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Muhilal, Iman Sumarno, and Komari
Iron-deficiency anaemia is one of the main nutritional problems in Indonesia, with a prevalence of 63.5% in pregnant women and 55.5% in pre-school children. Its frequency is related to low iron and folic acid contents of the diet. Intervention programmes to alleviate irondeficiency anaemia are iron tablets for adults, iron syrup for infants and schoolchildren, and iron fortification of foods. Our studies have demonstrated that iron supplementation can reduce the prevalence of anaemia in pregnant women by 20% to 25%, and iron fortification can reduce it by 20% for those consuming the fortified foods. If iron-supplementation, iron-fortification, and diet-modification programmes were fully implemented in a community, the expected reduction in the prevalence of anaemia would be greater.
Iron-deficiency anaemia is one of the main nutritional problems in Indonesia because of its devastating consequences and its magnitude. It is widespread not only in pregnant women but also among children under five years of age, schoolchildren, and low-income workers. Many studies have been conducted in Indonesia to assess the prevalence and the cause of anaemia and to evaluate various methods of solving the problem. As a result, considerable knowledge has been accumulated; however, despite many successful interventions in study settings, the prevalence of anaemia, especially in pregnant women, remains high. This raises many questions about the effectiveness of interventions in the community setting, including the question of compliance in consuming the recommended doses.
The prevalence of anaemia in Indonesia
Table 1 presents the prevalence of anaemia among pregnant women in various parts of Indonesia and its prevalence at the national level. These data show that the prevalence in various parts of the country ranges between 38.0% and 71.5%, and the average prevalence for all of Indonesia is about 63.5%. Surprisingly, Java, the most developed part of Indonesia, is among the areas with the highest prevalence- 57.8% to 71.5%. Irian Jaya, one of the less developed areas, has the lowest prevalence (38%).
The prevalence of anaemia in pre-school children in various parts of Indonesia is between 35.8% and 60.6%, and the average prevalence at the national level is 55.5% (table 2). Similar to the situation in pregnant women, the lowest prevalence in preschool children is in Irian Jaya (35.8%). In central Java the prevalence in schoolchildren (44.9%) is among the lowest, whereas that in pregnant women (62.5%) is among the highest.
Causes of anaemia in Indonesia
In the early 1970s, analysis of blood from pregnant women found that the transferrin saturation was less than 16%, indicating that anaemia was caused by iron deficiency . Although the vitamin B12 status of these women was normal, their folic acid status was marginal. Therefore, in addition to iron deficiency, it seemed that folate deficiency might be contributing to the problem of anaemia. Eighteen years later, more evidence was provided that anaemia was caused by iron deficiency with the finding that ferritin values of anaemic pregnant women were low and free erythrocyte protoporphyrin (FEP) (also known as zinc protophorphyrin) values were high .
The source and bioavailability of iron are influenced by the composition of the diet. In the early 1970s, a series of studies [4, 6] on the prevalence of anaemia among pregnant women was conducted in areas where the staple foods were rice, sweet potatoes, and cassava. There was a tendency toward a higher prevalence of anaemia among pregnant women in areas where the proportion of rice in the diet was higher (table 3). Among women in an area where rice was the only staple food, 77% suffered from anaemia, compared with only 46% in an area where cassava was the dominant staple food. Unfortunately, no information is available on the causes of the differences in the prevalence among areas with different staple foods. However, three questions arise: 1. Does rice contain more substances that inhibit the absorption of iron than other staple foods?
2. Do people in rice-eating areas have more hookworm infestation because of a greater number of worms in the environment and/or more exposure to worms from direct contact with mud, especially during land preparation and planting?
3. Do people in areas in which rice is not the only staple food consume more pulses or other foods rich in iron?
Hookworm infestations are another major cause of iron deficiency , and therefore any intervention to combat anaemia in Indonesia should include deworming.
TABLE 1. Prevalence of anaemia in pregnant women
|Province||No. of subjects||Prevalence (%)||Ref.|
|East Nusa Tenggara||441||51.0||3|
TABLE 2. Prevalence of anaemia in pre-school children
|Province||No. of subjects||Prevalence (%)||Ref.|
|West Nusa Tenggara||167||51.9||1|
|East Nusa Tenggara||493||48.9||3|
TABLE 3. Prevalence of anaemia in pregnant women in areas with different staple foods
|Area||Staple foods||Prevalence (%)|
|Indramayu + Purwakarta (west Java)||Rice||77|
|Bali||Rice + sweet potato||56|
|Gunung Kidul (Yogyakarta)||Cassava + rice||46|
|Bogor (west Java)||Rice||57|
An increase in hemoglobin and a decrease in the prevalence of anaemia have been consistently reported from daily iron supplementation studies. Table 4 shows the results summarized in a 1985 report for supplements provided by health workers or by teachers in the case of schoolchildren. Table 5 shows the results for other studies in which the distribution of iron supplements was supervised. It should be noted that compliance was particularly variable in the case of pregnant women, many of whom did not take the supplement because of side effects such as dizziness and nausea. Another reason for poor compliance was concern for the darkening of their faeces.
TABLE 4. Effect of iron supplements distributed by health workers or schoolteachers on haemoglobin (Hb) levels and prevalence of anaemia
|Subjects||Treatment per day||Hb (g/dl)||Prevalence (%)||% reduction in prevalence|
|Pre-school children||Ferrous sulphate syrup 3 mg Fe/kg||11.7||12.3||39.1||29.6||24|
|Schoolchildren||Ferrous sulphate tablet 60 mg||12.3||12.8||43.7||33.0||25|
|Fe, 2.5 mo|
|Pregnant women||Ferrous sulphate tablet 120 mg||11.8||12.5||37.3||24.7||34|
|Adult women||Fe, 2.5 mo||12.2||12.8||38.9||34.5||11|
Source: Ref. 7.
TABLE 5. Effect of supervised iron supplementation on haemoglobin (Hb) levels and prevalence of anaemia
|Hb (g/dl)||Prevalence (%)||Ref.|
|Subjects||Treatment per day||Before||After||Before||After|
|Workers||Ferrous sulphate tablet 120 mg Fe Placebo||11.95
|Schoolchildren||Ferrous sulphate tablet 60 mg Fe||10.40||13.47||9|
|Pregnant women||Ferrous sulphate tablet 120 mg Fe (through health centre)||70%Hb increased
5%Hb the same
|Schoolchildren||Ferrous sulphate tablet 60 mg Fe Placebo||47.5
|Infants||Ferrous sulphate syrup
3 mg Fe/kg Placebo
|Pregnant women||Ferrous sulphate tablet 60 mg Fe through traditional birth attendants)||10.3||11.3||13|
a. 41 % decrease in prevalence.
b. 14% increase in prevalence
Coverage of iron tablet distribution
Evaluations of the coverage of iron distribution among pregnant women were conducted in various areas in Indonesia [2, 14]. Coverage ranged from 30.8% to 78.6% (table 6). Unfortunately, these studies did not provide information on compliance. However, judging from the high prevalence of anaemia among pregnant women, one can conclude that despite moderate coverage, compliance was very low.
How to reduce the prevalence of anaemia among pregnant women
Three approaches have been considered for reducing the prevalence of anaemia: supplementation, fortification, and diet modification. Supervised supplementation with iron tablets was able to reduce the prevalence of anaemia by an average of 24%. Converting this reduction into the community-based programme setting, the reduction due to iron supplementation will depend on the degree of compliance achieved with a weekly dose that is essentially free of side effects. In our studies this reduction was 20% to 25%.
TABLE 6. Coverage of iron tablet distribution
Source: Refs. 2 and 14.
The reduction of the prevalence of anaemia by adding 10 mg of elemental iron was approximately 20%  when the fortified foods were consumed. Since not all pregnant women will be consuming the fortified foods, the actual reduction will be somewhat less.
There are no solid data on the impact of diet modification. The best estimate for reducing anaemia by this method, about 10%, is obtained by comparing the prevalence of anaemia in an area with deficient staple food to that in areas with other staple foods. Diet modification requires a long time to be implemented.
The most desirable outcome would be the concurrent implementation of all three approaches.
1. Institute for Health Research and Development and Central Bureau of Statistics. National household health survey. Bogor: Institute for Health Research and Development, 1992.
2. Nutrition Research and Development Centre and Directorate of Community Nutrition. Study on the assessment of nutritional anaemia. Bogor: Nutrition Research and Development Centre, 1993.
3. Nutrition Research and Development Centre and Directorate of Nutrition. Eastern island nutrition status prevalence study. In-country report. Bogor: Nutrition Research and Development Centre, 1991.
4. Martoatmodjo S, Abunain D, Muhilal, Enoch M, Husaini MA, Sastroamidjoyo S. Nutritional anemia among pregnant women and food consumption pattern. Penelitian Gizi den Makanan 1973;3:22-é41.
5. Permaesih D, Murdiana A, Riadi H. Hubungan status anemi den status besi wanita remaja santri. Penelitian Gizi den Makanan 1988;11:38-46.
6. Martoatmodjo S, Muhilal, Enoch M. Nutritional anemia in pregnant women in the village of Bendungan, Bogor. Penelitian Gizi den Makanan 1972;2:11-23.
7. Muhilal, Suharno D, Saidin S, Permaesih D, Satibi I. Iron supplementation pilot programme. Gizi Indonesia 1985;30-4.
8. Karyadi D. The relationship among endurance, nutritional status and iron deficiency anemia. Doctoral thesis, University of Indonesia, 1974.
9. Soemantri AG. The relationship between iron deficiency anemia and concentration and school performance. Doctoral thesis, Diponegoro University, 1978.
10. Martoatmodjo S, Muhilal, Sastroamodjojo S, Soemarno I. Prevention of iron deficiency anaemia in pregnant women with iron pills or ferrous sulphate through public health centre. Penelitian Gizi den Makanan 1980;4: 313.
11. Almatsier S. Pengaruh pendekatan belajar status anemia gizi besi den tambahan zat besi terhadap pretasi belajar IPA siswa Sekolah Dasar. Doctoral thesis, Institut Keguruan den Ilmu Pendidikan, Jakarta, Indonesia, 1989.
12. Idjradinata PS. Effect of iron supplementation on growth and development among iron deficient infants. Doctoral thesis, Pajajaran University, 1992.
13. Rustam E. Development of iron pills delivery system through traditional birth attendants and village midwives. Project report. Bogor: Nutrition Research and Development Centre, 1994.
14. Department of Health, Provincial Office of South-East Sulawesi and Nutrition Research and Development Centre. Study of anemia in pregnant women and underfives for planning program for combating anemia in the second step of long term development. Bogor: Nutrition Research and Development Centre, 1994.
15. Saidin S. Dampak fortifikasi besi den vitamin A pada mie instant terhadap status besi den vitamin A anak balita den ibu hamil. Project report. Bogor: Nutrition Research and Development Centre, 1995.
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