PHNOM PENH — Lucky Iron Fish were once a common sight in many Cambodian cooking pots. Villagers threw the fish-shaped, cast-iron ingots into their food as a way to treat anemia, a condition — characterized by a lack of enough healthy red blood cells to carry adequate oxygen to the body's tissues — that is frequently caused by iron deficiency.

With rates at 56% among children aged 6–59 months and 45% among women 15–49 years old, according to the 2014 Cambodia Demographic and Health Survey, Cambodia's anemia problem is significant. And this seemingly simple solution (a Lucky Iron Fish can slowly release about 7 mg of iron into whatever is being cooked) was heralded as a way to dramatically reduce incidence of the condition.

But there's just one problem: Iron deficiency is not the primary cause of anemia in Cambodia, according to researchers. The Lucky Iron Fish, in other words, addresses an issue that doesn't exist — at least not in this specific setting. And while it may be useful elsewhere, experts warn that in Cambodia, the Lucky Iron Fish may undercut efforts to address the actual causes of anemia.

Missing the mark

Lucky Iron Fish was the brainchild of Christopher Charles, who was shocked to discover while working in Cambodia, in 2008, just how widespread anemia is. With the World Health Organization (WHO) reporting iron deficiency to be the primary cause of anemia, the University of Guelph science graduate came up with an idea to modernize the age-old method of introducing iron to the diet by cooking in cast iron pots.

Kate Mercer, Lucky Iron Fish vice president of marketing and communications, told News Deeply, "We've done several studies in Cambodia and have found that although some results are inconsistent, overall there is great scientific support for using the Lucky Iron Fish as an easy and affordable way of increasing the dietary iron in food."

If we get rid of iron deficiency we get rid of 50%of anemia.

The initiative captured imaginations across the globe, scooping up a clutch of awards, including a prize for product design at the Cannes International Lions Festival and a 2015 Design for Asia award. It also secured a raft of funding, including $880,000 from the Bill and Melinda Gates Foundation to plow into research.

There are now some 5,000–7,000 Lucky Iron Fish being used in Cambodia. The majority have been distributed in bulk by NGOs and aid organizations for $5 a fish, with the remainder being sold to individuals for $25. And yet, researchers say that in Cambodia, at least, programs like Lucky Iron Fish that aim to eradicate iron deficiency may have little luck in also bringing down anemia.

"Iron deficiency is a very common cause of anemia globally, but dozens of other causes exist," said Dr. Reina Engle-Stone, a specialist in public health nutrition at the University of California, Davis. "With a few exceptions, causes other than iron deficiency have gotten relatively little attention in the context of large-scale programs to address anemia."

Anemic Cambodian woman receiving a Lucky Iron Fish — Photo: Lucky Iron Fish/Facebook

In 2014, Dr. Frank Wieringa, from France's Institut de Recherche pour le Developpement, and a team of researchers carried out a study in Cambodia. For the resulting paper, published in the journal Nutrients in 2016, blood samples of more than 2,000 women aged 15–39 across the country were surveyed. "We found almost no iron deficiency in Cambodia," Wieringa told News Deeply. The exception was in infants aged 6 months–2 years, with about 10% having iron deficiency anemia. He attributed this to fast growth rates that draw on iron stores.

Wieringa said the majority of anemia in Cambodia is related to genetic defects, such as Hemoglobinpathy E, where smaller than normal red blood cells are present. That might help explain why previous attempts, between 2005 and 2014, to reduce anemia by passing out free iron supplements had little effect. The researcher expects much the same from Lucky Iron Fish.

"We never thought it would have an impact," he said. "Even if iron deficiency was high in Cambodia, it wouldn't have a big impact because the absorption from this type of iron is so low; it's nothing."

Better than nothing?

While failing to reduce anemia rates is a problem in itself, Wieringa said interventions like Lucky Iron Fish can create even bigger complications.

"If 50% of anemia is caused by iron deficiency, then if we get rid of iron deficiency we get rid of 50%of anemia, so we should see an impact on anemia prevalence," he said. "But when that doesn't happen, politicians get disheartened and question why they have been investing in this."

It can also lead to policymakers resting on their laurels. "It makes it easier for Cambodian politicians to do nothing," Wieringa said. "There are all these initiatives going on and they don't have to do anything about it, which, of course, isn't true."

There will never be a single solution.

Still, some researchers are not ready to abandon Lucky Iron Fish entirely. Mourad Moursi, a nutrition expert at HarvestPlus, has carried out research in the area and argues that the fish may still be beneficial to some demographics in which people do have iron deficiencies. After all, they provide an affordable alternative to dishing out iron tablets.

"We now know the space for impact on iron deficiency is much lower than we thought," he said. "That means we can't say it is going to reverse iron deficiency and anemia, but it may be extremely useful as a prevention." This is especially true for women in the first trimester of pregnancy, he said, when their bodies draw heavily on iron stores. "This is where the Lucky Iron Fish can be useful in terms of prevention, if it's something they have in their daily lives."

And there is evidence it can work to reduce anemia in settings where anemia is the result of iron deficiency. In one trial conducted in three Cambodian villages, the fish ingots did reduce anemia among women who used the intervention by 46% compared to a control group.

Nevertheless, don't look to it as a panacea, warns Reina Engle-Stonewarned from the University of California, Davis. "There will never be a single solution, simple or not, to a complex problem like anemia," she said. "On the other hand, we cannot do nothing just because we don't have all the solutions."