Article

Iron-fortified milk and noodle consumption is associated with lower risk of anemia among children aged 6-59 mo in Indonesia

Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
American Journal of Clinical Nutrition (Impact Factor: 6.77). 07/2010; 92(1):170-6. DOI: 10.3945/ajcn.2010.29254
Source: PubMed

ABSTRACT

Anemia is common among children in developing countries and is associated with decreased cognitive and physical development. Iron-fortified foods may decrease child anemia.
The objective was to describe the association between iron-fortified milk and iron-fortified noodle consumption and anemia in children aged 6-59 mo.
Consumption of fortified milk and fortified noodles and child anemia were assessed in 81,885 families from rural and 26,653 families from urban slum areas in Indonesia.
The proportions of children who received fortified milk and noodles were 30.1% and 22.6%, respectively, in rural families and 40.1% and 48.9%, respectively, in urban families. The prevalence of anemia among children from rural families was 55.9% and from urban families was 60.8%. Children from rural and urban families were less likely to be anemic if they received fortified milk [odds ratio (OR): 0.76; 95% CI: 0.72, 0.80 (P < 0.0001) and OR: 0.79; 95% CI: 0.74, 0.86 (P < 0.0001), respectively] but not fortified noodles [OR: 0.98; 95% CI: 0.93, 1.09 (P = 0.56) and OR: 0.95; 95% CI: 0.88, 1.02 (P = 0.16), respectively] in multiple logistic regression models with adjustment for potential confounders. In rural families, the odds of anemia were lower when the child who consumed fortified milk also consumed fortified noodles or when the child who consumed fortified noodles also consumed fortified milk.
In Indonesia, consumption of fortified milk and noodles was associated with decreased odds of child anemia. Iron-fortified milk and noodles may be a strategy that could be applied more widely as an intervention to decrease child anemia.

Full-text

Available from: Klaus Kraemer, Nov 18, 2015
Iron-fortified milk and noodle consumption is associated with lower risk
of anemia among children aged 6–59 mo in Indonesia
1–3
Richard D Semba, Regina Moench-Pfanner, Kai Sun, Saskia de Pee, Nasima Akhter, Jee Hyun Rah, Ashley A Campbell,
Jane Badham, Martin W Bloem, and Klaus Kraemer
ABSTRACT
Background: Anemia is common among children in developing
countries and is associated with decreased cognitive and physical
development. Iron-fortified foods may decrease child anemia.
Objective: The objective was to describe the association between
iron-fortified milk and iron-fortified noodle consumption and ane-
mia in children aged 6–59 mo.
Design: Consumption of fortified milk and fortified noodles and
child anemia were assessed in 81,885 families from rural and
26,653 families from urban slum areas in Indonesia.
Results: The proportions of children who received fortified milk
and noodles were 30.1% and 22.6%, respectively, in rural families
and 40.1% and 48.9%, respectively, in urban families. The preva-
lence of anemia among children from rural families was 55.9% and
from urban families was 60.8%. Children from rural and urban
families were less likely to be anemic if they received fortified milk
[odds ratio (OR): 0.76; 95% CI: 0.72, 0.80 (P , 0.0001) and OR:
0.79; 95% CI: 0.74, 0.86 (P , 0.0001), respectively] but not forti-
fied noodles [OR: 0.98; 95% CI: 0.93, 1.09 (P = 0.56) and OR: 0.95;
95% CI: 0.88, 1.02 (P = 0.16), respectively] in multiple logistic
regression models with adjustment for potential confounders. In
rural families, the odds of anemia were lower when the child who
consumed fortified milk also consumed fortified noodles or when
the child who consumed fortified noodles also consumed fortified
milk.
Conclusions: In Indonesia, consumption of fortified milk and noo-
dles was associated with decreased odds of child anemia. Iron-for-
tified milk and noodles may be a strategy that could be applied more
widely as an intervention to decrease child anemia. Am J Clin
Nutr 2010;92:170–6.
INTRODUCTION
Anemia is highly prevalent among children in developing
countries, and it affects nearly 300 million preschool-aged
children worldwide (1). Anemia adversely affects the cognitive
and physical development of children and may have long-term
consequences in terms of physical productivity and reproductive
outcomes in adulthood (2). It is generally assumed that about one-
half of the cases of anemia are caused by iron deficiency, but the
proportion may vary in accordance with local conditions (3). The
main cause of iron deficiency among young children in de-
veloping countries is a lack of bioavailable iron in a diet that is
largely plant based and low in animal foods. Although evidence is
accumulating that improvement of iron status will confer large
health benefits, progress has been extremely slow in the pre-
vention of iron deficiency through public health interventions (4).
Iron deficiency is most prevalent and severe during the
weaning period. One of the major research priorities in the
prevention of iron deficiency is the improvement of the nutri-
tional quality of complementary foods. Fortified foods may
provide iron and other micronutrients as infants make the tran-
sition from a diet of breast milk to a mixed diet that includes
breast milk and other foods (5). A variety of approaches have
been shown to decrease iron deficiency and anemia, and include
in-home fortification with micronutrient powders and the use of
commercially fortified foods such as cereals, sauces, and lipid-
based spreads (5–7). Micronutrient-fortified powdered milk
provided through a national complementary food program in
Chile has been shown to improve iron status and decrease anemia
in infants and young children (8, 9). Since the mid-1990s, for-
tification of powdered milk with vitamins and minerals, which
includes iron, has been mandatory in Indonesia, and about one-
half of instant noodles have been fortified voluntarily. The use of
fortified powdered milk is fairly common in Indonesia, but the
use of fortified instant noodles is less common, especially among
households in remote rural areas (10). The relation between the
consumption of fortified powdered milk and fortified noodles and
health outcomes has not been well characterized.
We hypothesized that young children, aged 6–59 mo, who
consumed iron-fortified powdered milk and/or iron-fortified
noodles were at a lower risk of anemia. To address this hy-
pothesis, we examined the relation between the use of fortified
powdered milk and noodles and child anemia in a large population-
based sample of families from Indonesia.
1
From the Department of Ophthalmology, Johns Hopkins University
School of Medicine, Baltimore, MD (RDS, KS, and AAC); the Global
Alliance for Improved Nutrition, Geneva, Switzerland (RM-P); the Nutrition
Service, Policy, Strategy and Programme Support Division, World Food
Programme, Rome, Italy (SdP and MWB); Helen Keller International Asia
Pacific, Dhaka, Bangladesh (NA); Sight and Life, DSM, Basel, Switzerland
(JHR and KK); and the JB Consultancy, Johannesburg, South Africa (JB).
2
Supported by the Lew R Wassermann Merit Award from Research to
Prevent Blindness (to RDS).
3
Address correspondence to RD Semba, Johns Hopkins School of Med-
icine, 400 North Broadway, Suite 700, Baltimore, MD 21205. E-mail:
rdsemba@jhmi.edu.
Received January 22, 2010. Accepted for publication April 5, 2010.
First published online May 5, 2010; doi: 10.3945/ajcn.2010.29254.
170 Am J Clin Nutr 2010;92:170–6. Printed in USA. Ó 2010 American Society for Nutrition
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SUBJECTS AND METHODS
The study subjects consisted of families from rural areas who
participated in the Nutritional Surveillance System (NSS) in
Indonesia from March 1999 to August 2003 and families from
urban slum areas who participated in the NSS from January 1999
to July 2003. The NSS was established by the Ministry of Health,
Government of Indonesia, and Helen Keller International in 1995
(11). The NSS was based on United Nations International
Children’s Fund’s conceptual framework on the causes of
malnutrition (12) with the underlying principle to monitor public
health problems and guide policy decisions (13). The NSS used
stratified multistage cluster sampling of households in sub-
districts of administrative divisions of the country in rural and
slum areas of large cities. During the study period, there were 17
rounds of data collection, from an average of 4800 rural
households and 1560 urban households per round. Data collec-
tion involved 5 major urban poor populations from slum areas in
the cities of Jakarta, Surabaya, Makassar, Semarang, and Pa-
dang, and rural population from the provinces of Lampung,
Banten, West Java, Central Java, East Java, the island of Lom-
bok (West Nusatenggara), and South Sulawesi.
New households were selected every round and data were
collected by 2-person field teams. A structured, coded ques-
tionnaire was used to record data on children aged 0–59 mo; the
questionnaire included anthropometric measurements, date of
birth, and sex. The mother of the child or other adult member of
the household was asked to provide information on the house-
hold’s composition, parental education, and weekly household
expenditures, along with other socioeconomic, environmental
sanitation, and health indicators. For each child in the family, data
were collected on whether the child had received a vitamin A
capsule and/or a deworming medication in the previous 6 mo.
For each child in the family, data were collected on whether the
child had consumed industrially produced milk products in the
previousweek,the commercialbrand ofthe product, and howmuch
money was spent on the milk product in the previous week. Similar
data were collected on whether the child had consumed instant
noodles in the previous week, the commercial brand of the product
(which allowed classification of noodles as fortified or not), and
how much was spent on the noodles in the previous week. Data on
consumption of meat and poultry by the child in the previous week
were also collected. Hemoglobin was measured in mothers and
children in the family with the use of a HemoCue instrument
(HemoCue AB, Angelholm, Sweden). Birth dates of the children
were estimated with the use of a calendar of local and national
events and were converted to the Gregorian calendar.
The participation rate of families in the surveillance system
was .97% in both urban slum and rural areas, and the main
reason for nonresponse was that the family had moved out of the
area or was absent at the time the interviews were conducted.
Nonresponse because of refusal to participate in the surveillance
system was very low (,1%).
In each household, data were gathered regarding the expendi-
tures in the previous week. Expenditure and price variables were
collected in Indonesian rupiah. For this analysis, expenditures are
presented in US dollars to control for the fluctuation of the In-
donesian rupiah. In Indonesia, monthly exchange rates from 2000
to 2003 were established with the use of historic data available
publicly through the Bank of Canada (14). Mean exchange rates by
data collection round were calculatedbased onthe monthsin which
data were collected for each round. Expenditure and pricevariables
in US dollars per round were created and calculated with the use of
the exchange rates by round.
The study protocol complied with the principles enunciated in
the Helsinki Declaration (15). The field teams were instructed to
explain the purpose of the nutrition surveillance system and data
collection to each child’s mother or caretaker, and, if present, the
father and/or household head; data collection proceeded only
after written informed consent was obtained. Participation was
voluntary, no remuneration was provided to subjects, and all
subjects were free to withdraw at any stage of the interview. The
protocol of the NSS in Indonesia was approved by the Ministry of
Health, Government of Indonesia. The plan for secondary data
analysis was approved by the Institutional Review Board of the
Johns Hopkins University School of Medicine.
Rural and urban areas were analyzed separately because of
differences in sampling methods and because the availability of
fortified foods would be expected to differ between urban slums
and rural areas. The study was limited to children aged 6–59 mo
because the interpretation of low hemoglobin in children age ,6
mo is difficult. For families with more than one child aged 6–59
mo, the analysis was limited to the youngest child only (ie,
families were not counted more than once because anemia tends
to cluster within families). Anemia was defined as hemoglobin
,11 g/dL in children and ,12 g/dL in nonpregnant women, in
accordance with World Health Organization criteria (1). Ma-
ternal age was divided into quartiles. Maternal and paternal
education was categorized as 0, 1–6 (primary), 7–9 (junior
high), and 10 y (high school or greater). The proportion of
mothers and fathers who had achieved .12 y (high school
graduate) was 2.3% and 3.8%, respectively, and was thus
included in the category 10 y. Maternal smoking was not in-
cluded as a covariate because ,0.1% of women were smokers.
Weighting was used to adjust for urban as well as rural pop-
ulation size, by city and province, respectively, and all results
were weighted. Weekly per capita household expenditure was
used as the main indicator of socioeconomic status. Crowding
was defined as households where .4 individuals ate from the
same kitchen. Chi-square tests were used to compare categorical
variables between groups. Analysis of variance (ANOVA) was
used to compare the adjusted prevalence of anemia across
groups by expenditure. Multiple logistic regression models were
used to examine the relation between child anemia and the use
of fortified milk and the use of fortified noodles. Variables were
included in the multivariate models if significant in univariate
analyses. P , 0.05 was considered significant. Covariance
matrices were used to examine for multicollinearity among in-
dependent variables in the models. Data analyses were con-
ducted with the use of SAS Survey (SAS Institute, Cary, NC).
RESULTS
Of 81,885 families from rural areas and 26,653 families from
urban slum areas, the proportion of children who consumed
fortified milk was 30.1% and 40.1%, respectively. In families
from rural and urban areas, the proportion of children who
consumed fortified noodles was 22.6% and 48.9%, respectively.
The prevalence of anemia among children aged 6–59 mo from
rural and urban slum families was 55.9% and 60.8%, respectively.
IRON-FORTIFIED MILK AND NOODLES AND CHILD ANEMIA 171
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TABLE 1
Demographic and other factors related to anemia in children aged 6–59 mo from families in rural and urban slum areas of Indonesia
Variable
1
Rural Urban
n Child with anemia P value
2
n Child with anemia P value
2
%%
Child consumed fortified milk
Yes 24,638 47.4 ,0.0001 9987 56.1 ,0.0001
No 57,078 59.7 14,899 64.2
Child consumed fortified noodles
Yes 18,497 53.2 ,0.0001 13,031 59.1 ,0.0001
No 63,384 56.8 13,620 62.4
Child age
6–11 mo 16,419 75.4 ,0.0001 4957 75.6 ,0.0001
12–23 mo 26,406 65.7 8427 68.8
24–35 mo 18,908 47.6 6290 56.5
36–47 mo 12,656 37.8 4445 47.5
48–59 mo 7493 30.8 2534 39.3
Child sex
Male 42,127 58.3 ,0.0001 13,973 62.4 ,0.0001
Female 39,758 53.5 12,679 59.0
Maternal age
24 y 24,096 60.8 ,0.0001 7138 65.4 ,0.0001
25–28 y 20,525 56.0 6816 60.6
29–32 y 17,713 53.9 5901 59.3
33 y 19,462 51.8 6798 57.6
Maternal education
None 4,713 61.7 ,0.0001 1373 62.3 ,0.0001
1–6 y 44,040 57.3 12,516 62.7
7–9 y 16,520 56.0 6119 61.0
10 y 16,191 50.5 6565 56.7
Maternal BMI
,18.5 kg/m
2
10,188 62.4 3310 65.8
18.5 to ,25 kg/m
2
56,988 56.4 ,0.0001 16,768 61.8 ,0.0001
25 to ,30 kg/m
2
12,241 50.5 5179 56.0
30 kg/m
2
2035 46.7 1129 54.1
Mother was anemic
Yes 19,082 66.8 ,0.0001 7087 69.3 ,0.0001
No 58,674 52.8 17,742 57.6
Paternal education
None 3435 62.8 ,0.0001 632 63.4 ,0.0001
1–6 y 38,940 57.2 9635 63.1
7–9 y 14,982 55.5 6385 61.3
10 y 21,817 52.3 9375 57.9
Child currently breastfeeding
Yes 43,970 64.8 ,0.0001 13,005 70.8 ,0.0001
No 37,815 35.2 13,598 51.2
Child received deworming medication
Yes 14,051 49.4 ,0.0001 5482 58.0 ,0.0001
No 66,821 57.6 21,136 61.5
Child received vitamin A in past 6 mo
Yes 48,381 52.7 ,0.0001 15,455 58.4 ,0.0001
No 31,224 61.1 10,210 64.5
Child consumed beef in past week
Yes 6,099 53.6 ,0.0001 2404 55.3 ,0.0001
No 73,974 56.3 24,049 61.4
Child consumed poultry in past week
Yes 17,134 51.7 ,0.0001 8745 58.5 ,0.0001
No 63,192 57.3 17,799 62.0
Father is a smoker
Yes 59,726 56.7 ,0.0001 18,974 61.6 ,0.0001
No 20,387 53.6 7212 58.6
(Continued)
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The relation of demographic and other characteristics of
families from rural areas and urban slum areas with child anemia
is shown in Table 1. Factors associated with higher odds of child
anemia were younger child age, male sex, lower maternal age,
lower maternal education, maternal underweight, maternal
anemia, lower paternal education, current breastfeeding, pater-
nal smoking, .4 household members eating from the same
kitchen, and lower weekly per capita household expenditure.
Factors associated with lower odds of child anemia were con-
sumption of fortified milk, consumption of fortified noodles,
deworming, vitamin A supplementation, consumption of beef,
and consumption of poultry. These findings were consistent for
families from both rural and urban slum areas.
The relation between consumption of fortified milk and fortified
noodles and child anemia was examined in separate multiple lo-
gistic regression models for families from rural areas and urban
slum areas (Table 2). In rural and urban families, consumption of
fortified milk was associated with lower odds of child anemia in
separate multiple logistic regression models, with adjustment for
child age; child sex; maternal age, education, and body mass in-
dex; maternal anemia; current breastfeeding; deworming; vitamin
A supplementation; beef consumption; poultry consumption;
paternal smoking; household size; weekly per capita household
expenditure; and location. In rural and urban families, consump-
tion of fortified noodles was not significantly associated with
lower odds of child anemia in separate multiple logistic regression
models, when adjustment was made for the same covariates as
above.
An interaction was observed between the consumption of
fortified milk and fortified noodles (P = 0.028) in rural families
but not among urban families (P = 0.39). In rural families, the
consumption of fortified milk was associated with lower odds of
child anemia when the child who consumed fortified milk also
consumed fortified noodles (odds ratio: 0.70; 95% CI: 0.63.
0.76; P , 0.0001). The consumption of fortified noodles was
associated with lower odds of child anemia when the child who
consumed fortified noodles also consumed fortified milk (odds
ratio: 0.92; 95% CI: 0.84, 0.99; P = 0.04).
Vitamin A supplementation was associated with lower odds of
anemia in children from rural families. In the separate model for
urban families, vitamin A supplementation was not significantly
associated with anemia. Current breastfeeding was associated
with higher odds of child anemia in the same multiple logistic
regression models.
Families were divided into 4 categories on the basis of weekly
expenditure per child on fortified milk (Figure 1) and fortified
noodles (Figure 2). The prevalence of child anemia decreased
across the 4 categories of expenditure in both rural and urban
families, when adjustment was made for the same covariates as
in Table 2 (P , 0.0001).
DISCUSSION
The present study shows that children aged 6–59 mo who
consumed iron-fortified milk were less likely to be anemic than
children who did not consume iron-fortified milk. To our
knowledge, this is the first population-based study to show an
association between consumption of fortified milk and decreased
risk of anemia in children aged 6–59 mo. The findings in the study
were consistent for children from families from rural areas and
those from urban slums. The present study did not show that
children who consumed fortified noodles alone had a lower risk of
anemia; however, among rural families, children who consumed
both fortified noodles and fortified milk had lower odds of anemia
than if they consumed fortified milk alone. Less than one-half of
families had children who consumed fortified milk and/or for-
tified noodles, but it should be noted that uptake of these products
is passive because there is no active program for the provision of
fortified milk or fortified noodles in Indonesia.
Whether the consumption of fortified milk is causally related
to lower anemia cannot be definitively concluded from these
results, because the observation is based on cross-sectional
associations from a nutritional surveillance program. However,
such a conclusion seems reasonable. Previous interventional
studies have shown that fortified milk decreases anemia in
children (8, 9). A recent controlled trial in India showed that
fortified milk decreased infectious disease morbidity in children
aged 1–3 y (16). Diarrheal disease and infections are factors that
also contribute to anemia in children in developing countries, and
reduction of infectious disease morbidity by fortified milk would
TABLE 1 (Continued )
Variable
1
Rural Urban
n Child with anemia P value
2
n Child with anemia P value
2
No. of household members eating from same kitchen % %
2–4 33,203 54.8 ,0.0001 13,824 60.6 ,0.0001
.4 40,147 56.4 12,475 61.5
Weekly per capita household expenditure
3
Quintile 1 14,672 61.0 ,0.0001 5293 63.2 ,0.0001
Quintile 2 14,672 57.7 5295 61.9
Quintile 3 14,674 55.9 5293 60.4
Quintile 4 14,670 53.0 5293 60.8
Quintile 5 14,672 50.6 5294 58.2
1
Missing data for the following numbers of participants (rural, urban): fortified milk (69, 1717); fortified noodles (4, 2); child age (3, 0); child sex (0, 1);
maternal age (89, 0); maternal education (421, 80); maternal BMI (433, 267); maternal anemia (4129, 1824); paternal education (3711, 626); child
breastfeeding (100, 50); deworming (1013, 35); vitamin A (2280, 988); paternal smoking (1772, 467); number of household members (8531, 354); and
weekly per capita household expenditure (8525, 185).
2
Chi-square tests were used to compare categorical variables.
3
Quintiles 1 and 5 represent the lowest and the highest per capita household expenditure, respectively.
IRON-FORTIFIED MILK AND NOODLES AND CHILD ANEMIA 173
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be expected to lower anemia of infection. Although the present
study did not show a significant association between consumption
of fortified noodles and child anemia in Indonesia, a previous
study showed that iron-fortified noodles decreased iron-de-
ficiency anemia in a controlled trial among school children aged
6–8 y in rural Vietnam (17).
The strengths of this study are the large population-based
sample size, the consistency of the results between rural and
urban slum areas, and data that allowed analyses to be controlled
for potential confounding factors. In epidemiologic studies, it is
not possible to control for all factors, and unmeasured factors
may have influenced the relation between use of fortified milk
and child anemia. The present study is limited in that hemoglobin
alone was measured in children, with no measurement of bio-
markers of iron status or other micronutrients that could con-
tribute to anemia, such as vitamin A, folate, and vitamin B-12.
The identification of specific micronutrient deficiencies through
laboratory analyses was not an aim of the surveillance program
and would have been difficult with a sample size of .100,000
children. Iron deficiency is usually considered to be the cause of
about one-half of the cases of anemia in children (3). In In-
donesia, iron deficiency is the main cause of anemia among
TABLE 2
Multiple logistic regression models for consumption of both fortified milk and fortified noodles and child anemia in families from rural and urban
areas of Indonesia
1
Variable
Rural Urban
OR 95% CI P value OR 95% CI P value
Child consumed fortified milk 0.76 0.72, 0.80 ,0.0001 0.79 0.74, 0.86 ,0.0001
Child consumed fortified noodles 0.98 0.93, 1.04 0.50 0.95 0.88, 1.02 0.16
Child age
6–11 mo 1.00 1.00
12–23 mo 0.72 0.68, 0.77 ,0.0001 0.76 0.69, 0.85 ,0.0001
24–35 mo 0.41 0.38, 0.45 ,0.0001 0.57 0.51, 0.65 ,0.0001
36–47 mo 0.29 0.27, 0.32 ,0.0001 0.43 0.37, 0.49 ,0.0001
48–59 mo 0.21 0.19, 0.24 ,0.0001 0.30 0.26, 0.35 ,0.0001
P value for trend ,0.0001 ,0.0001
Male child 1.24 1.18, 1.29 ,0.0001 1.21 1.13, 1.29 ,0.0001
Maternal age
24 y 1.00 1.00
25–28 y 0.96 0.91, 1.02 0.20 1.01 0.92, 1.11 0.80
29–32 y 0.94 0.88, 1.00 0.04 0.99 0.89, 1.09 0.81
33 y 0.83 0.78, 0.88 ,0.0001 0.85 0.76, 0.94 0.002
P value for trend ,0.0001 0.0003
Maternal education
0 y 1.38 1.23, 1.56 ,0.0001 1.32 1.11, 1.57 0.001
1–6 y 1.21 1.14, 1.28 ,0.0001 1.31 1.21, 1.43 ,0.0001
7–9 y 1.17 1.09, 1.25 ,0.0001 1.20 1.09, 1.32 0.0003
10 y 1.00 1.00
P value for trend ,0.0001 ,0.0001
Maternal BMI
,18.5 kg/m
2
1.15 1.08, 1.23 ,0.0001 1.06 0.96, 1.18 0.24
18.5 to ,25 kg/m
2
1.00 1.00
25 to ,30 kg/m
2
0.99 0.94, 1.06 0.97 0.90 0.83, 0.98 0.02
30 kg/m
2
0.87 0.76, 0.98 0.03 0.85 0.71, 1.00 0.05
P value for trend 0.86 0.01
Mother was anemic 1.79 1.69, 1.88 ,0.0001 1.68 1.55, 1.81 ,0.0001
Child currently breastfeeding 1.11 1.09, 1.13 ,0.0001 1.12 1.09, 1.16 ,0.0001
Child received deworming medication in past 6 mo 0.99 0.94, 1.06 0.93 1.02 0.93, 1.11 0.72
Child received vitamin A in past 6 mo 0.92 0.88, 0.97 0.001 1.02 0.95, 1.09 0.58
Child consumed beef in past week 1.01 0.92, 1.10 0.89 0.91 0.81, 1.03 0.12
Child consumed poultry in past week 0.95 0.90, 1.01 0.09 0.93 0.86, 1.00 0.05
Father is a smoker 1.01 0.97, 1.06 0.57 1.01 0.94, 1.09 0.76
More than 4 individuals eating from same kitchen 1.08 1.03, 1.13 0.002 1.09 1.01, 1.18 0.03
Weekly per capita household expenditure
2
Quintile 1 1.00 1.00
Quintile 2 0.97 0.90, 1.04 0.33 0.97 0.87, 1.08 0.57
Quintile 3 1.04 0.97, 1.11 0.28 1.03 0.92, 1.15 0.61
Quintile 4 0.99 0.92, 1.07 0.84 1.05 0.94, 1.19 0.38
Quintile 5 0.98 0.90, 1.06 0.55 1.02 0.90, 1.16 0.73
P value for trend 0.62 0.43
1
OR, odds ratio. Separate multiple logistic regression models were analyzed for rural and urban participants. All models were adjusted for location
(province for rural model, city for urban model).
2
Quintiles 1 and 5 represent the lowest and the highest per capita household expenditure, respectively.
174 SEMBA ET AL
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children in the community (18). Although malaria can cause
anemia, the only study location that was endemic for malaria
was Lombok.
In the present study, children who were still breastfeeding at 6
to 59 mo of age were at higher risk of anemia. Although the
proportion of infants who were exclusively breastfeeding at 6 mo
of age was low, these findings are consistent with previous studies
of anemia in breastfeeding infants aged .6 mo. In Mexico, the
risk of anemia was increased among infants who were exclusive
breastfeeding after 6 mo of age (19). A study in Argentina
showed that iron-deficiency anemia was higher in exclusively
breastfed infants up to 9 mo (20). In Malaysia, prolonged
breastfeeding for .6 mo was associated with an increased risk
of iron deficiency and iron-deficiency anemia (21). By the age of
6 mo, exclusive breastfeeding is not sufficient to meet the nu-
tritional requirements for iron; therefore, complementary foods
that contain iron are needed to meet the needs of infants (22).
The results of the present study do not apply to children ,6mo
old who are breastfeeding.
The prevalence of anemia among preschool-aged children in
Indonesia, as in most of south and southeast Asia, is extremely
high. The prevalence of anemia fits the World Health Organ-
ization’s definition of anemia as a severe health problem, because
the prevalence is 40% (1). Although there are known inter-
ventions to decrease iron deficiency anemia, progress has been
slow (4). The results of the present study suggest that compul-
sory fortification of milk with micronutrients in Indonesia has
helped decrease child anemia. Use of fortified milk and noodles
was higher in urban slum areas compared with rural areas, as
would be expected based on their availability. Further work is
needed to determine whether wider use of fortified milk and
noodles for children aged 6–59 mo can decrease the high
prevalence of child anemia in Indonesia.
The authors’ responsibilities were as follows—KK and RDS: study design
and analysis; KS: data analysis; MWB: design and establishment of the
Nutrition Surveillance System in Indonesia; and all authors: interpretation
of data and writing and editing of the manuscript. None of the authors had
a conflict of interest.
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FIGURE 1. Prevalence of anemia in children aged 6 –59 mo from
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Indonesia by expenditure per child on fortified milk, adjusted for child
age, child sex, maternal ane mia, curre nt breast feeding, deworming,
vitamin A supple mentation, beef consumption, poultry consum ption,
paternal smoking, household size, weekly per capita household
expenditure, location, and maternal a ge, education, and BMI. P ,
0.0001 by ANOVA across the 4 categories for both rural and urban areas.
FIGURE 2. Prevalence of anemia in children aged 6–59 mo from families
in rural (gray bars) and urban slum (black bars) areas of Indonesia by
expenditure per child on fortified noodles, adjusted for child age, child
sex, maternal anemia, current breastfeeding, deworming, vitamin A
supplementation, beef consumption, poultry consumption, paternal
smoking, household size, weekly per capita household expenditure,
location, and maternal age, education, and BMI. P , 0.0001 by ANOVA
across the 4 categories for both rural and urban areas.
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  • Source
    • "With the progress in biotechnology, transgenic animals are produced that secrete milk, lysozyme, human lactoferrins etc so that animal milk can be at par with the human milk (Sabikhi, 2007). Various other forms of designer milk have been developed and evaluated by scientists viz., milk-based beverages fortified with apple or grape seed polyphenols (Axten et al., 2008), fermented milk fortified with lutein, prebiotic and probiotic fortified milk, lactoferrin-enriched fermented milk, calcium and vitamin D fortified milk along with zinc and magnesium; iron-fortified milk; Selenium enriched milk etc (Bonjour et al., 2009; Kruger et al., 2010; Kim et al., 2010; Granado-Lorencio et al., 2010; Sazawal et al., 2010; Rivera et al., 2010; Semba et al., 2010; Hu et al., 2010; Rajasekaran and Kalaivani, 2013). With the advancement in poultry biotechnology, the composition of egg can be changed by nutritional and genetic interventions (Mahima et al., 2012b). "
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    • "In order to improve nutritional status and reduce the mortality of infants and young children, adequate food-based nutrition interventions should be carried out, since such interventions might play a key role in saving lives through their impact on the nutrition and health of the target population aged 6 to 24 months of age. In the developing countries, food-based interventions have been demonstrated to be an efficiency way to decrease malnutrition and iron-deficient anemia among the children aged 6–59 months [9]–[13]. Such as iron-fortified milk and noodle or biscuits [9]–[11], and multiple micronutrient-fortified powder [12], [13] have been used for intervention to improve growth and other outcomes in young children. "
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    • "A total of 41 [25,26,28,30313235,39,48,49,54,56,57,65,70, 77,80,81,83,85,88,89,97,99,101,104,106107108112,113,114,116, 120,124,126,127,129,135,136,139] studies reported outcomes for impact of iron fortification. Four of the studies were before-after studies and the rest were RCTs. "
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