Nutrition Research. Vol. 18. No. 12, pp. 1953-1963.

1998
Copyright 0 1998 Else&z Science Inc.
P&t&in the USA. All rights reserved
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PI1SO271-5317(98)00165-l

‘IRON DEFICIENCY IN INDONESIA: CURRENT SITUATION AND

INTERVENTION
Benny Kodyat’, Soewarta Kosen*, Saskia de Pee3
’Directorate of Community Nutrition, Ministry of Health, Jakarta, Indonesia;
* National Institute of Health Research and Development, Ministry of Health, Jakarta,
Indonesia; 3 Helen Keller International, Jakarta, Indonesia

ABSTRACT

Iron deficiency anaemia (IDA) has a large impact on productivity,

mental performance, child growth, immunity and pregnancy outcome.
In Indonesia, 50 to 70 million people (2530% of the population) suffer
from IDA. In 1995, the prevalence among pregnant women, underfives
and female workers was 50.9%, 40.5% and 30%, respectively. Because
nutrition and health are essential to human development, Indonesia has
identified their improvement, including reducing IDA, a high priority.
Several programs are implemented to control IDA. Iron
supplementation for pregnant women started in 1974 and currently
provides 60% with 90 tablets. Because infants and children cannot
meet their iron requirements through diet alone, unless it contains
fortified foods, distribution of iron-rich syrup to underfives was started
in less developed villages in eastern Indonesia in 1996. Since 1996,
factories should supplement their female workers with iron
supplements once per week, 16 weeks per year, in order to increase
their well-being and productivity. Other groups, such as female
adolescents, school children and non-pregnant women are currently
targeted through special projects and through IEC, using dietary
guidelines, directed at a larger audience. With the increase in economic
growth, self-purchasing of supplements and food fortification become
more viable strategies. Producers of some brands of noodles and
weaning foods are currently fortifying their products, while producers
of “jamu” (traditional herb drinks) are increasing the content of
enhancers of iron absorption. Reducing IDA in Indonesia is the goal of
the Department of Health in collaboration with other departments, non-
governmental organisations, international agencies, and the private
sector. 0 1998Ehvicr Scicnffi Inc.
Key words: iron deficiency anemia, Indonesia, policies

IRON DEFICIENCY ANEMIA

Iron deficiency anaemia (IDA) is the most common nutritional deficiency in

Indonesia as well as in many other developing countries. It is estimated that 1.3

’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).

IDA has a large impact on physical performance, productivity and economic

growth (2-4), on mental performance and learning ability (5-7), on child growth (S-
lo), on the immune system (1 l), and on pregnancy outcome (12, 13). Severe anaemia
during pregnancy can result in miscarriages and premature deliveries (14).

HEALTH AND NUTRITION IN INDONESIA: DEVELOPMENT OF HUMAN

RESOURCES

Indonesia’s goal is to develop into a prosperous nation of healthy, productive

and intelligent people. The national state guidelines of 1993 therefore state that
progress in Indonesia should be achieved in economic development as well as in
human development. Human development concentrates on 4 components:
productivity, equity, sustainability and empowerment. Indicators of human
development include increased life expectancy, decreased morbidity, improved
cognitive development and improved work capacity. Nutrition and health are essential
for increasing human development.

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.

IRON DEFICIENCY ANEMIA IN INDONESIA: EPIDEMIOLOGY AND

ETIOLOGY

In 1960, a study among a population living in a poor hill area in West-hian

reported very low mean hemoglobin concentrations among non-pregnant non-
lactating women (90 g/L), pregnant women (78 g/L), and children aged l-2 years (81
g/L) (16). In 1975-76, surveys in East-Java found mean concentrations among non-
pregnant non-lactating, lactating, and pregnant women of 124-132, 121-13 1, and 1 lo-
118 g/L, respectively (17). The nationwide household survey of 1992 found that
63.5% of pregnant women and 55.5% of underfives suffered from anemia (18), while
the household survey of 1995 found anemia in 50.9% of pregnant women and in
40.5% of underfives (19). In addition, approximately 30% of female workers and 24-
35% of school children were found to suffer from anemia (19). From these figures it
is estimated that today, as many as 50-70 million of the 200 million Indonesians
 IRON DEFICIENCY IN INDONESIA 1955

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)

FIG. 1. Prevalence of iron deficiency anemia among pregnant women,

underfives and female workers in Indonesia in 1993 and aims for its
prevalence until 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).

CURRENT PROGRAMS FOR REDUCING THE PREVALENCE OF IRON

DEFICIENCY ANEMIA
 B. KODYAT et al.

Sunnlementing nregnant women

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.

The amount of iron-folate pills that is currently purchases and distributed by

the central government is enough to provide 60% of the pregnant women with 90 pills
during their pregnancy. Insufficient coverage and sub-optimal compliance may limit
the effectiveness of iron supplementation programs. Therefore, the Indonesian
program is regularly monitored and evaluated in order to evaluate its performance and
impact, and efforts are undertaken continuously to increase demand, coverage and
compliance.

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).

In Indonesia, exclusive breastfeeding is recommended till the age of 4 mo and

nutrition education about weaning foods includes iron-rich foods. However, these
alone cannot meet the iron requirements. While infant in Western countries receive
iron through fortified weaning foods, Indonesia is the first country in the world to
 IRON DEFICIENCY IN INDONESIA

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.

Sunnlementina female factorv workers

The prevalence of IDA among female factory workers is relatively high

(approximately 30%). A study in Jakarta found that the work productivity of anemic
women was 5.3% less and that they performed 6.5 h less housework per week as
compared to non-anemic women (24). Studies among plantation workers found that
treating their anemia increased their productivity by IO-20% (2, 3). A nationwide
campaign for distribution of iron-folate pills to female factory workers started in
1996. Supplements are given once per week for 16 weeks per year at the workplace
and the costs of the supplements are paid by the factories. In addition, when
menstruating workers should receive one tablet per day for 10 days. The distribution
of iron pills to female factory workers will benefit their current health and
productivity, as well as till their iron stores before a possible pregnancy.

Life-cvcle aDDroach for suDnlementation

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.

According to studies among female adolescents at schools in Jakarta,

Surabaya, and Madura, the prevalence of IDA among female adolescents is
approximately 1530% (25, 26). Because of this relatively high prevalence, and
because it is difficult to meet the iron needs of pregnancy during pregnancy alone, it
would be good to start improving iron status of women during adolescence. Because
the Indonesian government has recently introduced 9 years of compulsory education
(6- 15 years of age), female adolescents aged 12- 15 years could be most easily reached
through schools. HKI-Indonesia in collaboration with the Departments of Health,
Education and Religion, has recently started a program of iron supplementation in 15
junior high schools in Surabaya and Madura, East-Java. The impact on iron status will
be carefully evaluated. The program is funded by OMWIJSAID.

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).

Sunnlementation and Information. Education and Communication (IEC)

The government’s current plans are to strengthen the ongoing iron

supplementation to pregnant women (daily), to underfives with special attention to
 B. KODYAT et al.

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.

Food fortification and enhancement of iron absorntion

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.

It is envisaged that through cooperation of the government with the private

sector, more foods, such as other brands of instant noodles, sugar, wheat flour (30),
salt (3 l), fish products, and soy, will be fortified with multiple minerals and vitamins.

“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

Animal products are good sources of heme-iron which is relatively easy to

absorb. However, for a large part of the population, these foods are not within reach in
such amount that could meet their iron needs. Vegetables and fruits contain non-heme
iron, which has lower bioavailability, as well as relatively large amounts of inhibitors
of iron absorption such as phytate and other fibres. To what extent vegetables and
fruits can improve iron status is therefore unclear (11, 33).

Nutrition education in Indonesia promotes consumption of, amongst others,

foods rich in iron and/or vitamin C, including dark-green leafy vegetables, fruits and
animal foods. In addition, exclusive breastfeeding is recommended until the age of 4
mo.

CURRENT NUTRITION AND HEALTH PROGRAMS INDIRECTLY AIMED AT

REDUCING THE PREVALENCE OF IRON DEFICIENCY ANEMIA

Programs for nutrition improvement in Indonesia that can, amongst others,

benefit iron status, include:
?? The nutrition recuperation program, which aims at an improvement of family
food patterns with a healthy diet through exclusive breastfeeding and food
diversification;
?? The family nutrition improvement program (UPGK), which includes counselling
by village health volunteers and provision of nutrition services such as iron pill
distribution to pregnant women, monthly weighing of underfives, vitamin A
capsule distribution, iodized oil capsule distribution in endemic areas, and
promotion of home gardening;
?? Programs for nutrition improvement in institutions, such as schools, factories,
hospitals and sport centres; and
?? Food and nutrition surveillance at province and district level for the monitoring of
food crops and the early detection of food shortages.

The primary health care system also includes, besides iron supplementation,
deworming and nutrition education, which may both benefit iron status.

CONTRIBUTIONS FROM OTHER SECTOR TOWARDS REDUCING THE

PREVALENCE OF IRON DEFICIENCY ANEMIA

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.

Movement of Prosnerous Family Development

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

One of the goals of the Ministry of Manpower is to improve health of female

workers in order to increase productivity. Measures to achieve this goal include
improvement of occupational safety and health and working standards, and provision
of facilities such as canteen, child-care, and maternity leave. The provision of iron
supplements to female factory workers is an activity conducted by the private sector
itself, but regulated by law and under the supervisory guidance of the Ministry of
Manpower.

State Ministrv for Food Affairs

Food diversification is aimed at an increase of the consumption of foods rich

in heme iron and vitamin C and with a low content of inhibitors of iron absorption
such as tannins and phytate. Constraints for increasing the intake of food rich in
heme-iron, which are mainly animal products, include the price and the availability.
In dialogue with the industry, problems faced when fortifying foods, such as price
differences, legitimate support for the products, and enforcement of food laws, are
being tackled.

Mother Friendly Movement (Gerakan Savant Ibu. GSIl

 IRON DEFICIENCY IN INDONESIA 1961

The mother friendly movement is a movement of the community and the

government for the advancement of the quality of life of women, for the sake of
development of human resources. Its main aim is to accelerate the reduction of
maternal mortality. Prevention of iron deficiency anaemia among pregnant women is
one component of the activities for achieving this goal.

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Accepted for publication May 25, 1998.