a weekly basis, and power is limited to generators. 
2. San Miguel, Chiquimula
3. San Cristobal
4. Las Casitas, Gualan

Although data analysis from Phase 1 is still in progress (prevalence of anemia by sex, age, and community), one interesting assessment compared the prevalence of anemia among the 4 villages to prioritize public health significance within each region. Based on World Health Organization classifications, we characterize each village based on community screenings:

Category of Public Health significance

Prevalence of anemia (%) within a community:
       Severe > 40 %
       Moderate 20.0 - 39.9%
       Mild 5.0 - 19.9%
       Normal < 4.9%

1.  Pueblo Modelo (n=102) Classification: Moderate prevalence
     30.2%^* anemia based on hemoglobin (12.3 g/l + 3.4) ^**
2.  San Cristobal (n=153) Classification: Moderate prevalence
     32.0% anemia based on hemoglobin (12.4 g/l + 1.45)
3.  San Miguell (n=100) Classification: Moderate prevalence
     20.0% anemia based on hemoglobin (12.5 g/l + 1.3)
4.  Las Casitas (n=60) Classification: Severe prevalence
     41.7% anemia based on hemoglobin (11.6 g/l + 1.2)                          

This information will help public health officials to target communities at greatest risk for IDA. This is important due to limited resources. As indicated in the table above and attached figures, each community has IDA rates considered moderate to severe. Age-groups with the highest IDA prevalence (34%) are children 5-9 (y) and those 50 years of age and older (40%). As there is very little information regarding the prevalence of iron deficiency anemia among the elderly, this finding is particularly important.

Summary: In addition to data analysis, we are currently preparing for our follow-up study (Phase 2) to assess the impact of Lucky Iron Fish on iron status. Twenty-five students will be selected to participate in this medical mission. We will also be visiting 5 new communities, and will continue our work assessing iron status. It is our goal to purchase a new HemoCue and 300 Lucky Iron Fish to distribute to families with IDA. Financial contributions with these purchases, which in turn will help us to reach more people. Our goal is to better understand the impact of iron deficiency anemia in Guatemala, and the efficacy of this novel treatment - Lucky Iron Fish.

• Village Pueblo Modelo Figure (PDF)
  
• Village San Cristobal Figure (PDF)
  
• Village San Miguell Figure (PDF)
  
• Village Las Casitas (PDF)
  

We appreciate the generous contributions we have received in support of this on-going project. Although our first data collection is complete, we will return March 2017 to assess the effect of Lucky Iron Fish on iron status. We are still in the process of entering data collected during our last trip, but I do have some preliminary information to share. First, the 2016 Global Nutrition Report  "FROM PROMISE TO IMPACT: ENDING MALNUTRITION BY 2030" was just released. This report, which included Guatemala, is an important reminder malnutrition entails more than assessing hunger. Rather, it emphasizes the emerging trend of an overlap between the obesity epidemic, the prevalence of stunted growth, and impaired iron status in both children and women of reproductive age. Our data supports these observations. While we only have partial information, the trends are clear. We will post a more complete report within the next few months. However, based on partial analsys, we found the following:
1.  Anthropometric analysis of children between ages 5 - 18 (y)
Based on World Health Orgnization growth charts, a total of 11 (6%) children (female = 6 and male = 5) were classified as failure-to-thrive (BMI-for-Age < 3rd percentile) and 32 (17%) of children (female = 15 and 17 = male) were below the 15th percentile but above the 3rd percentile. Approximately 63% of the children (female = 40 and male = 20) were within healthy parameters (> 15th percentile < 85th percentile). However, there is a growing trend of overweight and obese children.  Approximately 10% (n=19; 15 female and 4 male) are considered overweight (> 85th percentile and < 97th percentile) while 3% (n=5; 3 female and 2 male) were classified as obese (>97th percentile). We will soon correlate these numbers with iron status. With respect to BMI-for-Age, sex differences at the lower range, but it appears that females are more likely than males to be classified as overweight. 

2. Anthropometric analysis of adults > 19 (y)

Anthropometric analysis of adults (1 village; 63 adults), 51% (n=32) have BMI > 26 kg/m), 14 of which were classifed as obese (BMI > 30 kg/m). Those with BMI > 28 (n= 14) were tested for impaired glucose regulation (A1c). Of these,  2% had elevated A1c (>7). These analyses will be repeated for the remaining sites. 

In conclusion, iron deficiency anemia appears to be problematic in children and women of child-bearing years. There is evidence that this may impact growth in children in terms of stature but not body weight. There is also evidence of the emerging problem of obesity. These trends may reflect starch-based diets that are inadequate in terms of certain nutrients (e.g. iron) but are abundent in terms of calories. Thus, Guatemala appears to struggle in terms of both forms of malnutrition - both undernutrition (iron) and overnutrition (energy intake). Because of a lack of clean, accessable water, both children and adults consume an abundance of sugar-sweetened beverages. This is partly because the cost of sugar-sweetened beverages is less than that of bottled water. As such, the problem of tooth decay is most apparent. Average number of children per household is approximately 5 (1 low; 19 high).