Decrease Rate of Stunting Among Anemic Indonesian Preschool Children Through Iron Supplementation

7/26/2019 Decrease Rate of Stunting Among Anemic Indonesian Preschool Children Through Iron Supplementation

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.4 ii J in Nutr 1 993 :58 :33 9-42 . P rin ted in U S A . 1993 A m erican S oc ie ty fo r C lin ica l N utrition

33 9

Dec reased ra te o f s tun ting am ong anem ic Indones ian

p re schoo l ch ild ren th rough iron supp lem en ta tio n

Im eld a T Ange les W ern er J Schu ltin k Pau l M atu le ss i R a ine r G ross and Soem ilah S astro am id jo jo

A B S T R A C T E ffec ts o f iron su pp lem en ta tion on gro w th and

h em ato log ica l s ta tu s o f Indones ian an em ic prescho o l ch ild ren

w ith low w eigh t-fo r-age w ere in vestiga ted . A trea tm en t g roup n

= 39) rece ived da ily supp lem en ts o f3O m g F e and 20 m g v itam in

C , w hereas a con tro l g ro up n = 37) rece ived 20 m g v itam in C

only fo r a p er io d of 2 m o. S upp lem en t a llo cation w as doub le

b lin d . A t the s ta rt an d fin ish of th e s tudy , body w eigh t, he igh t,

fo od in tak e. and hem oglob in and serum fem tin co ncen tra tion s

w ere de te rm ined . O nly the trea tm en t g rou p sho w ed a sign if ican t

inc rease in all hem ato log ica l v alues P < 0 .001). H e igh t and

w eigh t o f a ll ch ild ren increased P < 0 .01). Inc reases in he igh t

a nd h eig ht -f or -a ge

score in the trea tm en t g rou p w ere la rger

P = 0 .001 ) th an the increase in the con tro l g roup . T he pos itive

effec t o f iron su pp lem en tation on linear g row th w as no t caused

by in creased food in take , bu t seem s to be in fluenced by d ecreased

m o rb id ity . Iron supp lem en ta tio n m ay be a re la tive ly inexp en sive

w ay to he lp d ecrease the h igh p reva lence of s tun ting . A m J

C /in N u tr 1993:58 :339-42 .

KEY W ORDS Iron

supp lem en ta tion , an em ia , g row th ra te,

p rescho o lers, In dones ia

Introduction

Iron -defic iency anem ia and decreased grow th ra te a re tw o

m ajo r nu trition -re la ted prob lem s am o ng prescho o l ch ild ren in

deve lop ing coun tries 1 2). A nem ia in ch ild ren is assoc ia ted

w ith decreased p hys ica l capac ity and grow th , im p aired im m u ne

sys tem , and reduced lea rn ing capac ities (2 -5 ). A ch ild w h o h as

been iron-defic ien t anem ic in in fan cy risk s p ro trac ted deve l-

opm enta l d isadvan tages com pared w ith peers hav ing be tte r iron

sta tu s (6 ). D ecreased gro w th ra te in ch ild ren in deve lop ing

coun tries is asso cia ted w ith inc reased m orb id ity risk and redu ced

scho las tic ach ievem ent (7 ). G row th perfo rm ance in ch ild ren can

be assessed by m easuring w eigh t, he igh t, and ag e, and can b e

c lassified by co m bin ing the m easu rem en ts to fo rm the ind ica to rs

w eigh t- fo r-he igh t (W FH ), he igh t-fo r-age (H F A ), and w eigh t-fo r-

age (W FA ) (8) . A chro n ic lack of n u trien ts w ill lead to a low

H F A (stun ting ), w h ich is h ig h ly p reva len t in m any com m unitie s

in deve lop ing coun tries. S tun ting im plies tha t a ch ild s gene tic

po ten tia l is n o t fu lly exp ressed (9 ), and it m ay nega tive ly a ffec t

phy sica l w ork capac ity in la te r life becau se of sm aller b ody s ize

(10) . S tun ting u sua lly deve lop s f rom an early age onw ard , an d

ifle ft un trea ted afte r som e tim e , no ca tch ing up m ay be p oss ib le

(11 , 12 ).

T he occurren ce ofanem ia and red uced grow th ra te a re o ften

assoc iated am on g p reschoo l ch ild ren . A uke tt e t a l (3 ) and

C hw an g e t al ( 1 3) repo rted tha t iron supp lem en ta tion im pro ves

phy sica l g row th in anem ic ch ild ren . T here fo re , iron su pp le -

m en tation m ay have the du a l ef fect o f po sitiv e ly in flu en cing

bo th hem ato lo g ic sta tus and grow th ra te . H ow ever, the m ech-

an ism ofiron-en hanced grow th rem ain s e lusive . In theory , th is

inc rease in g row th m ay b e d ue to decreased m orb id ity , to in -

c reased food in take , o r to the d irec t e ffec t o f iron itse lf.

C ons idering the h igh preva lences of an em ia and reduced

g row th ra te in Sou th eas t A s ia , the presen t s tudy investiga ted

w hether iron supp lem en ta tion w ould sign if ican tly im prov e

p hysica l g row th , as w ell as hem ato log ica l s tatus , o fanem ic pre -

schoo l ch ild ren w ith a low W FA .

Sub jec ts and m ethod s

T he study w as carried ou t in Jakarta . In dones ia , a t tw o sub-

d istric t hea lth o ffices tha t cov ered n e ig hborh oods w ith a to ta l

p opu la tio n of 109 000 and a pop u lation d ensity o f 380 00 /

k m 2. T he s tudy group com pr ised the low er soc io eco nom ic c lass

(25-30 % have no s tab le jobs). an d env ironm enta l hyg iene in

the s tudy area w as poor.

T he se lec tion process sequen tia lly iden tif ied ch ild ren , ag ed 2-

5 y . as low W F A and then as anem ic . T he se lection criter ia w ere

as fo llow s: W FA Z sco re be tw een -2 and -3 . hem og lo b in con -

cen tra tion be tw een 80 and 1 10 g /L , and serum ferritin < 12 g/

L . T he upper lim its o f the hem ato log ica l m easu res a re usua l

v alues used to d ef in e anem ia (2 ). A ll sub jec ts w ere iden tified

from ex isting records a t the h ealth cen te rs , w h ich con ta in ed on ly

da ta on W F A . F rom the hea lth cen te rs lis t 2 1 6 ch ild ren w ere

se lected w ho m et the an th ro pom etrica l c rite ria . A ll 2 16 ch ild ren

cam e to the h ea lth cen ter a t the reques t o fhea lth cen ter s ta ff so

th at the ir h em o glob in concen tra tion cou ld be ana lyzed . F or th ose

w ith a low hem og lo b in con cen tra tion , se ru m fem tin concen-

tra tion w as m easu red . F ina lly . 84 ch ild ren m et th e hem ato log ica l

crite ria . T he paren ts o f 80 ch ild ren gave w ritten co nsen t fo r

th eir ch ild ren s partic ipa tion in the s tu dy . S too l sam ples o f the

sub jec ts w ere exam ined fo r the presence o f paras itic in fec tion s

(asca rias is and trich uriasis). C h ild ren w ith paras ite s rece iv ed an -

tihe lm in th ic trea tm en t (1 4) befo re sta rting iro n su pp lem en ta tion ,

F rom the S E A M E O -T R O PM E D C ente r Jakarta a t the U nivers ity

of Ind on esia , Jak arta , In do nes ia and G esellsch aft f { 252 }r echn ische

Z u sam menarbe it, E schbo rn , G erm any .

2 A dd ress rep rin t req uests to W J S chu ltink , S E A M E O /G T Z , P 0 B ox

3 852 , 10 038 Jakarta. Ind onesia .

R ece iv ed N o vem ber 20 . 1 992 .

A ccep ted fo r pub lica tion M arch 18 , 19 93 .


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34 0

A N G E L E S E T A L

so as to rem o v e h e lm in th ias is as a co n f o u n d er o f b o th g ro w th

an d h em ato lo g ical s tatu s . T h e 8 0 su b jects w ere assig n ed at ran -

d o m to a treatm en t g ro u p i i 4 0 ) an d a co n tro l g ro u p n 4 0 ) .

N o n e o f th e ch ild ren su f f e red f ro m o b v io u s, acu te in f ec tio u s

diseases.

T h e treatm en t g ro u p receiv ed su p erv ised d aily su p p lem en ts

f o r a p erio d o f 2 m o o f 3 0 m g e lem en tal iro n as 8 1 m g h y d rated

f erro u s su lf ate . co m b in ed w ith 2 0 m g v itam in C . b o th in p o w -

d ered f o rm . D u rin g th e sam e p erio d o f tim e, th e co n tro l g ro u p

rece iv ed d aily su p p lem en ts o f 2 0 m g v itam in C alo n e. w h ich

w as o f s im ilar ap p earan ce to th e su p p lem en t co n tain in g iro n

(su p p lem en ts p rep ared b y PT K im ia Farm a, Jak arta, In d o n es ia) .

D aily su p p lem en t in g estio n b y su b jec ts to o k p lace at cen tral

lo catio n s , b e tw een m eals f ro m 0 9 0 0 to 1 1 3 0 h , an d w as su p er-

v ised c lo se ly b y d istric t h ealth w o rk ers an d o n e o f th e re search ers

(IT A .). A llo catio n o f th e su p p lem en ts w as d o u b le b lin d b y u s in g

co d ed su p p lem en t p ack ag es .

A t th e s tart an d f in ish o f th e 2 -m o su p p lem en tatio n p erio d

w e ig h t. h e ig h t, an d f o o d in tak e w ere reco rd ed . Fu rth e rm o re ,

b lo o d sam p le s w ere co llec ted to d e te rm in e h em o g lo b in , m ean

co rp u scu lar v o lu m e (M C V ), an d seru m f erritin co n cen tratio n .

W h ite b lo o d ce ll co u n ts (W B C s) w ere carried o u t to d e term in e

th e p re sen ce o f o ccu lt in f ec tio n s. O v er th e en tire p erio d o f su p -

p lem en tatio n , th e in c id en ce an d d u ratio n o f f ev er (b o d y te rn -

perature

>

3 7 { 17 6 } C),e sp irato ry in f ec tio n s (1 5 ), an d d iarrh ea (f o u r

o r m o re lo o se , w ate ry s to o ls p er 2 4 h ) w ere ch eck ed an d reco rd ed

d aily b y th e research er (IT A .) o r th e d is tric t h ealth w o rk er.

T h e ch ild ren w ere w eig h ed w ith o u t c lo th in g b e tw een 0 9 0 0

an d 1 1 0 0 to th e n earest 0 . 1 k g b y u sin g an e lectro n ic , p latf o rm -

m o d el w e ig h in g scale (S E C A 7 7 0 alp h a: S E C A , H am b u rg ,

G erm an y ). H e ig h t w as m easu red to th e n eares t 0 . 1 cm b y u sin g

a m i cro to is e.

sco re s o f th e in d icato rs W FA , H FA , an d W FH

w ere calcu lated b y u s in g th e N atio n al C en te r f o r H ealth S tatis tics

(N C H S ) re f e ren ce d ata to co rrec t f o r e f f e c ts o f sex an d ag e o n

g ro w th (1 6 ).

Fo o d in tak e w as d e te rm in ed b y th e 2 4 -h recall m e th o d o v er

3 alte rn ate d ay s (o n e d ay b e tw een th e d ay s o f d ata co llec tio n )

b y u sin g g en eric f o o d m o d e ls d esig n ed to id en tif y p o rtio n s iz e .

E n erg y in tak es w ere calcu lated b y u s in g th e In d o n es ian f o o d -

co m p o sitio n tab le ( 1 7 ) . In tak e at th e s tart an d f in ish o f th e su p -

p lem en tatio n p erio d w as calcu lated as th e av erag e in tak e o f th e

3 d o f d ata co llec tio n .

B lo o d sam p le s (3 m L ) w ere co llec ted v ia v en ip u n c tu re b e tw een

0 8 3 0 an d 1 1 3 0 . H em o g lo b in co n cen tratio n , M C V , an d W B C s

w ere d e term in ed b y e lec tro n ic co u n te r (S y sm ex C C -l 8 0 : T O A

M ed ical E lec tro n ic s L td . K o b e . Jap an ). S e ru m f erritin w as d e -

te rm in ed b y rad io im m u n o assay p ro ced u re 1 8 ) b y u sin g a co rn -

m erc ial k it (R am co L ab o rato rie s, H o u sto n ). A ll h em ato lo g ical

an aly se s w ere carried o u t at th e D ep artm en t o f C lin ical Path o l-

o g y , M ed ical Facu lty , U n iv e rs ity o f In d o n es ia.

D ata an aly s is w as carried o u t b y u sin g th e M A N O V A re -

p eated -m easu res d es ig n o f SPSS/PC+ 4 .0 (S PS S In c. C h icag o )

(1 9 ) w ith treatm en t (iro n an d v itam in C v s v itam in C ) as a

b e tw een -su b jec ts f ac to r an d tim e (b e f o re v s af te r) as a w ith in -

su b ject f acto r. W hen th ere w as a sig n if ican t in te ractio n P < 0 .0 5 ) ,

th e d if f e ren ces b e tw een an d w ith in treatm en t g ro u p s w ere f u rth e r

in v es tig ated b y u s in g u n p aired an d p aired I te sts , re sp ectiv e ly .

W hen v alu es w ere n o t n o rm ally d is trib u ted , as f o r se ru m f erritin ,

d if f e ren ces w ith in g ro u p s w ere te sted b y u sin g W ilco x o n s

m atch ed -p airs s ig n ed -ran k te s t, an d d if f e ren ces b e tw een g ro u p s

w ere te sted b y u s in g th e M an n -W h itn ey te st (2 0 ), b ecau se a lo g -

arith m ic tran s f o rm atio n f ailed to g iv e a n o rm al d istrib u tio n . T o

te s t th e d if f eren ce in p rev alen ce o f h e lm in th ias is b e tw een g ro u p s

at th e tim e o f en ro llm en t, th e ch i-sq u are te st w as u sed .

T h e research p ro p o sal w as ap p ro v ed b y th e E th ical R ev iew

C o m m ittee o f th e U n iv ers ity o f In d o n esia, Jak arta. A t th e en d

o f th e 2 -m o su p p lem en tatio n p erio d th e ch ild ren in th e co n tro l

g ro u p receiv ed iro n su p p lem en ts o v er a 2 -m o p erio d to treat

th eir an em ia.

T h e f in al d ata set in clu d ed 3 9 (2 0 m ale an d 1 9 f em ale ) su b jec ts

in th e iro n -treatm en t g ro u p an d 3 7 (1 9 m ale an d 1 8 f em ale )

su b jec ts in th e co n tro l g ro u p . Fo u r o f th e se lected 8 0 su b jec ts

d ro p p ed o u t af te r an Islam ic h o lid ay o n w h ich th e ir p aren ts

to o k th em to v is it re lativ es o u tsid e Jak arta. M ean (S D ) ag e in

iro n -treated an d co n tro l g ro u p s w ere , re sp ectiv e ly , 3 7 .4 9 .5

an d 3 7 .2 1 0 .5 m o .

Resul ts

S to o l ex am in atio n b ef o re th e start o f th e su p p lem en tatio n

p erio d sh o w ed th at 5 6 .5 % o f th e ch ild ren in th e treatm en t g ro u p

an d 7 0 .3 % o f th e ch ild ren in th e co n tro l g ro u p w ere in f ec ted

w ith p aras ites (n o s ig n if ican t d if f e ren ce b y ch i-sq u are te st). A t

th e start o f th e stu d y . n o s ig n if ican t d if f e ren ces ex isted in h e -

m ato lo g ical v alu es (T ab le 1 n o r in w e ig h t an d h e ig h t (T ab le 2 )

b etw een th e treatm en t an d co n tro l g ro u p s . D u rin g th e su p p le -

m en tatio n p erio d W BC s o f all ch ild ren w ere w ith in th e n o rm al

lim its, in d icatin g ab sen ce o f se rio u s in f ec tio u s d isease s th at m ig h t

h av e in f lu en ced th e se ru m f erritin co n cen tratio n .

A f te r th e su p p lem en tatio n p erio d th e m ean v alu es o f th e

treatm en t g ro u p f o r h em og lo b in P 0 .0 0 1 ), M CV P 0 .0 2 ) ,

an d seru m f erritin P 0 .0 0 1 ) w ere h ig h er th an th e v alu es f o r

th e co n tro l g ro u p (T ab le 1 , w h ereas th e re w as n o sig n if ican t

d if f e ren ce f o r th e m ean v alu es o f w e ig h t, h e ig h t, an d th e

scores

o f W FA , H FA , an d W FH (T ab le 2 ). W ith resp ec t to th e ch an g e

in th e v ariab le s, th e b e f o re -af te r d if f e ren ces f o r th e treatm en t

g ro u p w ere sig n if ican tly g reate r th an th o se f o r th e co n tro l g ro u p

f or h em o gl ob in P

0 .0 0 1 , se ru m f em tin P

0 .0 2 ), M CV P

0 .0 2 ), h eig h t P 0 .0 0 1

,

an d H FA score P 0 .0 0 1

.

T he

ch an g e in W FH

sco re in th e co n tro l g ro u p w as h ig h er th an

th e ch an g e in th e treatm en t g ro u p P 0 .0 2 ) .

A f te r su p p lem en tatio n all h e rn ato lo g ical v alu es o f th e treat-

m en t g ro u p w ere ab o v e th e cu to f f p o in t co n cen tratio n s th at in -

d icate an em ia. W ith in -g ro u p in crease s in b o d y w e ig h t an d h e ig h t

T A B L E

1

H em ato lo g ical v alu es b e f o re an d af ter 2 m o su p p lem en tatio n *

B ef o re A f te r D if f e ren ce

Iron

+

v itam in C

3 9

H em o g lo b in (g IL ) 1 0 2

9

1 12 9 t 1 0 l 0 t

S eru m f erritin ( g /L )

6. 2

1 .7 1 5 .0

lO .2 t 8 .8

9.5j

M CV (f t.)

7 8 .2

7 .2 8 2 .5

5.4 4.0

4 .9

V itam in C n 37 )

H em o g lo b in (g IL ) 1 0 3

8 1 0 4

I 1

12

S eru m f erritin ( g /L ) 7 .1

2. 5

1 0 .0

1 0 .9 2 .9

1 0 .7

M C V (if .) 7 7 .6 7 .0 7 7 .9 9 .2 0 .3 8. 0

S D . M CV , m ean co rp u scu lar v o lu m e .

t S ig n if ican tly g reate r th an th e related v alu e o f th e v itam in C g ro u p :

tP 0 .0 0 1 , P < 0 .0 2 .

S ig n if ican t d if f eren ce b e tw een start an d f in ish o f su p p lem en tatio n

period,

P

0 .0 0 1 (w ith in -g ro u p ch an g e ).


3/4

G R O W T H A N D IR O N S T A T U S O F C H IL D R E N

34 1

D ef in ed as f o u r o r m o re lo o se , w ate ry s to o ls p er 2 4 h .

T A B L E 2

W eig h t, h e ig h t, an d Z sco res o f an th ro p o m etric in d icato rs b e f o re an d

af ter 2 m o s up ple m en tatio n*

B ef o re A f te r D if f e ren ce

Iron + v i t a mi n C

=

39 )

W e i g h t( k g )

1 0 .6 1 .2 1 1 .1 1 .4 0 .5 0 .5 t

H e ig h t (cm ) 8 6 .2

6 .5 8 8 .9

5 .9 2 .7

l .S t t

W e ig h t-f o r-ag e -2 .5 3 0 .4 2

-2 .3 7

0 .4 9 0 .1 7 0 .3 3

H e ig h t-f o r-ag e -2 .3 3 0 .8 3 -1 .9 6 0 .7 3

0 .3 7 0.4ltt

W e ig h t - fo r -h e ig h t

1 .4 8 0 .5 5

1 .5 7 0 .5 0 -0 .0 6 0 .4 6

V itam in C n

=

37 )

W e ig h t (k g ) 1 0 .6 1. 3

1 1 . 2 1 5 0. 6 6 t

H eig h t (cm ) 8 6 .6 6 .9 8 8 .1 6 .9 1 .5 0 .8 1

W e ig h t - fo r -ag e

-2 .5 4 0 .3 4 -2 .3 3 0 .5 4

0 .2 1 0 .3 6

He ig h t - fo r -a g e

-2 .1 8 0 .9 6 -2 .1 0 0 .9 2 0 .0 7 0 .2 3

W eig h t-f o r-h e ig h t -1 .5 6 0 .6 0

-1 .3 6 0 .6 8 0 .2 1 0.5l I

. S D .

t S ig n if ican t d if f e ren ce b e tw een s tart an d f in ish o f su p p lem en tatio n

p erio d (w ith in -g ro u p ch an g e ) tP < 0 .0 1 P < 0 .0 5 .

:j: S ig n if ican tly h ig h er th an th e re lated v alu e o f th e v itam in C g ro u p ,

P =

0 .001 .

II S ig n if ican tly h ig h er th an th e re lated v alu e o f th e iro n + v itam in C

g ro u p ,

P

=

2

w ere sig n if ican t in b o th g ro u p s (T ab le 2 ). T h e h e ig h t in c rease

in th e treatm en t g ro u p w as 2 .7 1 .5 cm

P =

0 .0 0 1 ) w hereas

th e in c rease in th e co n tro l g ro u p w as 1 .5 1 .8 cm P

=

0 .0 0 1 ) .

In th e iro n -treated g ro u p th e

sco re s o f W FA an d H FA in -

c reased s ig n if ican tly w h ereas in th e v itam in C -o n ly g ro u p

sco re s o f W FA an d W FH in creased d u rin g th e su p p lem en tatio n

period.

E n erg y in tak e at th e s tart o f th e su p p lem en tatio n p erio d w as

4 5 0 1 1 0 4 5 k J/d f o r th e iro n -treated g ro u p an d 4 1 1 3 1 18 7

k J/d f o r th e co n tro l g ro u p . A t th e en d o f th e su p p lem en tatio n

p erio d th e in tak es f o r th e treatm en t an d co n tro l g ro u p s w ere

4 4 1 8 8 4 0 an d 4 3 6 8 9 9 1 k J/d , resp ec tiv e ly . T h ere w ere n o

sig n if ican t ch an g es in e ith e r o f th e tw o g ro u p s .

E p iso d es o f f ev e r, resp irato ry in f ectio n s , an d d iarrh ea in th e

co n tro l g ro u p o ccu rred 1 .7 , 2 .5 , an d 3 .0 tim es m o re f req u en tly ,

re sp ec tiv e ly , th an in th e iro n -su p p lem en ted g ro u p (T ab le 3 ).

A v erag e d u ratio n o f th e illn e sse s w as ab o u t th e sam e in b o th

g ro u p s : 1 .5 , 3 .5 , an d 1 . I d , re sp ec tiv e ly , f o r f ev e r, re sp irato ry

in f ec tio n s, an d d iarrh ea. N o d ata w ere av ailab le o n m o rb id ity

b e f o re th e start o f th e stu d y .

Discussion

B o th an em ia an d g ro w th re tard atio n are h ig h ly p rev alen t in

In d o n esia an d are co n sid e red p u b lic h ealth p ro b lem s. In th is

m ilieu o f m u ltip le co n d itio n s , th e aim o f th is s tu d y w as to in -

v e s tig ate th e e f f e c t o f iro n su p p lem en tatio n o n th e b lo o d v alu es

an d p h y sical g ro w th v ariab le s o f an ern ic , u n d erw e ig h t, p re sch o o l

children.

T h e iro n d o sag e, w h ich w as in lin e w ith W o rld H ealth O r-

g an iz atio n (W HO ) reco m m en d atio n s (2 ) , p ro v ed to b e e f f ec tiv e .

T h e su b stan tial in c rease s in h em ato lo g ical v alu es o v er th e 2 -m o

su p p lem en tatio n p erio d o f th e iro n -treated g ro u p w ere sig n if i-

can tly larg er th an th e sm all ch an g es th at o ccu rred in th e v itam in

C -o n ly g ro u p .

D u rin g th e su p p lem en tatio n p erio d th e w e ig h t an d h eig h t o f

b o th g ro u p s in c reased as w o u ld b e ex p ec ted f o r g ro w in g ch ild ren .

T h is in c rease m ay h av e b een p o s itiv ely in f lu en ced b y th e d e -

w o rm in g treatm en t (2 1 ), b u t th e ex ten t to w h ich th is m ay b e

tru e can n o t b e es tim ated in th is stu d y . T h e w e ig h t g ain w as

sim ilar in b o th g ro u p s an d w as re f le c ted in a h ig h er W FA

sco re . T h e m ark ed ch an g e in h e ig h t in th e treatm en t g ro u p w as

1 .8 tim es g reate r th an th e h e ig h t ch an g e in th e co n tro l g ro u p ,

lead in g to a sig n if ican t rise in H FA

sco re f o r th e treatm en t

g ro u p o n ly . T h e f ac t th at th e W FA

sco re ch an g ed in th e co n tro l

g ro u p w h ile H FA

sco re d id n o t ch an g e re su lted in an in crease

in W FH

sco re in th e co n tro l g ro u p . B ef o re th e start o f th e

su p p lem en tatio n p erio d m o re ch ild ren in th e co n tro l g ro u p th an

in th e treatm en t g ro u p w ere in f ec ted w ith p aras ite s . T h e ch ild ren

in b o th g ro u p s rece iv ed an tih elm in th ic treatm en t, b u t n o rech eck

f o r p arasite in f ec tio n w as m ad e at th e en d o f th e su p p lem en tatio n

p erio d . If th e w o rm treatm en t g iv en b e f o re su p p lem en tatio n

h ad b een in e f f ec tiv e , th e re w o u ld h av e b een esp ec ially n eg ativ e

in f lu en ces o n g ro w th in th e co n tro l g ro u p . H o w ev er, su ch in f lu -

en ces are u n lik ely to h av e h ap p en ed co n s id e rin g th e su f f ic ien t

co m p arab le in c rease s in w e ig h t in b o th g ro u p s.

T h e en h an c in g e f f ec ts o f iro n su p p lem en tatio n o n g ro w th o f

an em ic ch ild ren h av e b een rep o rted e lsew h ere (3 . 1 3 ). T h e ch il-

d ren in th o se s tu d ie s h ad in itial H FA sco re s o f -0 . 1 4 (3 ) an d

I .6 6 1 3 ), w h ich d o es n o t c lass if y th em as b e in g s tu n ted , an d

th ey w ere n o t u n d erw e ig h t as o p p o sed to th e ch ild ren in th e

p resen t s tu d y . T w o stu d ie s am o n g T h ai ch ild ren d id n o t sh o w

an e f f ec t o f iro n su p p lem en tatio n o n g ro w th , b u t th is m ay b e

d u e to th e lo w am o u n t o f su p p lem en ted iro n o r to d if f e ren ces

in m e th o d o lo g y (2 2 , 2 3 ). N o rm ally , a ch ild 3 7 m o o f ag e w ith

a h e ig h t s im ilar to th e m ed ian o f th e N C H S re f e ren ce (1 6 ) w o u ld

n eed to g ro w 1 .4 cm in 2 m o to rem ain eq u al to th e m ed ian .

A n av erag e in crease in h e ig h t o f th e treatm en t g ro u p in th e p re s-

en t s tu d y w as 2 .6 cm . o r 1 8 6 % o f th e m ed ian g ro w th rate , in -

d icatin g a m ark ed acce le ratio n . In a stu d y in w h ich d aily f o o d

su p p lem en ts w ere p ro v id ed to stu n ted In d o n esian p resch o o l

ch ild ren f o r a p erio d o f 9 0 d (2 4 ), H FA

sco re s ch an g ed f ro m

-2 .3 4 to -2 .2 4 . w h ich re f le c ts a sm aller in c rease th an th e o n e

f o u n d in th is s tu d y . E f f ects o f f o o d su p p lem en tatio n o n p h y sical

g ro w th are rep o rted to b e m o s t ef f e ctiv e w h en ch ild ren are ag ed

< 1 y (2 5 , 2 6 ). In th e p re sen t stu d y , in w h ich n o f o o d su p p lem en ts

b u t o n ly iro n w ere d is trib u ted an d all ch ild ren w ere ag ed > 2 y ,

it is in te re stin g to n o te th at th e treatm en t g ro u p sh o w ed a m ark ed

im p ro v em en t in lin ear g ro w th .

In th e p re sen t stu d y , en erg y in tak e w as su f f ic ien t f o r th e ch il-

d ren s ac tu al w e ig h t acco rd in g to W H O d aily in tak e reco m -

m en d atio n s o f 3 9 7 k J/k g (9 5 k cal/k g ) (9 ) . T reatin g an em ia is

rep o rted to in crease ap p e tite in ad u lts (2 7 ). H o w ev er, th e treat-

T A B L E 3

E p iso d es o f f ev e r. re sp irato ry in f ectio n s, an d d iarrh ea d u rin g th e

su p p lem en tatio n p erio d in th e tw o g ro u p s

T yp e o f m orb id ity

Iron + v itam in C

n

=

39 )

V itam in C

n

=

37 )

%

Fev er 7 .7

1 3 .5

R esp irato ry in fe ctio ns

1 0 .3 2 7 .0

D iarrh ea* 5 .1 1 6 .2


4/4

34 2

A N G E L E S E T A L

m en t g ro u p d id n o t h av e in creased en erg y in tak e af te r th e su p -

p lem en tatio n p erio d . T h is su g g ests th at th e in c reased lin ear

g ro w th rate in th e treatm en t g ro u p w as n o t cau sed b y h ig h er

f o o d in tak e . D u rin g th e su p p lem en tatio n p erio d th e in cid en ce

o f in f ec tio u s d isease s in th e treatm en t g ro u p w as le s s th an in th e

co n tro l g ro u p . T h is m ay h av e in f lu en ced th e in c reased g ro w th

rate in th e treatm en t g ro u p . Fu rth e rm o re th e d irec t ac tio n o f

iro n o n o x id ativ e p ro cesse s m ay h av e s tim u lated g ro w th rate .

T h e re su lts o f th is stu d y in d icate th at iro n su p p lem en tatio n

m ay p lay an im p o rtan t ro le in o v erco m in g b o th g ro w th re tar-

d atio n an d an em ia in p re sch o o l ch ild ren . It is reco m m en d ed ,

th e re f o re . th at co n s id e ratio n b e g iv en to p ro v id in g iro n su p p le-

m en tatio n n o t o n ly to ex is tin g targ et g ro u p s su ch as p reg n an t

w o m en , b u t also to p re sch o o l ch ild ren . T h ere f o re , f u rth er stu d y

o n e f f ec tiv e su p p lem en tatio n sy stem s f o r p re sch o o l ch ild ren

w o u ld n eed to b e co n d u c ted . It is im p o rtan t to n o te th at th e

co s t o f iro n treatm en t is re lativ e ly lo w . In th e p resen t stu d y , f o r

ex am p le , treatm en t f o r o n e ch ild f o r 1 m o co s t $ 0 .1 8 .

T rad itio n ally , it is b e lie v ed th at lo w W FA o r H FA is cau sed

b y a lack o f p ro te in an d /o r en erg y . T h is assu m p tio n is to o lim ited

an d sh o u ld b e rev iew ed , tak in g in to acco u n t th e e f f ec ts o f m i-

c ro n u trien ts . N o t o n ly sh o u ld iro n b e co n s id e red , b u t also z in c .

w h ich is rep o rted to en h an ce g ro w th (2 8 , 2 9 ) an d th e in te rac tio n

b e tw een m icro n u trien ts su ch as th e o n e b etw een iro n an d v i-

tam in A (3 0 ). Fu rth e rm o re , a W H O w o rk in g g ro u p co n c lu d ed

th at stu n tin g w as n o t an ap p ro p riate in d icato r o f m aln u tritio n

b ecau se in f ec tio u s d isease s m ay also co n trib u te to g ro w th re tar-

d atio n o f ch ild ren (3 1

.

H o w ev er, th is s tu d y d id co n f irm th at

lack o f m ic ro n u trien ts m ay cau se in creased m o rb id ity , w h ich

lead s to g ro w th d ep ressio n in ch ild ren , an d m ay th ere f o re lead

in d irec tly to s tu n tin g . It is n ecessary to reco n s id e r th e ex is tin g

b e lie f s ab o u t ch ro n ic m aln u tritio n , th e u se o f s tu n tin g as an

ap p ro p riate in d icato r, an d th e se lec tio n o f su itab le treatm en t.

In c reased k n o w led g e ab o u t th e ro le o f m icro n u trien ts is v ital in

th is asp ec t. {163}3

W e th an k Po p p y H en d raw an , d irec to r o f T eb e t C o m m u n ity H ealth

C en te r, f o r h er ex ce llen t co o p eratio n . T he v alu ab le reco m m en d atio n s

o f N oe l S o lo m on s an d G u s taaf S ev en h u y sen are h ig h ly ap p rec iated .

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