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Instituto de Investigación Nutricional (IIN), La Molina, Lima, Peru
4To whom correspondence should be addressed.
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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KEY WORDS: • iron deficiency anemia • iron supplementation • adolescents
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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), and small children and women of
reproductive age are most affected (WHO 1992
). Global
estimates suggest that 47% of nonpregnant women and 60% of pregnant
women are anemic (Royston 1982
). A recent survey in Peru
found that 57% of children <5 y of age and 36% of women were anemic
(INEI 1997
). IDA reduces physical activity and affects
behavior, psychomotor development and school performance (Lozoff et al. 1991
, Soemantri et al. 1985
,
Soewondo et al. 1989
). In pregnancy, IDA is associated
with increased risk of preterm delivery, low birth weight and higher
maternal mortality (Murphy et al. 1986
, Scholl et al. 1992
, Viteri 1994
).
Iron supplementation is one of the recommended strategies to improve
iron status in the vulnerable groups. In many countries such as Peru,
iron supplements are given to pregnant women who receive checkups at
the health centers. However, iron deficiency anemia remains high,
affecting 54% of Peruvian pregnant women (Zavaleta et al. 1993
). Additional strategies to prevent and treat anemia must
be considered to reduce the high prevalence of IDA in women before they
become pregnant. One important option, as yet untested, is to give iron
supplementation to adolescent girls who are attending school.
The effectiveness of daily iron supplementation programs has been
questioned because of the low efficiency of health services and the
lack of compliance of the target groups (Schultink et al. 1995
). The use of intermittent supplementation schedules has
been suggested as a way in which to improve compliance by reducing side
effects. Several studies conducted in anemic preschool and
school-aged children have shown that the efficacy of an
intermittent iron supplementation schedule is similar to that of daily
dosing (Schultink et al. 1995
). This study aimed to
assess the feasibility, efficacy and acceptability of reducing anemia
in adolescent girls attending public school in Lima, Peru using daily
or intermittent iron supplementation.
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SUBJECTS AND METHODS |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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This was a double-blind, placebo-controlled study with 312 subjects assigned at random to one of the following groups: 1) 60 mg iron as ferrous sulfate, daily from Monday to Friday; 2) 60 mg iron as ferrous sulfate/d, two times per week (intermittent) and 3 d placebo; and 3) placebo, daily from Monday to Friday. The supplements were given for 17 wk. All tablets had the same brick color and shape and were produced for this study by a local pharmaceutical company (Instituto Quimioterapico S.A Lima, Peru) and distributed in coded blister packages. Supplements were administered daily at school, between meals, together with a sweetened flavored drink without ascorbic acid and under the close supervision of a field worker who also recorded acceptability and side effects. To ensure participation, girls received counseling on the benefits of taking iron tablets and about the possibility of side effects.
At entry, general socioeconomic information, weight, height and midupper-arm circumference were recorded. At the beginning and end of the trial, a blood sample was obtained by venipuncture for analysis of Hb, serum ferritin (SF) and free erythrocyte protoporphyrin (FEP). Hb was analyzed by the cyanometahemoglobin method, SF by ELISA using human antiferritin and antiferritin peroxidase antibodies from DAKO, and FEP by a hematofluoremeter. The cut-offs were defined as follows: for anemia, Hb < 120 g/L; for iron deficiency, SF < 12 µg/L; and for FEP, > 80 µg/L. At the beginning and end of the study, a digital scale (SECA, UK) measured weight to the nearest 0.1 kg and a portable wooden stadiometer measured height to the nearest 0.1 cm.
A total of 312 girls started the trial and 16 dropped out the study. Of these 16, eight girls moved to another school, two girls disliked the tablets, four girls claimed that side effects (constipation, gastric discomfort, headache) were the reason for withdrawal and two girls were absent at the time of final evaluation, although they took the tablets. Girls who withdrew and girls who concluded the study had the same age, weight and Hb.
Data analysis was done using the SPSS/PC Statistical Program V.7.5 (SPSS, Chicago, IL). Data analysis included descriptive statistics, paired t test, chi-square test, nonparametric tests and analysis of covariance with initial Hb as a covariate. Hb values were normally distributed; SF and FEP were not normally distributed and were normalized by using a natural logarithm transformation.
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RESULTS |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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Changes of iron status in the subjects are presented in Table 1
. Final Hb values in both iron-supplemented groups (daily and
intermittent) were significantly higher than those in the placebo group
(P < 0.05), and the daily supplementation group had
significantly higher Hb than the intermittent group (P
< 0.05). There were no differences in SF and FEP between daily
and intermittent groups at the end of the study. SF did not change in
the two iron-supplemented groups, but decreased significantly in
the placebo group (P < 0.05). FEP decreased in the
daily and intermittent groups (P < 0.05) but remained
the same in the placebo group. The proportion of anemic subjects was
similar in the three groups at entry into the trial, i.e., 19.8% in
the daily, 18.4% in the intermittent and 15.5% in the placebo group.
At the end of the trial the proportion of anemic subjects in the daily
group (10.9%) was lower compared with the intermittent (17.3%) and
the placebo (22.7%) groups (P < 0.05.).
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). The response in Hb concentration was correlated with initial Hb
values and did not change in the placebo group (P < 0.05). For the anemic subjects in all groups, the gains in Hb were 11.1
g/L (daily), 6.8 g/L (intermittent) and 1.6 g/L (placebo). Hb
concentrations among the nonanemic subjects did not change during the
time of supplementation in the daily group. However, Hb concentrations
declined in the placebo and the intermittent groups (P
< 0.05) in nonanemic girls.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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These results are different from the findings in other studies
comparing intermittent and daily doses of iron in Indonesian preschool
children (Schultink et al. 1995
). In animal experiments,
a similar effect on Hb for daily and intermittent doses has been
observed, and it has been argued that the intermittent dose allows time
for the turnover of the intestinal cells that have better absorptive
capacity than cells that have recently absorbed iron (Viteri 1996
). However, similar levels of absorption between the daily
and weekly doses have been reported in humans (Cook and Reddy 1995
). The better Hb response and a significant reduction in
anemia prevalence observed in girls taking iron supplements daily in
this study are explained by the greater amount of iron delivered. The
intermittent dose was effective in improving the iron status of this
population, although not as effective as the daily dose.
Acceptability of the iron supplements in this study was excellent because girls received information before and during the trial about benefits of taking iron, the possibility of side effects and that side effects or taking iron did not cause adverse health effects. Side effects were not a serious problem in any of the groups whether supplemented or not with iron, and the dose of iron (from no iron to 60 mg/d) had no significant effect. As a result, compliance was high.
In conclusion, iron supplementation given through the school system could be an intervention to improve iron status and prevent anemia in adolescent girls. It might also reduce the risk of iron deficiency and anemia before pregnancy, particularly among girls who marry and begin childbearing shortly after they finish school. Daily supplementation is more effective than intermittent supplementation in increasing Hb concentrations; however, the intermittent supplementation dose was also effective and could be used if given over a longer period than in this study. Targeting anemic girls might also be considered because the increase in Hb was highest in anemic girls, although this must be weighed against the cost and acceptability of screening girls.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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2 Presented in part at the 16th International Congress of Nutrition in Montreal, Canada, July 27-August 1, 1997. Abstracts PW 9.5, p. 62.
3 This publication was made possible in part through support provided by the Office of Health and Nutrition, USAID, under the terms of contract no. HRN-C-00–93-00038–00, and the MotherCare Project, John Snow, Incorporated (JSI). The contents and opinions expressed herein are those of the authors and do not necessarily reflect the view of USAID or JSI.
5 Abbreviations used: BMI, body mass index; FEP, free erythrocyte protoporphyrin; IDA, iron deficiency anemia; SF, serum ferritin.
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REFERENCES |
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TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
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1. ACC/SCN Second report on the world nutrition situation 1992;Vol 1 Global and regional results. ACC/SCN Geneva, Switzerland.
2.
Cook J., Reddy M. Efficacy of weekly compared with daily iron supplementation. Am. J. Clin. Nutr. 1995;62:117-120
3. INEI/Instituto Nacional de Estadística e Informática (1997) Encuesta demográfica y de salud familiar 1996. República del Perú. Macro International Inc., Calverton, MD.
4. Lozoff B., Jimenez E., Wolf W. Long-term developmental outcome of infants with iron deficiency. N. Engl. J. Med. 1991;325:687-693[Abstract]
5. Murphy J. F., Newcombe R. G., O’Riordan J., Coles E. C., Pearson J. F. Relation of hemoglobin levels in first and second trimesters to outcome of pregnancy. Lancet 1986;1:992-994[Medline]
6. Royston E. The prevalence of nutritional anemia in women in developing countries. A critical review of available information. World Health Stat. Q. 1982;35:52-91[Medline]
7.
Scholl T. O., Hediger M. L., Fischer R. L., Shearer J. W. Anemia vs iron deficiency: increased risk of preterm delivery in a prospective study. Am. J. Clin. Nutr. 1992;55:985-988
8.
Schultink W., Gross R., Gliwitz M., Karyadi D., Matulessi P. Effect of daily vs twice weekly iron supplements in Indonesian preschool children with low iron status. Am. J. Clin. Nutr. 1995;61:111-115
9.
Soemantri A. G., Pollitt E., Kim I. Iron deficiency anemia and educational achievement. Am. J. Clin. Nutr. 1985;42:1221-1228
10. Soewondo S., Husaini M., Pollitt E. Effects of iron deficiency on attention and learning processes in preschool children. Bandung, Indonesia. Am. J. Clin. Nutr. 1989;50:567-574
11. Viteri F. The consequences of iron deficiency and anaemia in pregnancy on maternal health, the foetus, and the infant. SCN News 1994;11:14-18
12.
Viteri F. Weekly compared with daily iron supplementation (letter). Am. J. Clin. Nutr. 1996;63:610-611
13. World Health Organization (1992) The Prevalence of Anemia in Women: A Tabulation of Available Information, 2nd ed., (WHO/MCH/MSM 92.2). WHO, Geneva, Switzerland.
14. Zavaleta, N., Berlanga, R., Lonnerdal, B. & Brown, K. H. (1993) Prevalencia y determinantes de la anemia por deficiencia de hierro en una muestra representativa de gestante en Lima Perú. Reporte final presentado a la Organización Panamericana de la Salud.
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