Intersectoral and eco-nutritional approaches to resolve
persistent anemia in Indonesia
Author:Widjaja Lukito, Mark L Wahlqvist,FRACP, FAFPHM
Keywords:econutrition, infectious diseases, non-communicable diseases, genetics, policy development
Abstract:Anemia in Indonesia has been of concerning persistence in all age groups for some 75 years since independence.The relationships between anemia and nutrition are complex being evident with compromised general health and
nutrition. Increased micronutrient intakes, especially iron and folic acid, has alleviated the problem, but encouraged nutrient-specific micronutrient interventions as attractive policy directions as if anemia were a stand-alone disease irrespective of associated disorder. Concerted action to deal with the fundamental causality has been missing. Much of the pathogenetic pathway may be nutritional, but its multifactoriality is ultimately socioecological. Given the intransigence and progression of societal and ecosystem dysfunction, it can be expected that failure to recognize their causal importance will further entrench endemic anemia. This review deliberates the practical measures taken to recognize anemia by symptomatology, food and nutrition surveys, screening (fingerpick
blood), nutrition assessment, and blood loss (menstrual and faecal). It identifies vulnerable groups including premenopausal and pregnant women, children and adolescents, unwell adults, and the dependent aged. Risk settings include food insecurity, infectious disease, non-communicable disease, inheritance and epigenetics, and socioeconomic disadvantage. Underlying socio-ecological problems are livelihood, food systems, cultural habits, belief systems, and social networks and activities. With this framework, policy directions could deal more comprehensively and effectively with the socioecological complexity which underpins and limits progress towards anemia eradication at a time of intense global food and health insecurity. It will require co-operative intersectoral
and eco-nutritional approaches which take into account the need for universal, sustainable livelihoods. Recommendations have been made accordingly.
Asia Pac J Clin Nutr. 2020;29(5):S1-S8.doi: 10.6133/apjcn.202012_29(S1).01
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Nutritional contributors to maternal anemia in Indonesia: Chronic energy deficiency and micronutrients
Author:Nur Indrawaty Lipoeto, Masrul, Ricvan Dana Nindrea
Keywords:anemia, pregnancy, risk factors, chronic energy deficiency, policies
Abstract:Background and Objectives: Despite enduring efforts in Indonesia to eliminate anemia in pregnancy, it remains a major nutritional problem. Its nutritional contributors were reevaluated. Methods: A meta-analysis of reports on anemia during pregnancy in Indonesia from January 2001 to December 2019 in the PubMed and ProQuest databases was conducted. Pooled ORs were obtained in fixed- and random-effects models. Funnel plots and Egger’s and Begg’s tests were used to evaluate publication bias. Review Manager 5.3 and Stata version 14.2 were used for analysis. Results: A total of 2,474 articles were appraised. Systematic review and meta-analysis were performed on 10 studies including 4,077 participants. Chronic energy deficiency had the highest OR for the risk of anemia (3.81 [95% CI: 2.36–6.14]) followed by greater parity (OR=2.66 [95% CI: 1.20–5.89]), low education level (OR=2.56 [95% CI: 1.04–6.28]), and limited health knowledge (OR=1.70 [95% CI: 1.17–2.49]), whereas older age and inadequate iron supplementation were not apparently associated with maternal anemia (p > 0.05). Conclusion: Future policies and strategic action to reduce nutritional anemia during pregnancy in Indonesia should increase emphasis on local nutritional epidemiology to establish the pathogenesis of anemia and the validity of stand-alone single-nutrient interventions. Attention to chronic energy deficiency as a barrier to preventing anemia in pregnancy may be necessary to enable health workers and women at risk to be better informed in their efforts.
Asia Pac J Clin Nutr. 2020;29(5):S9-S17.doi: 10.6133/apjcn.202012_29(S1).02
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Nutritional anemia in Indonesia children and adolescents: Diagnostic reliability for appropriate management
Author:Mohammad Juffrie, Siti Helmyati, Mohammad Hakimi
Keywords:multifactorial anemia, adolescent, children, Indonesia, nutritional interventions
Abstract:Background: Nutritional anemia in Indonesian children and adolescents is generally regarded and treated as iron-deficient anemia, as it is in individuals in other age groups. Objectives: Yet, it remains a public health threat without comprehensive management or a sustained solution. Methods: This review seeks to improve understanding of impediments to its resolution. Relevant studies reported in the past 5 years were identified in PubMed, Science Direct, Crossreff, Google Scholar, and Directory of Open Access Journals databases. Results: In all, 12 studies in several Indonesian cities provided the basis for the review. Most were conducted in schools, indicating the potential of these institutions as targets for intervention but pointing to serious deficiencies in identification of
the problem across the archipelago and in remote and rural areas. No study has evaluated coexistent anemia and malnutrition, which likely would have revealed the multi-factoriality of nutritional anemia. Data regarding nutrition education, food-based innovation, and supplementation, which may alleviate anemia in children and adolescents, are available, although study lengths and sample sizes have limited interpretation and comparison. Conclusions: Broadly, three intervention approaches to nutritional anemia have been undertaken, namely food-based interventions, nutrient supplementation, and nutrition education. Some progress has been made with these approaches, presumably through increases in iron intake. More information is needed regarding the underlying causality and pathogenesis, suboptimal food patterns, and comorbidities, any of which might limit the effectiveness of programs designed to resolve childhood and adolescent anemia in Indonesia.
Asia Pac J Clin Nutr. 2020;29(5):S18-S31.doi: 10.6133/apjcn.202012_29(S1).03
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Non-nutritional anemia: Malaria, thalassemia, G6PD deficiency and tuberculosis in Indonesia
Author:Safarina G Malik, Sukma Oktavianthi, Mark L Wahlqvist, FRACP, FAFPHM, FAIFST, FTSE, Puji Budi Setia Asih, Alida Harahap, Ari W Satyagraha, Din Syafruddin
Keywords:hemoglobin, malaria, thalassemia, G6PD, tuberculosis
Abstract:Anemia affects people worldwide and results in increased morbidity and mortality, particularly in children and reproductive-age women. Anemia is caused by an imbalance between red blood cell (RBC) loss and production
(erythropoiesis), which can be caused by not only nutritional factors but also non-nutritional factors, such as inflammation and genetics. Understanding the complex and varied etiology of anemia is crucial for developing effective interventions and monitoring anemia control programs. This review focusses on two interrelated nonnutritional causes of anemia: malaria infection and RBC disorders (thalassemia and G6PD deficiency), as well as tuberculosis. According to the Haldane hypothesis, thalassemia occurs as a protective trait toward malaria infection, whereas G6PDd arises in malaria-endemic regions because of positive selection. Indonesia is a malariaendemic region; thus, the frequency of thalassemia and G6PD deficiency is high, which contributes to a greater risk for non-nutritional anemia. As Indonesia is the second global contributor to the newly diagnosed tuberculosis, and active pulmonary tuberculosis patients are more anemic, tuberculosis is also contributes to the increasing
risk of anemia. Therefore, to reduce anemia rates in Indonesia, authorities must consider non-nutritional causes that might influence the local incidence of anemia, and apply co-management of endemic infectious disease such as malaria and tuberculosis, and of genetic disease i.e. thalassemia and G6PDd.
Asia Pac J Clin Nutr. 2020;29(5):S32-S40.doi: 10.6133/apjcn.202012_29(S1).04
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Non-nutritional and disease-related anemia in Indonesia: A systematic review
Author:Agussalim Bukhari, Firdaus Hamid, Rahmawati Minhajat, Nathania Sheryl Sutisna
, Caroline Prisilia Marsella
Keywords:anemia of inflammation, helminthiasis, non-nutritional anemia, chronic disease, iatrogenic anemia
Abstract:Non-nutritional anemia, the second most common type of anemia worldwide after nutritional anemia, includes the anemia of inflammation (AI) and that due to helminthiasis. In this review, we examine the contribution that non-nutritional anemia makes to incidence in Indonesia. Anemia due to helminthiasis is a common problem in Indonesia and contributes to prevalence, particularly in children under 5 years. We conducted a systematic literature review based on Google Scholar and Pubmed for non-nutritional anemia. We supplemented this with hemoglobin and chronic disease data in Makassar where prevalence and type of anemia were available. To effectively reduce anemia prevalence in Indonesia, interventions should address both nutritional and non-nutritional contributing factors, including infection and genetic predisposition.
Asia Pac J Clin Nutr. 2020;29(5):S41-S54.doi: 10.6133/apjcn.202012_29(S1).05
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Nutritional anemia: Limitations and consequences of Indonesian intervention policy restricted to iron and folic acid
Author:Nadiyah, Lintang Purwara Dewanti, Erry Yudhya Mulyani, Idrus Jus’at
Keywords:iron deficiency anemia, Indonesia, program policy, supplementation, fortification
Abstract:Background and Objective: Currently, anemia is a severe public health issue in Indonesia. The aim of this review was to examine policy measures and program implementation to reduce anemia attributed to iron deficiency in
Indonesia. Methods and Study Design: A literature search was conducted using Google Search, Sciencedirect.com, and PubMed to retrieve relevant studies in the last three decades. Qualitative data were also obtained from service providers. The search yielded 141 articles, of which 32 were excluded, and further screening was conducted based on the type and scale of the intervention program. Results: In the iron–folic acid (IFA) supplementation programs studied, antenatal care and health personnel capacity information were limited. Implementation often did not correspond to standard operating procedures. Analysis, follow-up, and feedback on IFA tablet programs were lacking.
Moreover, the IFA tablet supply was inadequate, facilities and infrastructure were insufficient, and counseling guidance, relevant material, and information media were lacking. In the national fortification program, wheat flour was used as a vehicle for anemia prevention. However, evidence from the Total Diet Study indicated that wheat noodles have limited value across the Indonesian archipelago. Conclusion: Programs to reduce the likelihood of anemia will be more successful if they are less dependent on nutrient-specific strategies and focus more on the
pathogenetic complexity arising from personal behavior, sociocultural factors, dietary and health patterns, local community, and ecology. Partnerships between the community and government reflected in evidence-based policy will always be of value, but continued research is required to examine the factors contributing to the successful outcomes of such programs.
Asia Pac J Clin Nutr. 2020;29(5):S55-S73.doi: 10.6133/apjcn.202012_29(S1).06
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