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Institute of Nutrition, Mahidol University, Salaya, Nakhon, Pathom 73170 Thailand
4To whom correspondence should be addressed. Institute of Nutrition, Mahidol University (INMU), Salaya, Nakhon, Pathom 73170, THAILAND. E-mail: nupwn{at}mahidol.ac.th.
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONAnemia trends in the...Policy on prevention and...Implementation of the prevention...Prevention and control of...Surveillance system in the...Other strategies currently being...AccomplishmentsChallenges and recommendationsLITERATURE CITED |
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KEY WORDS: • iron deficiency anemia • pregnant women • school-age children • iron fortification • Thailand
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONAnemia trends in the...Policy on prevention and...Implementation of the prevention...Prevention and control of...Surveillance system in the...Other strategies currently being...AccomplishmentsChallenges and recommendationsLITERATURE CITED |
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Anemia trends in the Thai population |
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TOPABSTRACTINTRODUCTIONAnemia trends in the...Policy on prevention and...Implementation of the prevention...Prevention and control of...Surveillance system in the...Other strategies currently being...AccomplishmentsChallenges and recommendationsLITERATURE CITED |
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) (1
,2
). The prevalence of anemia among lactating women, however, has remained unchanged during the same period. Despite limited data for children <5 y of age, comparison of the two national surveys shows a reduction in the prevalence of anemia from 41 to 25%. Recent evidence of a possible high prevalence of anemia in infancy is of concern. Based on the WHO cut-off value for hemoglobin (<11 g/dL), the prevalence of anemia in young infants (4–6 mo of age) in small survey areas was found to be as high as 32 and 62%, despite fairly proper growth (Winichagoon, P., unpublished data, April 1997, July 1998–April 1999). In addition to national survey data, the prevalence of anemia among pregnant women and school-age children has been reported through the routine health information systems6
since 1988 (3
) (Fig. 2
). These reports also indicate declining trends in anemia prevalence in both groups. A small increase was observed in the prevalence among pregnant women around 1998, which coincided with Thailand’s economic crisis.
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Policy on prevention and control of anemia in Thailand |
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TOPABSTRACTINTRODUCTIONAnemia trends in the...Policy on prevention and...Implementation of the prevention...Prevention and control of...Surveillance system in the...Other strategies currently being...AccomplishmentsChallenges and recommendationsLITERATURE CITED |
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summarizes the goals on anemia included in Thailand’s National Food and Nutrition Policy since the 1980s. The first notable goal was to eradicate anemia among pregnant and lactating women. This goal was later modified to include school children. The new goal specified a certain percentage reduction in the prevalence of anemia among both pregnant women and school children (Table 1)
. The community-based nutrition program, which has been an integral part of primary health care (PHC), was in charge of implementation of this policy. The specific strategy on IDA was confined almost solely to pregnant women and school children.
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30% of the population (4
). The referral system was poor because well equipped secondary hospitals were situated only in the provincial level, and were difficult to access from rural communities. Primary Health Care in Thailand was launched in the late 1970s and became established by the first half of the 1980s. District hospitals were expanded and were linked to work with the existing public health system (health centers) at the peripheries.
A crucial element of PHC lies in its creation of village-based health volunteers and their efforts to reach the villagers with the health services. Volunteers were selected by the community, trained on essential health knowledge and assigned specific preventive and promotive tasks with a focus on maternal and child health and nutrition. Activities include growth monitoring, diarrhea management using oral rehydration therapy (ORT), identifying pregnant women and encouraging them to attend antenatal care services (5
).
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Implementation of the prevention and control of anemia program for pregnant women, antenatal care (ANC) services and role of primary health care volunteers |
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TOPABSTRACTINTRODUCTIONAnemia trends in the...Policy on prevention and...Implementation of the prevention...Prevention and control of...Surveillance system in the...Other strategies currently being...AccomplishmentsChallenges and recommendationsLITERATURE CITED |
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). Improved access to health centers or district hospital was also a result of improved transportation from villages to subdistrict and district facilities. Iron tablet distribution.
Iron tablets (60 mg dose) are dispensed along with multivitamin mineral tablets monthly or bimonthly, according to ANC schedules. In each fiscal year, the central division in the Ministry of Public Health (MOPH) sets aside funds for iron tablets. The amount required is estimated from the prevalence of anemia and the potential number of pregnant women and children. Because prevention of anemia has been made a national policy, and the tablet cost is relatively low, in practice, iron tablets have also been purchased by using income generated at each health service unit to replenish the inventory when there is any shortfall of supply. District hospitals generally can also support the peripheral health facility when the need arises. Thus, scarcity of iron tablet supplies has not been a major problem.
Compliance with iron supplementation.
Important barriers to prevention and control of IDA among pregnant women are found among both service providers and pregnant women (Fig. 3
). Among service providers, anemia is not perceived to have health significance and a perception of its public health significance is lacking. Anemia is seen as a common symptom observed in clinical practice and its cure is seen as achieved simply by prescribing iron tablets for a few months. This perception was extended to the pregnancy period because it is commonly known that anemia is likely as pregnancy progresses. Prevention of anemia by iron supplementation is not considered necessary, despite the policy to dispense iron tablets for prophylactic purpose. Furthermore, the discontinuation of iron supplementation was related to the inability of service providers to follow up with pregnant women who missed ANC scheduled visits (6
).
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,7
). Side effects, although an important cause of termination of iron supplementation (8
) may, in fact, be overemphasized as the reason for poor compliance. Fear of having a large fetus could potentially be more problematic in communities in which childbirth still occurs at home, whether by tradition or inaccessibility to a health facility. This appears to be the case in rural communities in Thailand as reported in the efficacy trial conducted 1978–1979 (9
). In addition, forgetfulness was more frequently found to be a cause of noncompliance in the effectiveness study (6
,7
). In both studies, effective compliance could be achieved if messages regarding the importance of iron on functions and development, and specifics on iron tablets (dose, frequency and anticipated side effects) were provided. Winichagoon et al. (7
) also reported that among women who reported having side effects, those with prior knowledge of this outcome continued the supplementation. If access to a health center is difficult, VHV operated drug funds in the community can serve as an acceptable outlet for supply of iron tablets. In the large-scale program, the VHV made an important contribution by motivating pregnant women to initiate and continually use the ANC services (Fig. 4
).
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To date, there has been no evaluation of the effect of anemia policies and programs in Thailand. Although anemia surveillance has been established in the health information system since 1988, the data included mainly women attending hospital ANC, and are thus likely to reflect the status of women living in towns more than women living in rural areas. Also, the hematocrit measurement taken at the first ANC visit may not reflect the program’s performance because the hematocrit measured in early pregnancy more likely reflects the status before pregnancy. Moreover, there is likely to be a bias associated with women attending hospital ANC, as opposed to those attending health centers more at the periphery. Thus, the decline in prevalence as reported by the routine health system may not adequately represent the effectiveness of the anemia prevention and control program for pregnant women. Moreover, there exist some data on hematocrit that were taken before delivery. These data, although not representative of the pregnant population, are potentially useful for assessing program performance until a better evaluation design is implemented.
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Prevention and control of anemia among school children |
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TOPABSTRACTINTRODUCTIONAnemia trends in the...Policy on prevention and...Implementation of the prevention...Prevention and control of...Surveillance system in the...Other strategies currently being...AccomplishmentsChallenges and recommendationsLITERATURE CITED |
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Surveillance system in the prevention and control of Anemia in Thailand |
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TOPABSTRACTINTRODUCTIONAnemia trends in the...Policy on prevention and...Implementation of the prevention...Prevention and control of...Surveillance system in the...Other strategies currently being...AccomplishmentsChallenges and recommendationsLITERATURE CITED |
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. Some limitations of this system have been previously mentioned. The current surveillance system should be reviewed to assess how well it meets the purposes for which it is intended. Due to possible bias in collecting data from the routine health system, a national representative sample survey may be conducted periodically with inclusion of other important groups, namely, infants, young children and adolescents. |
Other strategies currently being implemented |
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TOPABSTRACTINTRODUCTIONAnemia trends in the...Policy on prevention and...Implementation of the prevention...Prevention and control of...Surveillance system in the...Other strategies currently being...AccomplishmentsChallenges and recommendationsLITERATURE CITED |
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Recognizing the need of a program for school children, weekly iron supplementation is now included in the school health package, mainly in the "health promoting schools" program, and for child-bearing age women, especially in the work place. In the year 2000, weekly iron supplementation was launched as a pilot program in schools in 13 provinces and is being extended throughout the country in 2001 (Department of Health, MOPH, personal communication, 2001). Currently, the supplementation is being provided only from the government’s budget. Extending weekly iron supplementation programs to various age groups will require a shift from government dependency to inclusion of the private sector through use of a marketing strategy and a community support scheme.
Iron fortification.
Partnership with industry has been successful in implementing triple-fortified instant noodles in the market (10
). This was a collaboration among academia and the public and the private sectors. Instant noodles were identified as a potential vehicle for fortification due to high consumption (six million packages sold per day) and wide distribution through the various outlets throughout the country. At about 5 baht/pack (about US$ 0.10), the poor can afford to buy the noodles. The next step was to develop the fortification process and to promote its use among the population at risk of micronutrient deficiency. Product development was done jointly by researchers at the Institute of Nutrition, Mahidol University (INMU), with involvement of industry, which provided food processing facilities. This fortified noodle product contains about one third the Recommended Dietary Allowance for vitamin A (267 µg retinol equivalents), iodine (50 µg) and iron (5 mg). The fortificants were put in the soup base included in the noodle package. Acceptability and stability of the fortified product, with a range of flavors, were tested and the product has now been launched commercially. The bioavailability or efficacy of this product, however, has not been tested.
Another product, which has been similarly studied and implemented, is the double-fortified (iron and iodine) fish sauce (Chavasit, C., personal communication, 2001). Fish sauce is a common condiment in Thai households. It may be used during cooking or put directly into food like table salt. The double-fortified product is ready to be launched in the market and studies of its bioavailability are being planned.
Food based strategy.
Thai eating patterns are largely plant based, with rice contributing as much as 60–70% of total daily energy intake. The proportion of nonheme iron is higher than heme iron, especially in rural Thai diets, and iron absorption from Thai meals is presumed to be low (11
–13
). In addition, there are several indigenous vegetables that are commonly consumed. Some vegetables have been shown to strongly inhibit iron absorption (14
). To date, there are limited data on enhancers and inhibitors of iron absorption in Thai foods. Therefore, development of a food based strategy, particularly improving habitual diets, requires more information about meal consumption patterns and food constituents in local or indigenous food sources that may modify iron bioavailability.
Other complementary strategies.
In the health program, plans for deworming for children, thalassemia and malaria eradication have already been developed. These programs can be integrated better to address anemia.
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Accomplishments |
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TOPABSTRACTINTRODUCTIONAnemia trends in the...Policy on prevention and...Implementation of the prevention...Prevention and control of...Surveillance system in the...Other strategies currently being...AccomplishmentsChallenges and recommendationsLITERATURE CITED |
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Challenges and recommendations |
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TOPABSTRACTINTRODUCTIONAnemia trends in the...Policy on prevention and...Implementation of the prevention...Prevention and control of...Surveillance system in the...Other strategies currently being...AccomplishmentsChallenges and recommendationsLITERATURE CITED |
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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2 This article was commissioned by the International Life Sciences Institute Center for Health Promotion (ILSI CHP). The use of trade names and commercial sources in this document is for purposes of identification only and does not imply endorsement. In addition, the views expressed herein are those of the individual authors and/or their organizations and do not necessarily reflect those of ILSI CHP.
3 Supported by the Micronutrient Initiative.
5 Abbreviations used: ANC, antenatal care; IDA, iron deficiency anemia; MOPH, Ministry of Public Health; ORT, oral rehydration therapy; PHC, primary health care; VHV, village healthcare volunteers.
6 Anemia surveillance for pregnant women mainly included women attending ANC at secondary hospitals and some at health centers due to limited facility for measuring hematocrit. It is possible that women residing in farther rural areas are not measured by this system. Underestimation of prevalence is possible.
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LITERATURE CITED |
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TOPABSTRACTINTRODUCTIONAnemia trends in the...Policy on prevention and...Implementation of the prevention...Prevention and control of...Surveillance system in the...Other strategies currently being...AccomplishmentsChallenges and recommendationsLITERATURE CITED |
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1. Nutrition Division, Ministry of Public Health (1995) The Third National Nutrition Survey 1995:1986 Bangkok Thailand. .
2. Nutrition Division, Ministry of Public Health (1999) The Fourth National Nutrition Survey, 1996/97 1999 Bangkok, Thailand. .
3. Nutrition Division () Ministry of Public Health (series of reports). Surveillance of anemia among pregnant women and school children (Mimeograph, Thai), 1988–1999 .
4. Family Health Division, Health Promotion Bureau, Department of Health, Ministry of Public Health (MOPH), Thailand (1996) Report on the Family Health Project Evaluation: The Seventh National Economic and Social Development Plan 1996 Bangkok Thailand. .
5. Nondasuta, A. (1992) Primary Health Care. Winichagoon, P. Kachondham, Y. Attig, G. A. Tontisirin, K. eds. Integrating Food and Nutrition in National Development: Thailand Experiences and Future Vision 1992 Institute of Nutrition Mahidol University and UNICEF/EAPRO Bangkok, Thailand. .
6. Winichagoon, P. (1991) A Conceptual Framework and Application for Evaluating Prenatal Iron Supplementation within Primary Health Care in Rural Northeast Thailand. Doctoral thesis 1991 Cornell University Ithaca, NY. .
7. Winichagoon, P., Thongnoppakhun, W., Kachodham, Y. & Viriyapanich, T. (1994) Iron Supplementation Delivery to Rural Pregnant Women through Primary Health Care in Central Thailand 1994 Ottawa, Canada. Report submitted to International Development Research Center.
8. Administrative Committee on Coordination/Sub-Committee on Nutrition (1991) Controlling Iron Deficiency. ACC/SCN State-of-the-Art Series 1991 Geneva, Switzerland Nutrition Policy Discussion Paper no. 9.
9.
Charoenlarp, P., Dhanamitta, S., Keawvichit, R., Silprasert, A., Suwanaradd, C. & Na-Nakorn, S. (1988) A WHO collaborative study on iron supplementation in Burma and in Thailand. Am. J. Clin. Nutr. 47:280-297.
10. Chavasit, V. & Tontisirin, K. (1998) Triple fortification of instant noodles. Food Nutr. Bull. 19:164-168.
11. Hallberg, L., Garby, L., Suwanik, S. & Bjorn-Rasmussen, E. (1974) Iron absorption from southeast Asian diets. Am. J. Clin. Nutr. 27:826-836.[Abstract]
12. Hallberg, L., Bjorn-Rasmussen, E., Rossander, L. & Suwanik, R. (1977) Iron absorption from southeast Asian diets. II: role of various factors that might explain low absorption. Am. J. Clin. Investig. 30:539-548.
13. Tuntawiroon, M., Sritongkul, N., Rossander-Hulten, L., Pleehachinda, R., Suwanik, R., Brune, M. & Hallberg, L. (1990) Rice and iron absorption in man. Eur. J. Clin. Nutr. 44:489-497.[Medline]
14.
Tuntawiroon, M., Sritongkul, N., Brune, M., Rossander-Hulten, L., Pleehachinda, R., Suwanik, R. & Hallberg, L. (1991) Dose-dependent inhibitory effect of phenolic compounds in foods on nonheme iron absorption in men. Am. J. Clin. Nutr. 53:554-557.
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