Evaluation of effectiveness of iron-folate supplementation and anthelminthic therapy against anemia in pregnancy--A study in the plantation sector of Sri

Lanka
Author: Atukorala, T M Sunethra; de Silva, L Dilip R; Dechering, Wim H J C; Da "erera, Ra#itha S Abstract: $ntervention mea ure again t anemia availa%le to plantation &orker during pregnanc! include 'orti'ied 'ood uplement and iron('olate upplement ) The e''ectivene o' the e upplement i di cu ed) enaeike, T Stanle! de C;

$*TR+D,CT$+* *utritional anemia i an important health pro%lem in man! developing countrie , including Sri Lanka, and it lead to decrea ed capacit! 'or ph! ical &ork -./) The prevalence o' anemia i ver! high during pregnanc! -0/) $t i a ma#or cau e o' maternal mor%idit! and mortalit! and it al o a''ect the outcome o' pregnanc! -1/) Several intervention mea ure are availa%le to pregnant &omen in Sri Lanka, including 'emale plantation &orker ) Monthl! antenatal clinic are held on plantation and pregnant &omen are e2amined %! a Medical A i tant3"u%lic Health Mid&i'e 'or clinical evidence o' anemia -ie, pallor o' tongue/ and their &eight change i monitored) The Mini tr! o' Health in Sri Lanka provide the 'ollo&ing 'ree o' charge to all pregnant &omen4 ./ a vitamin(mineral 'orti'ied 'ood upplement -thripo ha/; 0/ oral iron('olate upplement -'errou ulphate containing 56 mg elemental 7e and 6)08 mg 'olic acid/; and 1/ one cour e o' me%enda9ole, an oral anthelminthic agent, a'ter the 'ir t trime ter o' pregnanc!) De pite the availa%ilit! o' intervention mea ure , &e o% erved a high prevalence o' anemia and protein(energ! de'icienc! among plantation &orker during .6(05 &k o' ge tation) Hemoglo%in concentration :..6 g3L &ere noted in 8;)<= o' 16> u%#ect , &herea protein(energ! de'icienc! a indicated %! lo& -: .;)8/ %od! ma inde2 -?M$; in kg3m up 0 / &a o% erved in 16)>= and midupper arm circum'erence value :01 cm &ere o% erved in @1)0= o' the e u%#ect ) Su%clinical de'iciencie o' vitamin A and 9inc, a indicated %! lo& concentration o' vitamin A -6)@6 mu(mol3L, :06 mu(g3dL/ and 9inc -: ; mu(mol3L/ in the erum, &ere al o noted in <5)0= and <8);= o' the u%#ect , re pectivel!, during the ame period o' ge tation -LDR de Silva and TMS Atukorala, unpu%li hed o% ervation , .>>./) $t i important to a certain the e''ectivene o' the a%ove(mentioned intervention in improving nutritional tatu &hen delivered o' intervention mea ure given to pregnant plantation &orker to under 'ield condition , o that e''ective intervention mea ure can %e identi'ied) Thi report pre ent data on a tud! done to evaluate the e''ectivene improve their nutritional tatu and the outcome o' pregnanc!) S,?JACTS A*D MATH+DS +ne hundred ninet!('ive pregnant plantation &orker -.<(0< &k ge tation; mean B3( SD .>)5 B3( 5)1 &k/ aged .@(<8 ! -mean age 08). B3( <)> !/ &ere elected randoml! 'rom the large t plantation and neigh%oring plantation in 'ive o' i2 region %elonging to Sri Lanka State "lantation Corporation) Tea &a gro&n on the e plantation , &hich &ere ituated in the hill! area o' Sri Lanka) Selection o' the large t plantation in each region &a %a ed on the 'act that the e plantation had a higher num%er o' pregnant &omen and had %etter 'acilitie 'or conducting the tud!) The num%er o' u%#ect tudied had to %e limited %ecau e o' di''icultie in tran porting ing and anal! i ) +nl! &omen &ho e ed %lood ample 'rom plantation in remote area to the la%orator! 'or proce

did not have other kno&n di ea e &ere included in the tud!) +ne hundred and thirt! u%#ect &ere rea &ho had delivered %a%ie %! the econd a e ment &ere not included) The u%#ect

CC.< &k later, at D10 &k ge tation -mean period o' ge tation 11). B3( 1)@ &k/) La%orator! data on 58 u%#ect tudied &ere mainl! tea plucker ) Their mean -B3(SD/ monthl! income per 'amil! &a .56; B3( 580 Rupee -range .666(1@86 Rupee 3mo/, eEuivalent to CCF<6)66) There &a no igni'icant di''erence in the income %et&een plantation ) Although their income varied depending on the availa%ilit! o' &ork, it &a 'ood item &ere purcha ed, &herea u''icient to purcha e 'ood) The main ome vegeta%le &ere gro&n %! the &orker on communit! plot , or

around their o&n Euarter ) The average num%er o' &omen o' child%earing age &orking on the plantation

tudied during the 0(! period o' tud! &a @.06 and there &ere 86; and 881 pregnancie , re pectivel!, per !ear) 7i't!(nine percent o' 'emale plantation &orker in thi age group &ere literate) The prevalence o' anemia among nonpregnant &omen in the plantation ector ha not %een tudied) Some ociodemographic in'ormation regarding the u%#ect rea e tudied i given in Ta%le .) -Ta%le . omitted/ The parit! o' the u%#ect tudied ranged ed initiall! and 'rom . to 5 &ith a mean -B3(SD/ o' 0)16 B3( .)0;) The nutritional tatu o' u%#ect &a a e u%#ect &a mea ured -&ithout hoe / at each a e

ed CC.< &k later %! u ing anthropometric and %iochemical inde2e ) The &eight and height o' all ment %! u ing cali%rated cale to an accurac! o' B3(6)8

kg and B3(6)8 cm, re pectivel!, and the midupper an circum'erence &a al o mea ured %! u ing a peciall! de igned tape mea ure to an accurac! o' B3(6). cm according to the method de cri%ed %! Jelli''e -</) Tricep ( 'at'old thickne &a not mea ured in our tud!) ?ecau e the e u%#ect do not u uall! attend antenatal clinic in the 'ir t trime ter o' pregnanc! and prepregnanc! %od! &eight &ere not availa%le, the rate o' &eight gain during pregnanc! &a calculated according to the 'ormula given %elo&4 -AEuation omitted/ &here &eight 0 and &eight . are &eight at 10(<6 and .<(0< &k ge tation, re pectivel!) The anthropometric mea urement &ere carried out %! the ame inve tigator -TMSA/ to avoid an! intero% erver mea urement error) The outcome o' pregnanc! &a al o noted 'rom record availa%le at health center in plantation ) Aach pregnant &oman receive t&o @86(g packet o' the 'orti'ied 'ood upplement -thripo ha/ per month at antenatal clinic located on each plantation and i advi ed to con ume 86 g3d, either alone or mi2ed into other 'ood preparation ) Thi Euantit! &ould provide an average energ! content o' @81 kJ -.;6 kcal/, .6 g high(Eualit! protein, > mg 7e, and 06 mg a cor%ic acid -data provided %! the manu'acturer/) Mother &ere a&are o' the high palata%ilit! o' thripo ha and all mother collected it, i' it &a availa%le at antenatal clinic ) Aach u%#ect &a intervie&ed individuall! at %oth a e ment -in the a% ence o' plantation ta''/ regarding the intake o' upplement ) Mother &ere a ked &hether the! received the 'orti'ied 'ood upplement -thripo ha/ at ever! vi it to the antenatal clinic and al o &hether the! took it dail!) Data on attendance at antenatal clinic and collection o' upplement &ere o%tained 'rom entrie in motherG health record ) The Mini tr! o' Health, Sri Lanka, upplie iron('olate upplement -'errou ulphate containing 56 mg elemental 7e and 6)08 mg 'olic acid/ to antenatal clinic , and all mother are given the e upplement -a'ter the 'ir t trime ter o' pregnanc!/ &hen the! attend antenatal clinic ) The num%er o' ta%let given per mother and the recommended do e 'reEuenc! &a either one or t&o ta%let per da! in mo t clinic ) Aither 16 or 56 ta%let &ere given per month &herea a 'e& received >6 ta%let 3mo) The mother &ere told that the ta%let contained iron, and to take one ta%let once dail!, one ta%let t&ice dail!, or one ta%let thrice dail! -in a 'e& in tance /, %ut no other educational me A ample o' iron('olate ta%let &a age &a given) The num%er o' ta%let taken per da! depended on the recommended do e 'reEuenc! and on individual pre'erence ) ho&n to each mother -intervie&ed individuall!, in the a% ence o' plantation ta''/ and the! &ere a ked &hether the! took the ta%let dail! and &hether the! tarted taking the ta%let 'rom the 'ir t vi it to the antenatal clinic or later) The num%er o' iron('olate ta%let taken per da! &a deduced %! Eue tioning each mother regarding the time o' the da! at &hich he took the ta%let -morning, a'ternoon, and3or night/) When anthelminthic therap! -AHT/ &a given, mother &ere told that it i treatment given 'or &orm and all mother took it i' the! &ere given the ta%let ) Mother &ere a ked &hether the! &ere given AHT and &hether the! took it) Thi &a cro (checked %! e2amining the motherG health record ) 7e& u%#ect received parenteral iron therap! -$m'eron; MAD$SCA, Milano, $tal!/ and &ere e2cluded 'rom the tud! i' the! did) A venou %lood ample -.6 mL/ &a collected %et&een 6>66 and ..66 'rom each u%#ect -CC1 h a'ter the morning meal/ and an aliEuot -1 mL/ &a placed in a %ottle containing anticoagulant and u ed 'or e timating hemoglo%in and er!throc!te protoporph!rin, &herea the remainder &a collected into a %ottle &ithout anticoagulant) ?lood &a tran ported to the la%orator! in a re'rigerated %o2) The %lood collected &ithout anticoagulant &a centri'uged and the erum &a eparated &ithin 5 h o' %lood collection, divided into aliEuot ,

and tored at (06degC until anal!9ed) An aliEuot o' anticoagulated &hole %lood &a

tored at <degC and it tored

hemoglo%in concentration &a e timated &ithin 0< h o' %lood collection -8/, &herea the remainder &a

at (06degC; it er!throc!te protoporph!rin concentration &a e timated &ithin 1 d o' %lood collection -5/) The iron concentration and total iron(%inding capacit! o' the erum &a determined &ithin 0 &k o' %lood collection %! u ing reagent kit o%tained 'rom Sigma Chemical , St Loui -procedure no) 858/ and the percentage tran 'errin aturation &a calculated) The 'erritin concentration o' the erum &a determined &ithin 1 mo o' %lood collection %! u ing the and&ich en9!me immunoa gave in'ormed con ent) Statistical analyses Stati tical anal! e &ere carried out on an Apple Macinto h Computer %! u ing Data De k "ro'e t&o(varia%le and multiple(regre di tri%ution, Wilco2onG ion anal! e ) ?ecau e the erum 'erritin concentration ion anal! i ) ional 1)6 and a! method o' Linpi arn et al -@/) Thi pro#ect &a approved %! the Athical Revie& Committee o' the 7acult! o' Medicine, ,niver it! o' Colom%o, Sri Lanka, and u%#ect

A2 tati2 .)6). program -;/) The method u ed &ere StudentG r te t, paired t te t, anal! i o' variance, and ho&ed a ke&ed igned(rank te t and Hru kal(Walli te t &ere u ed, &herea log(tran 'ormed value o'

'erritin concentration &ere u ed in multiple(regre RESULTS The mean -B3(SD/ ?M$ o' u%#ect at 'ir t a e

ment -.<(0< &k o' ge tation/ &a .>)@ B3( .)> -n C .>8/, and e ed

0@)0= had ?M$ value :.;)8) ?irth &eight o' ne&%orn &a 0)5> B3( 6)<< kg, and 0.)>= had %irth &eight :0)8 kg, &herea 15)>= had %irth &eight %et&een 0)8 and 0)@ kg) The nutritional tatu o' u%#ect rea %et&een the t&o a e a'ter .< &k -n C .16/ i given in Ta%le 0) -Ta%le 0 omitted/ The mean rate o' &eight gain during the period ment &a 6)08 B3( 6).; kg3&k, and <5)>= o' the u%#ect had rate o' &eight gain :6)0 kg3&k) There &a al o a igni'icant decrea e in midupper arm circum'erence during thi period -" :6)6./) Although all &omen hould have received the 'ood upplement -thripo ha/, 0< u%#ect -.0)1=/ had not received an! 'ood upplement, &herea 1.)1= -n C 5./ o' the u%#ect had received it 'or :.6 &k during pregnanc! and 16)@= -n C 56/ and 08)@= -n C 86/ had received it 'or .6(.@ &k and D.@ &k, re pectivel! -Ta%le 1/) -Ta%le 1 omitted/ Mother &ho received the 'ood upplement &ere advi ed to con ume 86 d, %ut there &a con idera%le variation in the amount con umed and thi amount &a di''icult to Euanti'!) There &a no igni'icant a ociation %et&een the acce to the 'ood upplement and the rate o' &eight gain -r up 0 C 0)5=, to the 'ood upplement %! pregnant &omen and %irth &eight o' 7 C 0);0, n C .16, " D6)68/ or change in midarm circum'erence -r up 0 C 0)0=, 7 C 0)<0, " D6)68/) There &a al o no igni'icant relation hip %et&een acce hemoglo%in concentration and acce and econd a e their ne&%orn -r up 0 C 6)@=, n C .>8, 7 C 6)>5, " D6)68/) 7urther, the a ociation %et&een the change in to the 'ood upplement during pregnanc! &a al o not tati ticall! igni'icant -r up 0 C 0)0=, n C .16, 7 C 0)00, " D6)68/) The prevalence o' anemia -hemoglo%in :..6 g3L/ at 'ir t ment among mother &ho &ere 'ollo&ed up &a 58)<= and 8>)0=, re pectivel!) +' the .16 mother &ho &ere 'ollo&ed up, .< mother -.6);=/ did not take iron('olate upplement during pregnanc! %ecau e o' unde ira%le ide e''ect ) The do e 'reEuenc! could not %e determined in one u%#ect) *au ea, vomiting, and con tipation &ere the common ide e''ect ) The amount o' upplement taken varied 'rom one ta%let dail!, one ta%let t&ice dail!, or one ta%let thrice dail! in a 'e& u%#ect -n C .1/) There &a no igni'icant di''erence in age, parit!, period o' ge tation, or acce to the 'ood upplement -thripo ha/ among the group -Ta%le </) -Ta%le < omitted/ Hemoglo%in concentration at 10(<6 &k o' ge tation &ere igni'icantl! higher than value at .<(0< &k o' ge tation -" :6)68/ onl! in the group o' u%#ect &ho took one ta%let dail! -Ta%le </) Taking one ta%let per da! cau ed a igni'icant po itive change in hemoglo%in a compared &ith un upplemented u%#ect -t C 0).>, " :6)68/, &herea there &a no igni'icant di''erence %et&een tho e taking

one ta%let dail! and tho e taking t&o ta%let dail!) The er!throc!te protoporph!rin concentration at econd a e ment &ere igni'icantl! lo&er than initial value -" :6)60/ in the group o' u%#ect &ho took one ta%let o' iron('olate upplement dail!, %ut not in tho e &ho did not take upplement or in tho e &ho took more than one ta%let dail! -Ta%le </) The change in erum 'erritin concentration among u%#ect &ho took di''erent amount o' upplement &a not tati ticall! igni'icant) 7urther, the num%er o' iron('olate ta%let taken per da! had no igni'icant e''ect on the rate o' &eight gain during pregnanc!, or %irth &eight o' their ne&%orn ) To determine &hether taking more than one ta%let per da! had a %ene'icial e''ect on u%#ect &ith initial hemoglo%in concentration :;6 g3L, the change in hemoglo%in concentration during pregnanc! &a compared in u%#ect &ho took one, t&o, or three ta%let per da!) There &a no igni'icant di''erence among the group -n C 1., 7 C .)@@, " C 6).;@/) Si2t!(t&o u%#ect took iron('olate upplement 'or :C .@ &k, &herea 81 u%#ect took the upplement 'or D.@ &k during pregnanc!) There &a no igni'icant di''erence in age, parit!, period o' ge tation, or duration o' intake o' thripo ha %et&een the e t&o group o' u%#ect -Ta%le 8/) -Ta%le 8 omitted/ Hemoglo%in concentration at 10(<6 &k o' ge tation &ere igni'icantl! higher than initial value -" :6)6./ onl! in the group upplemented 'or D.@ &k -Ta%le 8/) A igni'icant po itive change in hemoglo%in during pregnanc! &a noted in the group upplemented 'or D.@ &k &hen compared &ith un upplemented u%#ect -t C 1)6., " :6)6./, or tho e taking upplement 'or :C .@ &k -t C 0)@., " :6)6./) 7urther, the er!throc!te protoporph!rin concentration and the ratio o' protoporph!rin to hemoglo%in &ere igni'icantl! lo&er -" :6)68/ in the group upplemented 'or a longer period) Ho&ever, there &a no igni'icant di''erence %et&een initial and 'inal 'erritin concentration in the erum in %oth group ) To determine &hether there i a di''erence in each group %et&een u%#ect taking one or t&o ta%let per da!, the change in hemoglo%in &a compared &ithin each group) Tho e taking three ta%let per da! &ere e2cluded %ecau e the num%er o' u%#ect in each group &a mall) There &a no igni'icant change in hemoglo%in re ulting 'rom di''erent do e 'reEuencie &ithin each group -duration :C .@ &k4 7 C 1)<5, " C 6)65<; duration D.@ &k4 7 C 6)85, " C 6)8</) +nl! <<)1= o' the iron('olate( upplemented u%#ect had received one cour e o' AHT %et&een 'ir t and econd a e a e ment , &herea none had received it %e'ore the 'ir t ment) The u%#ect &ho did not take iron('olate upplement had al o not taken AHT) The hemoglo%in

concentration and iron tatu &ere compared in u%#ect &ho took onl! iron('olate upplement &ith tho e &ho received AHT in addition to upplement ((AHT group -Ta%le 5/) -Ta%le 5 omitted/ There &a no igni'icant di''erence in age, parit!, period o' ge tation, or duration o' intake o' thripo ha %et&een the t&o group ) Hemoglo%in concentration at 10(<6 &k o' ge tation &ere igni'icantl! higher than initial value in the AHT group -" :6)66./, %ut not in the group o' u%#ect &ho received onl! iron('olate upplement ) A igni'icant po itive change in hemoglo%in &a noted in u%#ect &ho received AHT in addition to upplement , &hen compared &ith tho e &ho received onl! iron('olate upplement -t C 8)>;, " :6)66./) A igni'icant decrea e in er!throc!te protoporph!rin concentration -t C 0).;, " :6)68/ and the ratio o' protoporph!rin to hemoglo%in -t C 0)81, " :6)60/ and a igni'icant increa e in erum 'erritin concentration -Hru kal(Walli te t 'or t&o group , H C ;)85, " :6)668/ &a al o noted in the AHT group &hen compared &ith the untreated group) To determine &hether there i a di''erence &ithin group due to di''erence in duration o' upplementation, the change in hemoglo%in concentration &a compared in tho e upplemented 'or :C .@ &k &ith tho e upplemented 'or D.@ &k) There &a no igni'icant di''erence &ithin the group given onl! upplement -7 C 6)1, " C 6)8@/ and in the group given AHT -7 C 1)8<, " C 6)65/) The in'luence o' everal independent varia%le Ihemoglo%in concentration at .<(0< &k o' ge tation -H%./, duration and do e o' iron 'olate upplementation, and receipt o' AHTJ on hemoglo%in concentration at 10(<6 &k o' ge tation -H%0/ &a a e ed %! multiple(regre ion ion anal! i ) A igni'icant po itive correlation &a noted -R up 0 C 01)8=, 7 C .6)8, " C 6)666/) The regre

eEuation i given %elo&4 H%0 C <)>5 B 6)<10 K H%. B .)50 2 AHT ( 6)16 2 num%er o' iron ta%let B 6)6< 2 iron duration A igni'icant partial correlation &a noted %et&een H%0 and H%. -t C 8)<5, " C 6)666/, duration o' iron

upplementation -t C 0).@, " C 6)610/, and AHT -t C <).8, " C 6)666./) ?ut, there &a no igni'icant e''ect o' the num%er o' iron('olate upplement taken per da! on H%0) Similarl!, a igni'icant po itive correlation -R up 0 C ..)5=, 7 C <)>>, " C 6)661/ e2i ted %et&een the log(tran 'ormed value o' 'erritin concentration at econd a e ment and initial 'erritin concentration -" C 6)608/ and AHT -" C 6)66./, %ut the a ociation &ith do e 'reEuenc! or duration o' iron('olate upplementation &a not igni'icant)

!S"USS!#$ +ur tud! &a an attempt to a e the e''ectivene o' intervention mea ure availa%le to pregnant plantation

&orker a a component o' routine antenatal care, and not to determine the e''ect o' upplement under controlled condition ) The con umption o' the 'orti'ied 'ood upplement -thripo ha/ during pregnanc! had no igni'icant %ene'icial e''ect on maternal &eight gain, change in midarm circum'erence, or hemoglo%in concentration) 7urther, there &a no igni'icant e''ect on %irth &eight o' ne&%orn ) $n contra t, in an Aa t Java pregnanc! tud!, giving energ! upplement during the la t trime ter o' pregnanc! re ulted in a mode t improvement in %irth &eight ->/) 7urther, it &a e''ective in promoting po tnatal gro&th and reducing malnutrition in pre chool children -.6/) A igni'icant %ene'icial e''ect on maternal &eight gain and intrauterine gro&th &a al o o% erved &hen protein(energ! upplement &ere given to pregnant A ian mother at nutritional ri k living in ?irmingham, ,H -../) $t i important to note that the data mentioned a%ove re'er to controlled tudie in &hich upplementation &a carried out in a peci'ic area under upervi ion) $n contra t, in our tud! the 'ood upplement &a given a a component o' routine antenatal care and it intake &a dependent on availa%ilit! o' the 'ood upplement at antenatal clinic and motherG attendance at the clinic) $t &a o% erved that <1)5= o' pregnant plantation &orker tudied had either not received the 'ood upplement, or received it 'or :.6 &k during pregnanc!) Thu , the duration o' intake o' the upplement &a pro%a%l! too hort to cau e a igni'icant e''ect) The 7A+3WH+3,*, con ultation on energ! and protein reEuirement have recommended an additional energ! intake o' .066 kJ -0;8 kcal3d/ i' the ame activit! pattern i maintained -.0/) $t i po i%le that the energ! increment provided %! the 'ood upplement &a in u''icient to meet the additional demand o' pregnanc! and the high energ! co t o' their occupational activitie - uch a clim%ing mountain , plucking tea leave , and carr!ing %a ket o' tea leave /) There'ore, it ma! %e nece ar! to increa e the energ! content o' the 'ood upplement) 7urther, it i likel! that the 'ood upplement &a o'ten hared &ith other mem%er o' the 'amil!, o that the energ! and nutrient received %! pregnant &omen &ere le than e2pected) Thu , optimal %ene'it 'rom the 'ood upplement &ould more likel! %e achieved %! having an Lon iteL 'eeding program at place o' &ork, creche , home , or other meeting place , or %! providing a 'amil! 'ood package) $ron('olate upplement &ere availa%le at antenatal clinic and good compliance &a noted among the u%#ect tudied, although ome complained o' ide e''ect ) Compliance could %e increa ed 'urther i' the %ene'icial e''ect o' upplement and their ide e''ect &ere e2plained to each mother &hen the ta%let &ere given, %ecau e thi &a not done in the antenatal clinic ) The do e recommended %! the Mini tr! o' Health, Sri Lanka, and the World Health +rgani9ation -0/ i t&o ta%let per da!) The do e 'reEuenc! depended on the num%er o' ta%let given per month and on individual pre'erence ) Taking one ta%let o' iron('olate upplement per da! cau ed a igni'icant po itive change in hemoglo%in concentration , %ut there &a onl! a light improvement in the iron tatu ) $ncrea ing the amount taken to t&o ta%let per da! did not cau e an! igni'icant additional %ene'it &ith re pect to hemoglo%in concentration or to iron tatu ) +nl! a 'e& u%#ect claimed to have taken three ta%let per da!) The di''erence %et&een group could not %e due to di''erence in age, parit!, or period o' ge tation %ecau e there &ere no igni'icant di''erence among the group ) The varied re pon e to higher do e 'reEuenc! could %e partl! due to

the 'act that coe2i tent energ!(protein de'iciencie limited the utili9ation o' iron in ome u%#ect ) $n 'act, the mean rate o' &eight gain during the interval %et&een t&o a e ment &a onl! 6)08 B3( 6).; kg3&k, and <5)>= had rate o' &eight gain :6)0 kg3&k) $t i al o likel! that the u%optimal vitamin A tatu noted among the e u%#ect -LDR de Silva and TMS Atukorala, unpu%li hed o% ervation , .>>./ ma! have limited the utili9ation o' iron) A cro ( ectional tud! on the iron and vitamin A tatu o' pregnant &omen in We t Java, $ndone ia, i%le that u%#ect &ho i%l! at nigh %e'ore ho&ed a relation hip %et&een the meta%oli m o' vitamin A and that o' iron -.1/) $t i po practical approach &ould %e to advi e that the iron upplement %e taken once dail!, po

claimed that the! took more than one ta%let per da! ma! not have taken the higher amount regularl!) A more leeping %ecau e thi &ould minimi9e ide e''ect ) $n a recent tud! on the e''icienc! o' an e ta%li hed program 'or iron upplementation during pregnanc! at a communit! health center in Jakarta, $ndone ia, <8 &omen &ho attended the normal pregnanc!(care program &ere tudied over a 0(mo period -.</) The! received 16 ta%let o' iron upplement per month -containing 56 mg elemental 7e in each ta%let/) +' the 11 &omen &ho continued to participate in the tud!, 0. claimed to have taken the upplement %ut onl! .0 had a po itive tool te t 'or iron) The e &orker have ugge ted that the do e o' iron upplement hould %e increa ed %ecau e the compliance i lo&) 7urther tudie are needed to determine &hether ta%let containing .06 mg elemental 7e once dail! &ould %e more e''ective than 56 mg3d) $n a WH+( pon ored colla%orative tud! on iron upplementation in ?urma and in Thailand, admini tration o' .06 or 0<6 mg 7e a 'errou ulphate to anemic &omen o' reproductive age re ulted in a igni'icant increa e in the concentration o' %oth hemoglo%in and erum 'erritin, %ut there &a no igni'icant di''erence in erum 'erritin concentration &ith the increa e in do e -.8/) $ron('olate upplementation 'or D.@ &k during pregnanc! cau ed a more po itive change in hemoglo%in than did the horter period o' upplementation) Thi di''erence could not %e attri%uted to di''erence in parit!, period o' ge tation, or intake o' the 'ood upplement, %ecau e the! &ere imilar in the t&o group ) 7urther, there &a no igni'icant di''erence &ithin group due to a di''erence in num%er o' ta%let taken per da! or to AHT) ,nlike hemoglo%in or erum 'erritin, the 'ree er!throc!te protoporph!rin concentration increa e in iron de'icienc! and decrea e &hen iron i availa%le and protoporph!rin i u ed 'or er!thropoie i -./) The igni'icantl! lo&er er!throc!te protoporph!rin concentration at 10(<6 &k o' ge tation than at 'ir t a e ment ugge t that the availa%ilit! o' iron 'or er!thropoie i increa ed &hen upplement &ere taken 'or D.@ &k) Thu , increa ing the duration o' upplementation had a greater %ene'it than did increa ing the do e 'reEuenc!) Ho&ever, there &a no igni'icant improvement in iron tore ) Thi i pro%a%l! %ecau e %lood lo due to hook&orm in'ection prevented an! net torage o' iron) +ne cour e o' AHT a'ter the 'ir t trime ter o' pregnanc! in addition to iron( 'olate upplement re ulted not onl! in a marked increa e in hemoglo%in concentration , %ut al o in a igni'icant improvement in iron tatu ) Thu , AHT greatl! improved the %ene'icial e''ect o' iron('olate upplement ) Whether AHT alone -&ithout iron('olate upplement / &ould cau e an improvement in iron tatu could not %e determined %ecau e none o' the u%#ect received onl! AHT) $n our tud!, ample o' tool &ere not te ted 'or hook&orm in'ection) Ho&ever, tudie carried out %! A Soren on and MM $ mail -unpu%li hed o% ervation , .>>0/ have ho&n a high prevalence o' mild hook&orm in'ection among Sri Lankan plantation &orker o' child%earing age) $t i important to note that @1)0= o' the u%#ect lived in cro&ded d&elling and anitar! 'acilitie &ere not availa%le to 11)1= o' the u%#ect ) Similar %ene'icial e''ect o' AHT &ould %e e2pected among &omen living in ur%an lum or rural &omen &ith no toilet 'acilitie ) The e tudie al o highlight the need to adopt mea ure to prevent hook&orm in'ection, uch a more e''ective health education and improvement o' anitar! 'acilitie ) A 'e& tudie on e2perimental animal have ho&n that AHT ma! have teratogenic e''ect &hen it i given during earl! pregnanc! -.5/, %ut a imilar e''ect ha not %een conclu ivel! ho&n in human ) 7urther, the teratogenic e''ect , i' an!, are unlikel! to occur i' AHT i given a'ter the 'ir t trime ter o' pregnanc!) $n our tud!, upplementation &ith thripo ha did not have a igni'icant e''ect on nutritional tatu or outcome o'

pregnanc!) $t i likel! that greater %ene'it could %e o%tained 'rom thripo ha %! increa ing it energ! value and al o %! an on( ite 'eeding program) "onclusion +ur data ugge t that an increa e in the duration o' iron('olate upplementation during pregnanc! con'erred a greater %ene'it than did an increa e in the do e 'reEuenc!) AHT in addition to iron('olate upplement not onl! cau ed a greater increa e in hemoglo%in, %ut al o a marked improvement in iron tatu ) There'ore, iron('olate upplementation 'or D.@ &k during pregnanc! together &ith AHT -a'ter the 'ir t trime ter/ i population and other living under poor condition ) ugge ted 'or thi

+ur thank to the Social Development Divi ion o' the Sri Lanka State "lantation Corporation and manager and health ta'' o' the re pective plantation 'or providing 'acilitie to conduct the tud!) We al o thank Chandralal de Silva -Dutch *or&egian Technical A i tance Team/ 'or a i tance &ith data anal! i ) . 7rom the Department o' ?iochemi tr!, 7acult! o' Medicine, ,niver it! o' Colom%o, and the Social Development Divi ion, Sri Lanka State "lantation Corporation, Colom%o, Sri Lanka) 0 Supported %! the government o' *etherland and *or&a! -Technical A ;, Sri Lanka) RA7ARA*CAS .) +ppenheimer S, Hendrick e R) The clinical e''ect o' iron de'icienc! and upplementation) *utr A% tr Rev .>;1;8148;8(;) 0) DeMae!er AM, Dallman ", Murne! JM, Hall%erg L, Sood SH, Srikantia SM) "reventing and controlling iron de'icienc! anaemia through primar! health care) Meneva, S&it9erland4 World Health +rgani9ation, .>;>) 1) Dallman "R) $ron de'icienc!4 doe it matterN J $ntern Med .>;>;005415@(@0) <) Jelli''e D?) The a e ment o' the nutritional tatu o' the communit!) World Health +rgan Monogr Ser .>55;8145;(@@) 8) $nternational *utritional Anaemia Con ultative Mroup -$*AC7/) Mea urement o' iron tatu (( a report o' $*ACM) Wa hington, DC4 The *utrition 7oundation $nc, .>;8) 5) Heller SR, La%%e R7, *utter J) A timation o' er!throc!te protoporph!rin in &hole %lood) J Clin Chem .>@.;.@4808(;) @) Linpi arn S, Hricka LJ, Henned! JH, Whitehead J") The and&ich en9!me immunoa a! 'or 'erritin e timation) Ann Clin ?iochem .>;.;.;4<;(81) ;) Milton SJ) Stati tical method in the %iological and health cience ) 0nd ed) *e& Oork4 McMra& Hill $nternational, .>>0) >) Hard#ati S, Hu in JA, De With C) Anerg! upplementation in the la t trime ter o' pregnanc! in Aa t Java4 .) A''ect on %irth &eight) ?r J +% tet M!naecol .>;;;>84@;1(><) .6) Hu in JA, Hard#ati S, Houtkooper JM, RenEvi t ,H) Anerg! upplementation during pregnanc! and po tnatal gro&th) Lancet .>>0;1<64501(5) ..) Piega +AC, Scott "H, Cole TJ, Aaton ", *eedham "M, Wharton ?A) Dietar! protein energ! upplementation o' pregnant A ian mother at Sorrento, ?irmingham $$4 elective during third trime ter onl!) ?r Med J .>;0;0;848>0(<) .0) 7ood and Agriculture +rgani9ation -7A+/, World Health +rgani9ation -WH+/, ,nited *ation ,niver it! -,*,/) Anerg! and protein reEuirement ) Report o' a #oint 7A+3WH+3,*, con ultation) WH+ Tech Rep Ser .>;8;@0<4;5) .1) Suharno D, We t CA, Muhilal, et al) Cro ectional tud! on the iron and vitamin A tatu o' pregnant &omen in We t Java, $ndone ia) Am J Clin *utr .>>0;854>;;(>1) .<) Schultink W, van der Ree M, Matule i ", Mro R) Lo& compliance &ith an iron( upplementation program4 a tud! among pregnant &omen in Jakarta, $ndone ia) Am J Clin *utr .>>1;8@4.18( >) .8) Charoenlarp ", Dhanamitta S, Hae&vichit R, et al) A WH+ colla%orative tud! on iron upplementation in ?urma and Thailand) Am J Clin *utr .>;;;<@40;6(>@) .5) ?aker ville M, Wood M, *e&ton CM) Me%enda9ole 'or &orming mice; e''ectivene and ide e''ect ) La% Anim .>;;;004051(;) ( i tance Team ../) 1 Reprint not availa%le) Addre corre pondence to TMS Atukorala, Department o' ?iochemi tr!, 7acult! o' Medicine, "+ ?o2 0@., ,niver it! o' Colom%o, Colom%o

Sub%ect: "regnanc!; *utrition; Medical re earch; $ron; 7ood additive ; Anemia &ublication title: The American Journal o' Clinical *utrition