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Iron Deficiency in Indonesia: Current Situation and Intervention
Iron Deficiency in Indonesia: Current Situation and Intervention
1998
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ABSTRACT
’Correspondingauthor: Dr Saskia de Pee, Helen Keller International (Indonesia). Jl. Patra Kuningan
XIV/IZ, Jakarta 12950, Indonesia, Tel. +62-21-5263872, Fax +62-21-5250529, e-mail:
sdepee@compuserve.com
1953
1954 B. KODYAT et al.
billion people of the world’s population of nearly 6 billion people suffer from IDA (1).
In Indonesia, 50 to 70 million people, out of the total population of 200 million, suffer
from IDA. In developed countries, the prevalence of IDA among adolescent and adult
women can also be as high as 10% (1).
In 1993, Infant Mortality Rate and Maternal Mortality Rate were 58/1000 and
425/100,000, respectively, while life expectancy was 62.7 years (15). The goals for
1998 are that Infant Mortality Rate and Maternal Mortality Rate are reduced to
5011000 and 225/100,000, respectively, and that life expectancy is increased to 64.6
years.
Indonesia’s most prevalent nutrition problems that restrict human development
are nutritional deficiency problems, including iodine deficiency disorders, nutritional
anemia, vitamin A deficiency and protein energy malnutrition, as well as upcoming
problems of over nutrition, such as obesity, coronary heart disease and diabetes.
suffer from IDA. The target for the end of the second Long Term Development Plan
(PJP II, 1993-2018) is that the prevalence of anemia is reduced to 9% in pregnant
women and to 10% in both underfives as well as female workers (Figure 1).
70 - 1
60
0 Pregnant women
50 . ??Under-five children -
40
30
20
10
0 -e-
End of End of End of End of End of End of
REPELITAV REPELITA VI REPEL.ITA REPELITA REPELITA IX REF’JZLITA
X
(1993) (1998) VII (2003) VIII (2008) (2013) (2018)
The direct causes of anemia are a too low iron intake and a too low bioavailability of
dietary iron. The main staple in Indonesia, rice, contains little iron and is rich in
phytate, which reduces iron bioavailability. The consumption of animal food, a good
source of iron with relatively high bioavailability, is low. The consumption of green-
leafy vegetables is high, but the bioavailability of their iron is low due to inhibitors
such as phytate (20). In addition, anemia can be associated with chronic diseases or
recent infection such as worm infestation, especially hookworm, malaria and
tuberculosis (11).
The iron needs during pregnancy can rarely be met through the diet alone. Not
only in developing countries, but also in Western countries, many pregnant women
receive iron supplements. Since 1974, Indonesia has a program of iron
supplementation for pregnant women, that is organized through the Family Nutrition
Improvement Program (UPGK) and the Maternal-Child Health Program. Pills
containing 60 mg elemental iron and 250 pg folic acid are distributed for free by the
Health Centres (Puskesmas), village health posts (Posyandu), traditional birth
attendants, village midwives and village drug posts (Pos Obat Desa). Currently, it is
recommended that one pill is taken per day for a period of at least 90 days.
Sunnlementine. underfives
“Underfives” can be divided into 3 groups: infants (~12 mo), children aged
12-23 months, and children aged 2-5 years. During infancy, iron requirements are
very high, because of rapid growth.(21). It is estimated that iron stores, if they were
adequate at birth, will be depleted within 4-6 mo after birth. Because the
bioavailability of iron from breastmilk decreases when weaning foods are introduced,
exclusive breastfeeding is recommended till the age of 4-6 mo. After that, when the
sources of iron are breastmilk and complementary food, complementary food should
be rich in iron.
From the age of 1-2 years, iron needs decrease. Thus, when infants reach the
age of 12-18 months with adequate iron stores, they are likely to maintain their
adequate stores throughout childhood. However, poor sanitation, infection, parasitic
infestation and poor nutrition increase the risk of depleting the iron stores and may
thus cause IDA in children.
Because in many areas of the world, including Indonesia, the iron content of
complementary foods is too low, the infant’s iron needs should be met by
supplementation. In 1996, an interagency consultation (22) recommended that in areas
where a food-based solution is not yet possible, a daily dose of 12.5 mg elemental
iron should be given to children aged 6-24 mo. It has been shown that iron
supplementation of infants aged 12-18 months can improve their hemoglobin
concentration as well as their indicators of iron stores such as transferrin saturation
and serum ferritin concentration (23).
have introduced iron supplementation for infants and pre-school children. Since 1996,
approximately 30% of underfives in deprived areas in Eastern Indonesia receive iron-
rich syrup, through the primary health care system. The dose of elemental iron
currently recommended in Indonesia is 15 mg/d for 60 days for infants and 30 mg/d
for 60 days for children aged l-5 years.
Health policies in Indonesia take a “life-cycle approach”. For IDA this means
that it should be prevented throughout life and that interventions should take place in
the periods that individuals are most at risk, such as during infancy, adolescence and
pregnancy.
Because it has been found that providing iron supplements to anemic children
in primary school can improve their learning capabilities (5, 6, 9). The working group
recommended that iron supplements should also be given to school children (see
Kosen et al, this issue).
low income and less developed areas (daily), and to female workers (daily)*. Pregnant
women and underfives are reached through health services, such as health centres,
posyandu (integrated community health post), hospital and private practices,
supporting an inter-sectoral approach of the government, the community and the
private sector, while the female workers are reached through the non-health sector.
School children, at primary school as well as at junior high school, as well as non-
pregnant women not working in a factory, are not yet targeted at a large scale.
However, IEC strategies that aim at increasing consumer awareness and procurement
of iron supplements are broadening their approach to also include these target groups.
Apart from IEC, efforts to improve coverage and compliance for iron-folate pills also
focus on improving the distribution system and on monitoring and evaluation of
coverage and compliance.
Because meeting the requirements for iron through the diet is very difficult,
supplementation and food fortification are very important strategies to combat IDA.
Fortified foods that are currently being marketed in Indonesia include infant formula
and weaning foods produced by larger (multinational) companies, imported products,
and some of the instant noodles produced by some Indonesian companies (28). The
first category of foods are only within reach of the highest socio-economic strata,
whereas a much larger proportion of the population is purchasing (fortified) noodles.
One brand of noodles is currently fortified with, per 100 g, 7 mg iron, 1800 IU
vitamin A, 0.7 mg vitamin Bl, 0.5 mg vitamin B6, 1.3 ug vitamin B12, 0.7 mg
panthotenic acid, 130 pg folic acid and 7.5 mg niacin. A community trial in West-
Java that tested the effect of distributing mono-sodium-glutamate fortified with
vitamin A found, in addition to an improvement of vitamin A status, an improvement
of hemoglobin concentration in the target population (29). While the costs of the
technology required do not yet allow this to be introduced at a large scale, it indicated
that a lack of vitamin A also played a role in the etiology of anemia. This strengthens
the argument that food fortification should, where possible, be done with multiple
micronutrients.
“Jamu”, traditional herb drinks, are another category of products which has for
long been regarded as a good “vehicle” for delivery of iron, because it reaches a large
proportion of the population vulnerable to IDA. Particularly women take “jamu” and
it is commercialy produced as well as home made. Recent analysis have shown that
the iron content of “jamu” is high, however, the content of inhibitors of iron
absorption is also high (32). Therefore, and because the traditional recipes for
preparing “jamu” do not allow the addition of non-natural substances, the possibility
of adding natural enhancers of iron absorption, such as the vitamin C-rich tamarind, is
currently being considered by commercial producers of “jamu”.
* For discussion of daily or weekly iron supplementation see Schultink and Drupadi, this issue, as well
as work by Muhilal and colleagues on supplementing different target groups once in two weeks (5).
IRON DEFICIENCY IN INDONESIA 1959
Dietarv diversification
The primary health care system also includes, besides iron supplementation,
deworming and nutrition education, which may both benefit iron status.
In addition to health and nutrition, other sectors also contribute to recuding the
prevalence of iron deficiency anemia. These sectors and how they contribute are
described below.
Education
Economic growth increases the need for good quality human resources. In
South Korea for example, human resources contribute 37% of the economic added
B. KODYAT et al.
value, while in the Asian superpowers it is already 62%. School enrolment, school
performance and quality of education thus need to be improved in order to increase
the quality of the human resources.
In order to improve education, to reduce school drop-out, and to achieve a
universal nine years basic education, and to increase awareness about the importance
of good health and nutrition, a national school-feeding program was started in 1996.
In the first year, the program covered 2.3 million children at schools in deprived
villages outside Java and Bali. In the next school year (1997-1998), 7.3 million
children will be covered at schools in deprived villages throughout Indonesia. The
program is coordinated by the national planning board (BAPPENAS) and is part of
the poverty alleviation plan. The children receive 3 snacks per week at school and are
dewormed twice per year.
In 1995, the Family Planning Movement was turned into the Movement of
Prosperous Family Development (MPFD). The objective of the MPFD is to empower
families to become good manpower for national development. Some of the indicators
for assessing progress towards a prosperous family are related to the reduction of
anemia: non-soil floor of the house; approaching a modem service point for health
care; meal of good quality (at least once per week egg/fish/meat) and quantity; having
one meal per day together as a family to balance the meal quality; and at least one
family member with a more or less guaranteed income. Family planning avoids the “4
too’s”: married too young, became pregnant too young, too little spacing between
children, and pregnant at a too old age. These all may play a role in the etiology of
anemia. An additional strategy for iron supplementation would be to replace the 7
placebos in the anti-conception pill with iron supplements.
Ministrv of ManDower
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