European Journal of Clinical Nutrition (2004) 58, 927–937

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ORIGINAL COMMUNICATION
Effectiveness of weekly vitamin A (10 000 IU) and iron
(60 mg) supplementation for adolescent boys and
girls through schools in rural and urban East Java,
Indonesia
DD Soekarjo1,2*, S de Pee3, JA Kusin2, WHP Schreurs2, W Schultink4, Muhilal5 and MW Bloem3

1
Helen Keller International Indonesia, Jakarta, Indonesia; 2University of Amsterdam, Netherlands; 3Helen Keller International,
Singapore; and 4UNICEF, New Delhi, India; and 5Nutrition Research and Development Centre, Bogor, Indonesia

Objective: High prevalences of vitamin A deficiency and anaemia among adolescents warrant interventions. This study
evaluated the effectiveness of school-based supplementation to reduce anaemia and improve vitamin A status.
Design: School-based, grade-randomized, intervention.
Subjects and setting: In all, 1757 girls and 1859 boys, aged 12–15 y, in 24 Junior High Schools.
Interventions: Weekly supplementation for 14 weeks with 60 mg iron and 250 mg folate (Fe group; n ¼ 978), 10 000 IU vitamin
A (VA group; n ¼ 970) or both (VAFe group; n ¼ 1042) to subjects in 15 schools, compared to subjects in nine other schools not
receiving supplements (control; n ¼ 626).
Results: The baseline anaemia prevalence (Hb o120 g/l) in girls was 20% (prepubertal) and 26% (pubertal), and in boys 24%
(pre-pubertal) and 11% (pubertal). Serum retinol concentrations were low (o1.05 mmol/l) in 41% of boys and 45% of girls. The
interventions did not increase haemoglobin concentrations. Serum retinol concentration of boys, but not girls, in the VA group
increased (0.33 vs 0.07 mmol/l in controls; Po0.01). The risk factors for low serum retinol concentration were lower baseline
serum retinol concentration (OR 0.02–0.03) with, for girls, nightblindness at baseline (OR 5.88), and for boys, not receiving
vitamin A (OR control: 1.00; VA: 0.37; Fe: 0.77; VAFe: 0.34) and maternal illiteracy (OR mother never attended school 1.00,
mother received any formal education 0.17–0.33).
Conclusions: Supplementation with vitamin A increased serum retinol concentration of boys. Iron supplementation did not
change Hb. This appeared to be due to poor compliance, and partly related to side effects.
Sponsorship: This study was funded by USAID through the OMNI Project.
European Journal of Clinical Nutrition (2004) 58, 927–937. doi:10.1038/sj.ejcn.1601914

Keywords: weekly supplementation; anaemia; vitamin A deficiency; adolescents; Indonesia

*Correspondence: DD Soekarjo, Helen Keller International, PO Box 4338,
Jakarta Pusat, Indonesia.
E-mail: ddsoekarjo@hkiasiapacific.org
Guarantor: MW Bloem.
Contributors: DDS supervised and conducted the field work,
performed preliminary statistical analyses and drafted the paper.
SdP conducted further statistical analyses and contributed to writing
the paper. JAK and WHPS gave critical comments on the interpreta-
tion of the results and contributed to the writing of the paper.
WS contributed to the design and gave comments on the draft
versions of the manuscript. M gave critical comments on the design of
the study and interpretation of the results. MWB contributed
substantially to the design and analytic strategy.
Received 17 January 2003; revised 21 September 2003; accepted 3
October 2003
Introduction
Anaemia and vitamin A deficiency are very prevalent
throughout the world. Globally, 55% of underfives and
56% of pregnant women are anaemic (ACC/SCN, 1997). In
Indonesia, prevalences are similar (UNICEF, 1996). Among
Asian adolescents, anaemia prevalences have been found to
be range from 11 to 26% (Sunethra Atukorala & De Silva,
1990; Ahmed et al, 1996; Angeles-Agdeppa et al, 1997;
Soekarjo et al, 2001). Vitamin A deficiency is also prevalent
in Indonesian preschool children (51% serum retinol
o0.70 mmol/l; Muhilal & Permaesih, 1994), and pregnant
(33.5%, Suharno et al, 1992), lactating (36%; de Pee et al,
1995) and adolescent women (30% o0.70 mmol/l; Angeles-
Agdeppa et al, 1997).
 Vitamin A and iron supplements for adolescents
DD Soekarjo et al
928
The main cause of anaemia and vitamin A deficiency is
inadequate intake of bioavailable iron and vitamin A, in
addition to other factors like excessive blood loss, frequent
infections and other micronutrient deficiencies. Both con-
ditions have negative consequences for health, develop-
ment, well-being and productivity (Delisle et al, accessed
2002). In addition, vitamin A deficiency plays a role in the
development of anaemia (Mejia et al, 1977; Bloem, 1995),
and vitamin A supplementation can enhance the effect of
iron supplementation (Mejia & Chew, 1988; Suharno et al,
1993).
Adolescence (the period between the ages of 10 and 19 y,
according to the WHO definition) is the period of the third-
fastest growth a human being experiences, after the foetal
and infancy periods (Tanner, 1978). This rapid growth highly
increases the physiological needs for micronutrients such as
iron and vitamin A (Brabin & Brabin, 1992; Antilla & Siimes,
1996), and thus the susceptibility to deficiency in these
phases of the lifecycle. As important changes (physiological,
psychological and social) occur, and many adult patterns are
established, adolescence provides a window of opportunity
to prevent adult health problems. However, adolescents’
needs are not met by the health services, especially in
developing countries.
Iron supplementation programmes focus mainly on
pregnant women, while vitamin A capsule distribution
programmes for underfives and postpartum women exist in
Indonesia as in many other countries. Supplementation
during adolescence might be more effective as it could take
place over a relatively long period of time, and weekly dosing
would be sufficient (Fogelholm et al, 1994; Viteri, 1996;
Angeles-Agdeppa et al, 1997). Schools and worksites may be
appropriate distribution channels, while teachers and peer
group support to promote behavioural change might lead to
higher compliance than found among pregnant women.
The present study was aimed to test the feasibility and
effectiveness of weekly vitamin A and iron supplementation
when delivered in a programmatic context to adolescent
girls and boys attending Junior High Schools in rural and
urban East Java, Indonesia. It was implemented by Helen
Keller International in cooperation with the Ministry of
Health of the Government of Indonesia as part of the GIRLS
(Gizi: Intervensi Remaja Lewat Sekolah/Nutrition Interven-
tion for Adolescents through Schools) Project.
Methods
Subjects
24 schools were selected to represent the two main school
types in Indonesia as well as both rural and urban locations.
Eight rural general Junior High Schools (R-SMP ¼ rural
Sekolah Menengah Pertama) were randomly selected from
two districts (Bangkalan and Sampang) on the island of
Madura. The urban area was represented by 16 randomly
selected schools in Surabaya, the capital of East Java: nine
urban general Junior High Schools (U-SMP ¼ urban Sekolah
European Journal of Clinical Nutrition
Menengah Pertama) and seven Islamic Junior High Schools (U-
MTs ¼ urban Madrasah Tsanawiyah). Pupils in all selected
schools were of middle and low socioeconomic class, of
Javanese or Madurese ethnicity, and Muslim, except for one
U-SMP, where the majority was Christian Chinese.
Except in the control schools, all pupils received supple-
ments. However, data were collected only on pupils who
were between 12 and 15 y old at the start of the study, and
whose parents gave written informed consent for taking
supplements and being enrolled in the data collection
(91.4% of eligible pupils; n ¼ 5166).
This study was conducted between October 1996 and May
1997, in collaboration with the Indonesian Ministries of
Health and Education after approval from the Medical
Ethical Committee of the Ministry of Health, Indonesia.
Sample size
Based on the sparse data available at the time on anaemia
prevalence among Indonesian adolescent girls (Schultink,
1995, personal communication), an anaemia prevalence of
30% was presumed. In order to be able to detect a 50%
reduction from this prevalence at a ¼ 0.05 and b ¼ 0.80, and
accounting for an expected dropout rate of 25%, 168 subjects
per intervention group were needed (total 672).
Design
Adolescents from 15 schools (four U-MTs, seven U-SMP and
four R-SMP) (n ¼ 2990) were randomly selected to receive
weekly supplements, while adolescents in the other nine
schools (three U-MTs, two U-SMP and four R-SMP) served as
controls (n ¼ 1750). In each of the schools receiving supple-
ments, each of the three grades was randomly allocated to
receive one of the three supplementation regimes: weekly
10 000 IU vitamin A (VA group; n ¼ 970), weekly 60 mg
elemental iron (as ferrous sulphate) plus 250 mg folate (Fe
group; n ¼ 978) or weekly 10 000 IU vitamin A and 60 mg
elemental iron plus 250 mg folate (VA þ Fe groups; n ¼ 1042)
(Figure 1). Owing to the theoretical possibility of pregnancy
occurring in the study population, the supplements used in
the intervention complied with the official recommenda-
tions of the Indonesian government for safe use of supple-
ments in pregnancy. Therefore, the dosage of vitamin A did
not exceed 10 000 IU and iron-folate tablets were used, such
as are routinely distributed to pregnant women in Indonesia.
The red iron/folic acid tablets and yellow sugar-coated
vitamin A tablets were all produced locally (Kimia Farma,
Jakarta, Indonesia). All pupils were aware of which supple-
ment(s) they were taking and they were told that the
supplements would improve their health and prevent/cure
anaemia. This information was also disseminated to the
parents by means of a leaflet, which was part of the informed
consent procedure.
Field workers supplied drinking water and the pupils took
the supplements in their classrooms. One or two field

workers supervised a classroom of approximately 50 pupils.
Intensive supervision was avoided as the purpose of the
study was to implement the distribution in a way resembling
as closely as possible the context of a school-based
programme. The supplements were given once weekly for 3
months (a total of 14 times). Nine tablets were taken under
group supervision by trained fieldworkers, while the five
tablets that had to be taken during the Muslim fasting
month and school holidays were distributed at the schools
and taken home with instruction to take them once a week
on a fixed day.
Data collection
At baseline, trained field workers (the majority of whom
were graduates of the Nutrition Academy in Malang, East
Java) collected data on the socioeconomic background and
health status of the pupils, using a standard questionnaire.
After the intervention, all data were collected again, except
those on socioeconomic background. Self-reported compli-
ance for the supplementation was recorded for a random
subsample (n ¼ 413; 13.8%) after the intervention.
The dietary intake of vitamin A was assessed semiquanti-
tatively with the 24-h vitamin A semiquantitative (24 VASQ)
method (De Pee et al, 1999), and pubertal status was assessed
with the status quo method (Cameron, 1993), using me-
narche and first nocturnal emission as indicators for the
onset of puberty in girls and boys, respectively.
Anthropometric measurements consisted of height (using
microtoise (Cameron, 1986), recorded to the nearest 0.1 cm),
weight with light clothing and without shoes (using Soehnle
digital weighing scales, recorded to the nearest 0.1 kg), and
mid upper-arm circumference (MUAC) (using a special
measuring tape developed by the Indonesian Department
of Health, recorded to the nearest 0.1 cm).
Haemoglobin concentration was assessed in all adoles-
cents with the HemoCue device (HemoCuet, Angelholm,
Sweden) using peripheral blood from the fingertip. However,
venous blood for HPLC analysis of serum retinol concentra-
tion was collected only from a random subsample drawn
from all grades in all schools (11.4%, n ¼ 625) (see Figure 1).
Trained nurses and laboratory staff drew approximately 3 cc
blood from the antecubital vein between 0800 and 1400.
Between blood collection and serum collection, the samples
were stored in the dark on ice. Sera were obtained the same
day by centrifuging the blood at 750  g for 15 min and
stored at 201C. Retinol analysis was carried out by HPLC
(column: Bondapak C18, Waters, Milford, MA, USA; detector
Waters LCM1 þ ; standards: Sigma; solvent: Merck, Darm-
stadt, Germany) with methanol/water (90/10 v/v) as mobile
phase (Thurnham et al, 1988).
The pupils in the control schools were not seen during the
supplementation intervention, but the data collections at
the start and end of the study were similar to that in the
other schools.
Vitamin A and iron supplements for adolescents
DD Soekarjo et al
929
Data analysis and statistics
Results are presented on all subjects in the intervention
groups and on a stratified random sample of the control
group (n ¼ 626) (see Figure 1). This was done to arrive at the
same proportional representation of the three school types
(urban and rural SMP and urban MTs) as in the supplemen-
tation groups. As type of school is an important indicator of
socioeconomic status and closely related to haemoglobin
concentration (Soekarjo et al, 2001), it may be a significant
confounder in the assessment of effects of supplementation.
Values are expressed as means7s.d., quartiles (median (25–
75%)) or percentages. To assess comparability between
groups at baseline, w2 tests, Kruskal–Willis and Mann–
Whitney U-tests and analysis of variance (ANOVA) were
applied. To assess the change in haemoglobin and serum
retinol concentrations in the different intervention groups
before and after the intervention, ANOVA and a paired t-test
were referred to. Logistic regression analysis was used to
determine the relative risk of having low serum retinol
concentration after the intervention for different factors
(Snedecor & Cochran, 1980). The computer program SPSS
(SPSS 7.5 for Windows, SPSS Inc., Chicago, IL, USA) was used
for statistical analyses. A P-value of o0.05 was considered to
be statistically significant.
Results
At baseline, data were collected from 5166 subjects. After 3
months of intervention, data were collected again from 4904
of these subjects. Complete sets were available on 4810
subjects (2990 in intervention schools and 1820 in control
schools). Dropout during the study (5.1%) was mainly
caused by absenteeism on several consecutive days during
the end-line data collection. There was no difference in
dropout rate between the four groups. In the intervention
groups, dropout of boys was similar to that of girls, but in the
control group 6.6% of boys dropped out compared to only
3.9% among girls. Subjects who dropped out were slightly
older than those who remained in the study, and more
subjects in the urban religious schools dropped out com-
pared to the other school types. Otherwise, there were no
differences between those who finished the study and those
who did not. All boys and girls in the supplementation
groups with complete sets of data were included in the
analyses (n ¼ 2990), while a selection was made from the
control group (n ¼ 626) as described in the data analysis
section (Figure 1).
The baseline characteristics of the 1757 girls and 1859 boys
on whom data were used for this paper are shown in Table 1a
and b. A proportion of the subjects did not know their
parent’s educational level. They were not excluded and the
numbers of subjects for whom this information is available
are mentioned in the footnotes to the table. There were no
differences in sex distribution between the four groups.
Among girls, all groups were similar with respect to the
European Journal of Clinical Nutrition
 Vitamin A and iron supplements for adolescents
DD Soekarjo et al
930
Baseline Schools, each 3 grades:
(nov-dec 1996) 8 SMP-R (n=1617; boys=1044; girls=573)
boys: 2705 7 MTs-U (n=1748; boys=736; girls=1012)
girls: 2461 9 SMP-U (n=1801; boys=925; girls=876)
Total: 5166

Allocation to supplementation groups

Controls (n=1958): Supplementation, randomized per
4 SMP-R (n=809) grade (n=3208):
3 MTs-U (n=851) 4 SMP-R (n=808); 4 MTs-U (n=897);
2 SMP-U (n=298) 7 SMP-U (n=1503)

Control (n=1958) VA (n=1033) Fe (n=1045) VAFe (n=1130)

Boys n=1035 Boys n=544 Boys n=529 Boys n=597
Girls n=923 Girls n=489 Girls n=516 Girls n=533

Drop out: 262 (5.1%)

Controls: 104 (5.3%)
VA: 36 (3.5%)
Fe: 50 (4.8%)
Endline VAFe: 72 (6.4%)
apr-may 1997
boys: 2554 Control (n=1854) VA (n=997) Fe (n=995) VAFe (n=1058)
girls: 2350 Boys n=967 Boys n=526 Boys n=504 Boys n=557
Total: 4904 Girls n=887 Girls n=471 Girls n=491 Girls n=501

Complete data Control (n=1820) VA (n=970) Fe (n=978) VAFe (n=1042)

boys: 2485 Boys n=945 Boys n=507 Boys n=490 Boys n=545
girls: 2325 Girls n=875 Girls n=463 Girls n=488 Girls n=497
Total: 4810
Stratified
random sample
(see text)

Data
presented Control (n=626) VA (n=970) Fe (n=978) VAFe (n=1042)
boys: 1859 Boys n=317 Boys n=507 Boys n=490 Boys n=545
girls: 1757 Girls n=309 Girls n=463 Girls n=488 Girls n=497
Total: 3626

Subsample
for serum Control (n=128) VA (n=175) Fe (n=154) VAFe (n=168)
retinol Boys n=74 Boys n=85 Boys n=68 Boys n=92
boys: 319 Girls n=54 Girls n=90 Girls n=86 Girls n=76
girls: 306
Total: 625

Figure 1 Supplementation study design (VA ¼ vitamin A; Fe ¼ iron; VA þ Fe ¼ vitamin A and iron; SMP ¼ general junior high school;
MTs ¼ religious junior high school).

percentage of pubertal subjects, vitamin A intake from
animal sources and the level of maternal education. Boys
in the four groups did not differ with regard to the
percentage of pubertal subjects, vitamin A intake from
animal and plant sources and anthropometric indicators.
There was no difference in vitamin A intake from either
animal or plant sources between girls and boys.
Paternal educational level and anthropometric indicators
were slightly worse for girls in the control and VA þ Fe groups
compared to the other two groups; however, this was not
related to differences in any of the micronutrient-related
indicators (haemoglobin and serum retinol concentrations,
and nightblindness). Boys in the control group had parents
with lower education than in the other groups, indicative of
lower socioeconomic status.
There were no differences in any of the indicators of
micronutrient status among the girls, while among boys
there were no differences among the groups in the
prevalence of anaemia or nightblindness. However, the
mean haemoglobin concentrations were slightly higher
among boys in the iron group compared to the VA group,
and the mean serum retinol concentration was higher in
boys in the VA þ Fe groups than in the VA group.
Differentiation between pubertal and prepubertal subjects
is not shown in Table 1a and b, as this would make the table
very complicated, but the proportions of pubertal subjects in
each group are indicated and were similar in the four groups
for both boys and girls. Anaemia prevalence was 20% among
prepubertal and 26% among pubertal girls, 24% among
prepubertal and 11% among pubertal boys. There was a
positive relationship between pubertal status and haemoglo-
bin concentration in boys (129713 g/l in prepubertal boys vs
136714 g/l in pubertal boys, Po0.001), but not in girls
(128711 vs 126712 g/l).
Serum retinol concentrations were o1.05 mmol/l in 41.4%
of boys and 45.1% of girls. The proportions of subjects with
serum retinol concentrations o0.70 mmol/l were 11.4% boys
(range 6.5–10.8%) and 7.7% girls (range 4.4–9.3%), and did
not differ between the four groups in either sex. There was a
positive relationship in girls between puberty and serum

European Journal of Clinical Nutrition

 Vitamin A and iron supplements for adolescents
DD Soekarjo et al
931
Table 1 Characteristics of study population at baseline: (a) girls (n ¼ 1757) and (b) boys (n ¼ 1859)

Control (n ¼ 309) Vitamin A (n ¼ 463) Iron (n ¼ 488) Vitamin A and iron (n ¼ 497) P-value

(a) Girls
Age (y)a 14.4 (13.6; 15.0)B 14.3 (13.5; 14.9)B 14.3 (13.5; 15.0)B 13.9 (13.2; 14.7)A o0.001
% that had reached pubertyb 82.5 (255) 83.6 (387) 85.0 (415) 81.1 (403) NS
Weight (kg)c 38.976.7A 41.478.6B 40.978.2B 39.576.9A o0.001
Height (cm)c 147.676.2A 148.976.1B 148.875.7B 148.775.5B o0.05
BMI (kg/m2)c 17.872.4A 18.673.1B 18.473.1B 17.872.6A o0.001
VA intake from retinol sources (RE)a 175 (60;350) 175 (60;375) 185 (60; 360) 180 (60; 350) NS
VA intake from plant foods (RE)a 50 (20; 225) 100 (20; 375) 80 (20; 376) 90 (30; 295) o0.05
Fathers with primary education or lessb,d 58.0B 47.6A 47.1A 47.9B o0.05
Mothers with primary education or lessb,e 76.2 65.7 66.0 65.6 NS

Hb (g/l)c 127712 126712 126712 127712 NS

Anaemiab 23.9 (74) 26.1 (121) 25.2 (123) 22.9 (114) NS
Serum retinol (mmol/l )c,f 1.0870.38 1.2170.40 1.1570.40 1.2170.47 NS
Serum retinolo1.05 mmol/lb,f 58.9 (32) 40.0 (36) 47.7 (41) 38.2 (29) NS
Serum retinolo0.70 mmol/lb,f 9.3 (5) 4.4 (4) 5.8 (5) 9.2 (7) NS
Nightblindnessb 3.6 (11) 3.5 (16) 3.5 (17) 3.4 (17) NS

Control (n ¼ 317) Vitamin A (n ¼ 507) Iron (n ¼ 490) Vitamin A and iron (n ¼ 545) P-value

(b) Boys
Age (y)a 14.2 (13.6; 14.9)BC 14.1 (13.4; 14.7)B 14.3 (13.6;15.1)C 14.0 (13.3; 14.7)A o0.001b
% that had reached pubertyb 67.2 (213) 70.0 (355) 72.2 (354) 68.8 (375) NS
Weight (kg)c 40.678.3 40.8710.4 41.779.4 41.179.6 NS
Height (cm)c 152.078.6 152.179.8 153.379.4 152.478.8 NS
BMI (kg/m2)c 17.472.5 17.472.8 17.572.5 17.572.8 NS
VA intake from retinol sources (RE)a 175 (60;350) 185 (70; 350) 185 (60;375) 180 (60;360) NS
VA intake from plant foods (RE)a 80 (20;295) 90 (20;385) 80 (20;385) 90 (20;370) NS
Fathers with primary education or lessb,d 68.2B 53.1A 53.1A 49.0A o0.001
Mothers with primary education or lessb,e 77.8c 66.5AB 70.5BC 62.5A o0.001

Hb (g/l)c 134714AB 133713A 135714B 134714AB o0.05

Anaemiab 16.1 (51) 15.8 (80) 12.9 (63) 14.3 (78) NS
Serum retinol (mmol/l)c,f 1.2070.41AB 1.0870.41A 1.1570.39AB 1.2670.52B o0.05
Serum retinolo1.05 mmol/lc,f 35.1 (26)AB 56.5 (48)C 48.5 (33)BC 27.2 (25)A o0.001
Serum retinolo0.70 mmol/lb,f 10.8 (8) 14.1 (12) 10.3 (7) 6.5 (6) NS
Nightblindnessb 2.5 (8) 4.9 (25) 3.1 (15) 4.4 (24) NS
a
Median (25th percentile; 75th percentile); P-value of Kruskal-Willis test, Mann-Whitney U-tests for differences between the groups.
A,B,C
Within a row, significant differences exist between groups that do not share the same letter (Po0.05).
b
Percentage with numbers in parentheses; P-value of w2 test.
c
Mean7s.d.; P-value of ANOVA with Bonferroni correction for multiple post hoc multiple comparisons.
d
n ¼ 1560 (part a), n ¼ 1619. (part b)
e
n ¼ 1648. (part a), n ¼ 1702 (part b)
f
n ¼ 319 (controls: n ¼ 74; vitamin A: n ¼ 85; iron: n ¼ 68; vitamin A and iron: n ¼ 92) (part a); n ¼ 308 (controls: n ¼ 54; vitamin A: n ¼ 90; iron: n ¼ 86; vitamin A and
iron: n ¼ 76) (part b).

retinol concentration: 1.0670.32 vs 1.1970.43 mmol/l in
prepubertal and pubertal girls (Po0.05). The same trend was
seen in boys, although it was not significant: 1.1170.43 vs
1.2170.45 mmol/l in prepubertal and pubertal boys, respec-
tively (NS).
After the supplementation was over, self-reported compli-
ance for iron supplements was collected from 136 boys and
134 girls and for vitamin A supplements from 134 boys and
137 girls. Almost all respondents (90–97%) claimed to have
taken at least half the tablets distributed under supervision
(data not shown). Without supervision, however, this
proportion dropped to 50–70% (Figure 2). Self-reported
compliance without supervision was higher among girls
than among boys, and higher in the VA þ Fe groups than in
the groups that received only one type of supplement. More
girls than boys reported to have taken at least 50% of the
iron tablets without supervision (70.1 vs 50.7%; Po0.05),
but there was no such difference for vitamin A (70.1 vs
61.2%; NS).
There was a nonsignificant relationship between reported
side effects (in particular, nausea, vomiting and bad taste/
smell often associated with nausea, which together are
referred to here as gastrointestinal (GI) side effects) and
reported compliance among girls. Girls who reported GI side
effects of iron tablets (41.4% of 134 interviewed girls)
reported a lower compliance to iron tablets when there was
no supervision than girls without GI side effects: 60.0 vs
76.9% reported having taken at least 50% of the tablets. No

European Journal of Clinical Nutrition


932
less than 50% taken
100%
90%
80%
Percentage of respondents reporting compliance
70%
60%
50%
40%
30%
20%
10%
0%
Boys (136)
Iron tablets
Figure 2 Self-reported compliance of adolescent girls and boys in
taking iron (136 boys and 135 girls) and vitamin A supplements (134
boys and 138 girls) without supervision.
such relationship was present for complaints about GI side
effects of vitamin A tablets (reported by 16.2% of girls).
Among boys, no relationship between side effects of iron
tablets (reported by 24.3% of 136 boys) and reported
compliance was found. However, boys who complained
about GI side effects of vitamin A tablets (13.4%) were less
compliant than those who did not complain (38.9 vs 64.6%
reported having taken at least 50% of the vitamin A tablets;
Po0.05). No relationship, however, was found between
reported side effects and impact of the intervention on
haemoglobin or serum retinol concentrations.
Initially, analyses of the effect of the supplementation
were performed on the total population. As no effect of the
supplementation was found, analyses were repeated in
subgroups based on pubertal and anaemia status or serum
retinol concentration.
The change in haemoglobin concentration in these
subgroups is shown in Table 2. Anaemic pubertal girls in
the Fe group showed a higher increase in the mean
haemoglobin concentration than those in the VA group.
However, there was no difference between either of these
groups and the control group, and no effect was found in the
VA þ Fe group. Among anaemic prepubertal girls, there was
a nonsignificant trend of an increasing effect in the VA, Fe
and VA þ Fe groups, but the control group did nearly as well
as the VA þ Fe group. Among nonanaemic girls, and among
boys, no effect of the interventions was found. However,
anaemic pubertal boys seemed to respond better to vitamin
A, with or without iron, than to iron alone, while the change
in haemoglobin concentration in the Fe group was compar-
able to that in the control group. No significance was
reached due to the small numbers of anaemic pubertal boys.
The interventions did not increase the serum retinol
concentrations of girls (Table 3). When all boys were
European Journal of Clinical Nutrition
Vitamin A and iron supplements for adolescents
DD Soekarjo et al
50-74% taken at least 75% taken considered, regardless of their initial serum retinol concen-
trations or pubertal status, subjects in the VA group showed a
significantly (Po0.01) higher increase than those in the
control group. After differentiation for pubertal status, this
effect occurred in the pubertal boys (Po0.05), while among
prepubertal boys it did not reach statistical significance.
Among boys with normal serum retinol concentrations
(Z1.05 mmol/l), no impact of the interventions was found.
Boys who received vitamin A alone but not in combination
with iron experienced a significantly higher increase in
serum retinol concentration. This effect was also found in
the subgroup of pubertal boys, but not among prepubertal
boys. No effect of the interventions on serum retinol
concentration was found among boys with normal baseline
serum retinol concentrations. However, among those with
low serum retinol concentrations, boys receiving vitamin A
Girls (134) Boys (134) Girls (137)
alone experienced a higher increase than those receiving
Vitamin A tablets iron only or nothing. In the group receiving both vitamin A
and iron, the increase in serum retinol concentrations was
only higher than that in the iron-only group, while no
difference was found with the control group. Within the
subgroup of boys with low serum retinol concentrations,
prepubertal boys experienced a significantly higher increase
in serum retinol concentrations in the vitamin A only group
compared to the control group, but not in the group
receiving both vitamin A and iron. In contrast, pubertal
boys receiving vitamin A either alone or with iron had a
higher increase than those receiving iron alone, but not than
those receiving nothing. The fact that the increase was
higher in the VA than in the VA þ Fe group might be
explained by the higher baseline serum retinol concentra-
tions in this latter group.
When the percentage of low serum retinol concentration
(o1.05 mmol/l) is considered, rather than the mean serum
retinol concentration, there is a clear impact of both VA and
VA þ Fe in the boys, while no effect is seen in the girls. Of the
boys with low serum retinol concentrations at baseline, only
29.2% (n ¼ 14) and 24.0% (n ¼ 6) still had concentrations
below the cutoff after the intervention, when they had
received vitamin A alone or with iron, respectively, com-
pared to 61.5% (n ¼ 16) and 60.6% (n ¼ 20) in the control
and iron groups (Po0.005). In the girls, the corresponding
figures were 50.0 (n ¼ 16) in the control group, 52.8 (n ¼ 19)
in the VA group, 56.1 (n ¼ 23) in the Fe group and 44.8
(n ¼ 13) in the VA þ Fe group. It was not possible to
distinguish between prepubertal and pubertal subjects, as
the numbers of subjects with low baseline serum retinol
concentrations were too small for this analysis.
As no impact of the intervention was found on haemo-
globin concentration, logistic regression analysis was only
performed to assess the risk of having low serum retinol
concentrations after the intervention (Table 4). In girls
(n ¼ 280), the only factors increasing this risk were having
a low serum retinol concentration at baseline and being
nightblind at baseline. Boys (n ¼ 284) had a higher risk of
having a low serum retinol concentration when they had a

Table 2 Change of haemoglobin concentration (g/l) in girls (n ¼ 1757) and boys (n ¼ 1859) by initial anaemia status and initial pubertal status (mean
(95% confidence interval) (n)).
Control
Girls
Prepubertal (297)
Nonanaemic (237) 2.7 (6.2; 0.8) (46)
Anaemic (60) 9.0 (4.4; 13.6) (8)
Pubertal (1460)
Nonanaemic (1088) 6.1 (7.7; 4.5) (189)
Anaemic (372) 5.6 (2.5; 8.6) (66)AB
Boys
Prepubertal (562)
Nonanaemic (426) 4.3 (7.1; 1.5) (72)
Anaemic (136) 7.5 (3.8; 11.1) (32)
Pubertal (1297)
Nonanaemic (1161) 3.1 (4.8; 1.3) (194)
Anaemic (136) 9.8 (5.2; 14.4) (19)
A,B
Within a row, significant differences exist between groups that do not share the same letter (Po0.05, ANOVA with Bonferroni correction for post hoc multiple
comparisons).
mother with no formal education, and received either no
supplementation or iron only, in addition to having a lower
baseline serum retinol concentration.
Discussion
This school-based intervention among 12–15 y-old adoles-
cents found no effect on haemoglobin concentration of 14
weeks of supplementation with 60 mg iron þ 250 mg folate
and 10 000 IU vitamin A, either alone or in combination.
While there was no effect of the supplementation on the
serum retinol concentration of girls, boys showed an
increase in serum retinol concentration after supplementa-
tion with vitamin A alone but not with iron.
At the time this study was designed, not much literature
was available on iron and vitamin A supplementation among
adolescents. However, based on supplementation studies in
other groups like children (Angeles et al, 1993) and pregnant
women (Suharno et al, 1993), it was deemed reasonable to
expect an impact in adolescents as well. Lately, other studies
have shown the efficacy of weekly supplementation with
iron and/or vitamin A to increase haemoglobin (and serum
retinol) concentrations among adolescent girls (Angeles-
Agdeppa et al, 1997, Tee et al, 1999, Ahmed et al, 2001). No
studies among boys were found. The differences in findings
with the present study may be explained by the following
critical review of the various factors, which can cause
differences in impact of the supplementation on haemoglo-
bin and serum retinol concentration of adolescents.
The main difference is that those studies were efficacy
trials and therefore only reported on compliers, while the
study presented here assessed the effectiveness of supple-
mentation in a programmatic setting. Only two studies
included vitamin A in the intervention (Angeles-Agdeppa
et al, 1997; Ahmed et al, 2001), and in particular the latter
Vitamin A and iron supplements for adolescents
DD Soekarjo et al
933
Vitamin A Iron Vitamin A and Iron
4.9 (7.4; 2.4) (58) 5.6 (8.0; 3.2) (58) 5.0 (7.6; 2.4) (75)
5.9 (0.9; 11.0) (18) 7.5 (0.5; 14.6) (15) 10.2 (6.1; 14.3) (19)
7.0 (8.4; 5.6) (284) 7.1 (8.3; 5.8) (307) 6.3 (7.6; 5.0) (308)
2.7 (0.5; 4.9) (103)A 7.8 (5.7; 9.9) (108)B 4.4 (1.9; 6.9) (95)AB
4.0 (6.1; 1.8) (119) 6.1 (8.3; 4.0) (102) 3.3 (5.3; 1.4) (133)
8.4 (3.5; 13.3) (33) 5.3 (1.2; 9.4) (34) 7.1 (3.1; 11.1) (37)
3.8 (5.3; 2.3) (308) 5.5 (6.8; 4.2) (325) 3.5 (4.9; 2.1) (334)
12.0 (8.6; 15.4) (47) 7.4 (3.4; 11.4) (29) 12.9 (8.5; 17.3) (41)
found results resembling those documented by Suharno et al
(1993) in pregnant women. However, the subjects of both
studies were older, were all postmenarcheal, had lower serum
retinol concentrations and, in Ahmed et al’s study, were all
anaemic, which can explain part of the difference in impact.
Tee et al found an increase in haemoglobin concentration of
anaemic girls after iron/folate supplementation, but there
was no placebo group to compare this with. Among
nonanaemic girls, weekly supplementation with 120 mg
but not 60 mg iron increased haemoglobin concentration.
Their subjects were older, and no details on pubertal or
socioeconomic status were provided. Recent studies among
pregnant women also did not find an additional benefit of
vitamin A supplementation on haemoglobin concentrations
in pregnancy nor postpartum, nor of postpartum serum
retinol concentrations (Muslimatun et al, 2001a, Muslima-
tun et al, 2001b, Semba et al, 2001).
The interventions were randomized per grade and the
proportion of pupils attending the different types of schools
was similar in all four treatment groups. The control group
consisted of pupils from similar schools in the same area who
did not receive any intervention and were measured at the
same periods as the intervention groups. Differences
between schools could thus not influence the results of the
intervention. No difference was found between the control
group and the intervention groups, and there is no reason to
assume this would have been different had a placebo been
used. Mix up of supplements between the different groups
was highly unlikely because the supplements had different
colours and no placebo was used.
The study coincided with Ramadan, the Muslim
fasting month. This could not be avoided, because
otherwise the time between school examinations
(during which no supplementation and/or data collection
activities were allowed in the schools) would have been
European Journal of Clinical Nutrition
 934
European Journal of Clinical Nutrition

Table 3 Changes in serum retinol concentrations (mmol/l) in girls (n ¼ 306) and boys (n ¼ 319) by initial serum retinol concentration status and initial pubertal status (mean (95% confidence

Vitamin A and iron supplements for adolescents

interval) (n))

Sex Baselinea Pubertyb Control Vitamin A Iron Vitamin A and Iron

Girls Overall Overall (306) 0.14 (0.05; 0.23) (54) 0.14 (0.06; 0.22) (90) 0.09 (0.01; 0.17) (86) 0.14 (0.02; 0.26) (76)
Pre (47) 0.17 (0.11; 0.45) (7) 0.15 (0.06; 0.36) (17) 0.09 (0.23; 0.41) (8) 0.30 (0.07; 0.66) (15)
Post (259) 0.13 (0.03; 0.23) (47) 0.13 (0.05; 0.22) (73) 0.09 (0.01; 0.18) (78) 0.10 (0.02; 0.23) (61)
Z1.05 mmol/l Overall (168) 0.07 (0.17; 0.03) (22) 0.06 (0.05; 0.18) (54) 0.01 (0.10; 0.11) (45) 0.03 (0.14; 0.21) (47)
Pre (17) (0) 0.11 (0.18; 0.95) (4) 0.07 (0.51; 0.65) (5) 0.31 (0.45; 1.08) (8)
Post (151) 0.07 (0.17; 0.03) (22) 0.08 (0.03; 0.19) (50) 0.00 (0.12; 0.11) (40) 0.02 (0.18; 0.14) (39)

DD Soekarjo et al
o1.05 mmol/l Overall (138) 0.28 (0.16; 0.40) (32) 0.24 (0.14; 0.35) (36) 0.19 (0.07; 0.30) (41) 0.31 (0.18; 0.44) (29)
Pre (30) 0.17 (0.11; 0.45) (7) 0.23 (0.05; 0.41) (13) 0.13 (0.53; 0.79) (3) 0.28 (0.08; 0.48) (7)
Post (108) 0.31 (0.17; 0.45) (25) 0.25 (0.12; 0.39) (23) 0.19 (0.07; 0.31) (38) 0.32 (0.15; 0.49) (22)

Boys Overall Overall (319)c 0.07 (0.01; 0.15) (74)A 0.33 (0.22; 0.45) (85)B 0.17 (0.08; 0.27) (68)AB 0.19 (0.07; 0.30) (92)AB
Pre (83) 0.08 (0.06; 0.22) (20) 0.27 (0.07; 0.46) (26) 0.17 (0.03; 0.38) (18) 0.33 (0.12; 0.53) (19)
Post (236)d 0.07 (0.03; 0.17) (54)A 0.37 (0.22; 0.51) (59)B 0.17 (0.06; 0.28) (50)AB 0.15 (0.02; 0.29) (73)AB
Z1.05 mmol/l Overall (187) 0.02 (0.12; 0.08) (48) 0.11 (0.06; 0.28) (37) 0.19 (0.02; 0.35) (35) 0.08 (0.06; 0.22) (67)
Pre (42) 0.03 (0.26; 0.32) (9) 0.06 (0.45; 0.33) (10) 0.13 (0.22; 0.48) (11) 0.31 (0.01; 0.64) (12)
Post (145) 0.03 (0.14; 0.07) (39) 0.17 (0.02; 0.37) (27) 0.21 (0.02; 0.40) (24) 0.03 (0.13; 0.19) (55)
o1.05 mmol/l Overall (132)e 0.25 (0.14; 0.36) (26)AB 0.51 (0.37; 0.65) (48)C 0.16 (0.05; 0.26) (33)A 0.47 (0.33; 0.60) (25)BC
Pre (41)d 0.12 (0.04; 0.27) (11)A 0.47 (0.31; 0.63) (16)B 0.24 (0.07; 0.41) (7)AB 0.35 (0.10; 0.59) (7)AB
Post (91)f 0.35 (0.20; 0.49) (15)AB 0.53 (0.32; 0.74) (32)B 0.13 (0.01; 0.26) (26)A 0.52 (0.34; 0.69) (18)B
a
Baseline serum retinol concentration.
b
Pre ¼ pre-pubertal; Post ¼ pubertal.
c
Po0.01.
d
Po0.05.
e
Po0.001.
f
Po0.005.
A,B,C
Within a row, significant differences exist between groups that do not share the same letter (Po0.05, ANOVA with Bonferroni correction for post-hoc multiple comparisons).
 Vitamin A and iron supplements for adolescents
DD Soekarjo et al
935
Table 4 Odds ratios (OR) (95% confidence interval (CI)) for having a serum retinol concentration o1.05 mmol/l postintervention: forward entrance into
the multiple logistic regression modelsa

Girls (280) Boys (284)

OR (95% CI) P-value OR (95% CI) P-value

Baseline serum retinol concentration (mmol/l ) 0.02 (0.01–0.07) o0.0001 0.03 (0.01–0.09) o0.0001
Nightblindness at baseline 5.88 (1.21–28.6) o0.05
Intervention o0.05
Control 1.00
Vitamin A 0.37 (0.16–0.87) o0.05
Iron 0.77 (0.32–1.85) NS
Vitamin A and iron 0.34 (0.14–0.82) o0.05

Maternal formal education o0.05

None 1.00
Primary 0.30 (0.12–0.72) o0.01
Junior High 0.33 (0.11–1.03) o0.10
Senior High 0.17 (0.05–0.61) o0.01
a
In addition to the variables shown in the table, other variables that were available for entrance into the LR models, but that did not enter were age, haemoglobin
concentration, puberty, height, weight, BMI, type of school, paternal formal education, vitamin A intake from plant sources and vitamin A intake from retinol-rich
sources.

insufficient for the supplementation to be effective. During
Ramadan people generally consume more meat and other
sources of haem iron, which might have led to higher
haemoglobin concentrations. However, due to the double
randomization scheme, there is no reason to assume that
this effect, if at all present, differed between intervention
groups.
During the fasting month and holidays supplements had
to be taken at home without supervision (n ¼ 5 tablets). Self-
reported compliance without supervision was low, but
similar to what Angeles-Agdeppa et al (1997) found for
supplements taken at home. Thus, it should be assumed that
the actual duration of supplementation in this study was
only 9 weeks, which was probably too short for the
supplements to have an effect.
The fact that vitamin A supplements were not effective in
increasing serum retinol concentration in girls and haemo-
globin concentration in both girls and boys might be due to
the fact that the dose was relatively low. A measure of
10 000 IU on a weekly basis amounts to only 428 retinol
equivalents (RE)/day, while the RDA for vitamin A in this age
group is 700 RE for girls aged 14–18 y and 900 RE for boys of
the same age (US Institute of Medicine, 2000).
However, short duration and low vitamin A dose alone
cannot completely explain these results. In boys with low
serum retinol concentrations, the increase in serum retinol
concentration in the two groups receiving vitamin A was
almost twice as large as in the other two groups (and also
compared to the girls). In addition, there was a nonsignifi-
cant increase in haemoglobin concentration among pubertal
anaemic boys in these treatment groups, showing that the
dose was probably adequate for boys.
The larger increase in serum retinol concentrations of boys
with low initial serum retinol concentrations in the VA
group compared to those in the VA þ Fe groups was expected
because of their lower baseline serum retinol concentrations.
Owing to the similar baseline concentrations of girls and
boys, and the lower recommended daily allowance (RDA), a
similar increase would have been expected in girls. It is
possible that the RDA for girls is either not correct or not
applicable in this population, that subclinical infections
were more prevalent among girls or that there were other
factors selectively decreasing absorption in girls, despite the
similar conditions of supplement consumption. However,
another factor that potentially could explain the lack of
impact particularly among the girls is poor compliance.
In view of the lack of impact found, it is highly probable
that respondents over-reported compliance rates, and that
this occurred more among girls than among boys. This is
confirmed by reports from field workers that supplements
were found on the floors of the schools, indicating that even
under supervision, actual compliance was lower than
reported, especially for iron. Thus, self-reporting is not a
reliable tool to measure compliance. Almost all subjects
claimed to have taken a considerable number of the
supplements and as a result, there was no relationship
between self-reported compliance and impact. This phenom-
enon of over-reporting compliance has also been found
among Indonesian pregnant women (Schultink et al, 1993;
Ridwan et al, 1996).
Most studies to date have focused on anaemic subjects.
However, from a public health point of view, it may be
worthwhile to target the whole population to have
an impact among a subgroup, rather than identify subjects
and then specifically target those. Therefore, this study
included all pupils in the schools, but analyses were
performed with the aim to determine differential effects in
subgroups.

European Journal of Clinical Nutrition

 Vitamin A and iron supplements for adolescents
DD Soekarjo et al
936
Based on these results, the authors conclude that: (1)
anaemia and subclinical vitamin A deficiency are prevalent
in the study population, (2) vitamin A supplementation is
effective to increase serum retinol concentration in adoles-
cent boys, in particular those with low serum retinol
concentrations, but that 10 000 IU on a weekly basis is
probably a relatively low dose, (3) there is a sex difference in
response to iron and vitamin A supplementation, probably
due to differences in compliance, which should be investi-
gated further and (4) GI side effects appear to play an
important role in decreasing compliance.
Policy and programme implications
Given the high prevalence of anaemia and subclinical
vitamin A deficiency among adolescents, this group forms
a window of opportunity to break the generational cycle of
these deficiencies. It is becoming increasingly clear that
micronutrient supplementation may be a long-term neces-
sity and the efficacy of iron and vitamin A supplements in
adolescent girls has been proven in strictly controlled trials.
Where school enrolment is adequate, schools form a better
entry point than the health system, especially in developing
countries. Not only are future adults’ attitudes and beha-
viour formed in schools, but supplementation and health
education can be integrated in the school curriculum.
However, this study shows that caution is called for when
applying the results of controlled trials directly to pro-
grammes. More operations research should be dedicated to
school-based supplementation with micronutrients in ado-
lescents, focusing on improving effectiveness, in particular
implementation, monitoring and compliance issues. Special
efforts have to be undertaken to increase the involvement of
teachers and students. The low compliance found in this
study, in particular in the iron group, and its relationship
with GI side effects, indicates the need to use better-quality
iron tablets. The dose of vitamin A was relatively low and the
impact of higher doses of weekly vitamin A supplementa-
tion, such as 20 000 IU, should be explored.
Acknowledgements
We are grateful to the Directorate General for Socio-political
Affairs of the Internal Department for the permission to
conduct this research, and to the Departments of Health and
Education at all levels from central to district level for their
cooperation. Special gratitude is extended to the schools,
teachers and other staff, pupils and parents involved in the
study. Without the hard work of the field workers, especially
Erna, Wawan and Ibnu, this intervention study would not
have been possible. We thank Dr Susilowati Herman, Joko
Pambudi MPH and Ms Yetty Yuniar from the Nutrition
Research and Development Centre in Bogor for the analysis
of the serum samples, and Mrs Eha Sulaeha and Mrs Sugiatmi
Nurdin for the data entry. This study was funded by USAID
through the OMNI project.
European Journal of Clinical Nutrition
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