ASSIGNMENT COVER SHEET

Every piece of written work you submit for assessment must have this cover sheet attached COURSE DETAILS Course Code: NUTR 7001 Course Co-ordinator: Dr. Lisa Schubert

Course Name: Health and Nutrition Assignment No: 4 th Assignment Due Date: 4 June 2010

STUDENT CONTACT DETAILS Student Number: 4222697 Address: 35, Boblynne, St., Chapel Hill, QLD 4069 Telephone: (BH) (AH) Mobile: 0415800376

Student Name: Aly Diana Email address: aly.diana@uqconnect.edu.au Program you are enrolled in: (circle) Degree Certificate Diploma

Masters

STUDENT DECLARATION TO ACCOMPANY INDIVIDUAL STUDENT ASSIGNMENT

I declare that I have read the UQ Academic Integrity and Plagiarism policy including the approved use of plagiarism detection software, the consequences of plagiarism and the principles associated with preventing plagiarism. * (http://www.uq.edu.au/hupp/index.html?page=25128) I declare that the material contained in this assignment is my own work and that where I have used the ideas or writing of other authors that this has been acknowledged according to accepted academic guidelines. I further declare that the material contained in this assignment has not been submitted in whole or substantial part, to meet the assessment requirement in another course at this, or any other, university. I have kept a copy of this assignment.
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Date: 4th June 2010 Word count: 1882 Submitted date: 4th June 2010

Due Date: 4th June 2010

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Reducing Anaemia in Adolescent: a Step Forward for a Better Generation

Adolescence (age 10-19 years old) is a crucial phase during a life time, when hormones influence the speed of growth spurt and puberty processes begin; affecting every organ in the body (Whitney & Rolfes 2010). For adolescence girl, this is the important preparation period to meet nutritional demands for near future steps in life, including pregnancy, lactation, and heavy workloads (Kurz 1994). These roles of become a mother; result in higher nutrition requirements for girl compare to boy. In Indonesia, especially in rural areas where the age of marriage is very young around 17 years (Kurniawan et al. 2006), the nutritional requirements and health risks become higher. Young marriage can increase risk of delivering pre-term or low birth weight baby (Kurz 1994). If appropriate intervention is not available, this baby will become underweight adolescent and mother, who are more likely to produce, again, low birth weight baby (Cordeiro et al. 2005; Darnton-Hill, Nishida & James 2004; Julia et al. 2008). Furthermore, anaemia which is found to be prevalent in Indonesia can make this life course cycle become worse. To see the factual number of anaemia in adolescent, the determinant factors, and the proposed interventions in Indonesian context, 5 annotated bibliographies are presented here.

A study by Julia et.al (2008) gives a brief overview that children who are underweight can remain underweight or become overweight. Children who remain underweight in adolescent most likely will produce low-birth weight baby and continue the cycle of poor nutritional status. On the other hand, children who become overweight increase their own risk of having chronic disease (Darnton-Hill, Nishida & James 2004).

Julia, M, van Weissenbruch, MM, Prawirohartono, EP, Surjono, A & Delemarre-van de Waal, HA 2008, 'Tracking for underweight, overweight and obesity from childhood to adolescence: a 5-year follow-up study in urban Indonesian children', Horm Res, vol. 69, no. 5, pp. 301-6. A 5-years longitudinal study has been held to assess any change in BMI from children to adolescent (n=308) in urban area in Yogyakarta, Indonesia. The results show that almost half of the children who are not overweight during childhood become overweight or obese during adolescent period, which follow the trend in developed country. However, more than half Aly Diana_42226976_Assignment4_NUTR7001 Page 2

remained underweight. The author assumed that this condition has been caused by difference amount of food intake, that those who were poor remained underweight, while those who were rich tended to be overweight. The assumption might be true, but it was not supported by data of socioeconomic status and energy intake. The small number and limitation of sample population which is only from urban area in Yogyakarta without any random sampling technique considered, makes the result difficult to be generalized to overall Indonesian population. Despite of its limitation, the results of this study bring a new interest about the actual changes of nutritional status along time in both urban and rural area in Indonesia. As the risk of life course impacts on disease are population specific and are influenced by social, economic, cultural, and ethnic differences, a better designed study can help government to develop more appropriate intervention to prevent poor health outcomes in older age. Beside weight, iron deficiency anaemia also becomes a risk factor of producing low quality maternal conditions. Anaemia initiated worse growth, appetite, immune function, learning capacity, school achievement, and work performance in people who are affected (Latham 1997). If it happens in pregnancy, it can lead to intrauterine growth retardation, low birth weight and peri-natal mortality. This cycle should be broken to produce a better generation, because the necessity to treat iron deficiency anaemia is therefore both a health and an economic issue (Soekarjo et al. 2001, p. 932).

Soekarjo, DD, de Pee, S, Bloem, MW, Tjiong, R, Yip, R, Schreurs, WH & Muhilal 2001, 'Socio-economic status and puberty are the main factors determining anaemia in adolescent girls and boys in East Java, Indonesia', Eur J Clin Nutr, vol. 55, no. 11, pp. 9329. In Indonesia, iron deficiency anaemia is still considered as a major public health problem. To determine prevalence and contributing factors of anaemia in adolescent in East Java, Indonesia; a survey of 6468 boys and girls aged 12-15 has been conducted. The prevalence was 25.8% amongst girls, 24.5% amongst pre-pubertal boys, and 12.1% amongst pubertal boys. The risks are higher in children who come from poor family. Given current situation of poverty, low intake of haem-iron, lower retinol-intake and have rice as main staple in Indonesia, the authors recommend to increase adolescents micronutrient status by giving supplements for all girls and pre-pubertal boys. Although the sound methodology of this study produces reliable result, the Aly Diana_42226976_Assignment4_NUTR7001 Page 3

difference of anaemia prevalence in pre-pubertal and pubertal boys might be caused by falsenegative answers to the question on pubertal status, as physical examination cannot be done due to ethical issue. This study also not covered adolescent who not attend school or already drop-out that most likely come from the poorest socio-economic. This fact result in reduction of true burden of the problem and not represent general condition in rural and urban area in East Java, Indonesia, which should be taken into consideration for future intervention.

Kurniawan., YAI, Muslimatun., S, Achadi., EL & Sastroamidjojo., S 2006, 'Anaemia and iron deficiency anaemia among young adolescent girl from peri urban coastal area of Indonesia', Asia Pac j Clin Nutr, vol. 15, no. 3, pp. 350-6. School girls aged 10-12 years (n=1358) from 2 poor coastal areas are screened for haemoglobin concentration. After administering antihelminthic drug to all girls with Hb <115 g/L, second examination is performed. All girls with Hb < 120 g/L were recruited to join the study to compare characteristics of adolescent girls who suffering anaemia with or without deficiency. The findings suggest that the main cause of iron deficiency anaemia was insufficient iron in red blood cells rather than insufficient iron storage. The average energy, protein, iron, and vitamin C intakes were below the Indonesian RDA. Eating habit of adolescent girl in this population is quite similar. The dietary recall revealed that adolescent girls usually skip breakfast or lunch, more likely due to social-economic condition rather than dieting or thinking about body image. The consumption of haem-iron, foods which are expensive is low. This study emphasized the high prevalence of iron deficiency anaemia among adolescent and recommended iron supplementation program to be expanded to this group. Although all the research process seems quite well-structured, the aim of comparing the characteristics of anaemia with or without deficiency is not clear.

Indonesia has implemented iron supplementation program for around 30 years, yet anaemia is still a widespread problem in Indonesia. Intervention for pregnancy women might be too late for improving outcomes. For this reason an earlier intervention during adolescence period is assumed to improve reproductive performance, as many of them enter marriage in a very young age (Kurniawan et al. 2006). Prevention is a better approach to reduce anaemia in pregnancy and to avoid any complications related to it. An idea of combining iron and vitamin A Aly Diana_42226976_Assignment4_NUTR7001 Page 4

supplementation is considered, because vitamin A deficiency plays a role in developing anaemia, and vitamin A can enhance the effect of iron supplementation (Latham 1997; Whitney & Rolfes 2010).

Soekarjo, DD, Pee Sd, S, Kusin, JA, Schreurs, WH, Schultink, W, Muhilal & Bloem, MW 2004, 'Effectiveness of weekly vitamin A (10,000 IU) and iron (60 mg) supplementation for adolescent boys and girls through schools in rural and urban East Java, Indonesia', Eur J Clin Nutr, vol. 58, no. 6, pp. 927-37. As a follow-up study to reduce prevalence of anaemia amongst adolescent, an experimental study of weekly vitamin A (10.000 IU) and iron (60 mg) supplementations has been conducted. Total number of 1757 girls and 1859 boys aged 12-15 from schools in rural and urban area in East Java is divided into 4 groups who received 14 weeks supplementation of vitamin A (VA group), iron (Fe group), both (VAFe group), and control group. Generally, there are no improvements of haemoglobin and serum retinol concentrations in all groups, except increase of serum retinol in boys VA group. Some assumptions are made to explain the results, which are low compliance related with gastrointestinal side effect, over-reporting of compliance, short period of effective supplementation, and low dose of vitamin A. This study is well prepared, has a valid methodology; and presented the effectiveness of supplementation in programmatic setting which can give more practical recommendations. Some pilot projects considering better quality of iron tablets supported by a rigour qualitative research to increase compliance and higher dose of vitamin A should be explored before implementing the supplementation in a larger scale. The concept of transitions when a person experiences changes in social roles or responsibilities and linked lives when development of one person dependent on the presence, influence, or development of another, can be seen when somebody is marriage (Wethington 2005). This life course perspective might also play a big role in the success of intervention through marriage registries, as it leads to a stronger commitment. Another reason might be that these women have higher reception of behaviour change than older generation (Jus'at et al. 2000).

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Jus'at., I, Achadi., EL, Galloway., R, Dyanto., A, Zazri., A, Supraktito., G, Zizic., L & Elder., L 2000, 'Reaching young Indonesian women through marriage registries: an innovative approach for anemia control', J Nutr, vol. 130, pp. 456S-8S. An anaemia control program for newlywed women through marriage registries has been implemented in order to prepare iron stores before pregnancy and reduce prevalence of anaemia in Indonesia. The Ministry of Health and the Mother care Project provided affordable iron supplementation and used information, education and communication (IEC) approach to support this program. The prevalence of anaemia at baseline, 1 month and 3-4 months after registration are documented. The results show a decrease of anaemia prevalence from 23.8% at baseline to 14.2% and 14% at first and second monitoring, respectively. Support from a respected and influential member of the community in marriage registries and help from radio spots are essential. In spite of the success of the program, some limitations can be found from the study. It said that qualitative research with women of reproductive age is used to develop IEC materials, but no reference or further information available to explain this phase. In addition, the dropout rate is high (24%) from baseline to the first monitoring. To scale up this program to national level; larger sample size, better monitoring mechanism in community, cost effectiveness, cultural concern, and sustainability of the program should be measured.

Poor nutrition status in adolescent is a serious public health issue, as it can influence the nutrition status of the further generation. These 5 studies can give a general overview about the pattern of nutrition status from childhood to adolescent, the prevalence of anaemia in adolescent, poor food intake related to socioeconomic status as major determinants of anaemia, and strength and weakness of proposed new interventions programs for adolescent in Indonesia. Limited data around eating habits, low compliance, and food beliefs around this population produce a missing link for a better prevention and intervention approach. Combination of quantitative and qualitative research should be considered to give more holistic overview that can help to solve the problem. More attention from government is indeed necessary to reduce the burden of the problem.

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References

Cordeiro, LS, Lamstein, S, Mahmud, Z & Levinson, FJ 2005, 'Adolescent malnutrition in developing countries: a close look at the problem and at two national experiences', SCN News, vol. 31, pp. 6-13. Darnton-Hill, I, Nishida, C & James, WP 2004, 'A life course approach to diet, nutrition and the prevention of chronic diseases', Public Health Nutr, vol. 7, no. 1A, pp. 101-21. Julia, M, van Weissenbruch, MM, Prawirohartono, EP, Surjono, A & Delemarre-van de Waal, HA 2008, 'Tracking for underweight, overweight and obesity from childhood to adolescence: a 5-year follow-up study in urban Indonesian children', Horm Res, vol. 69, no. 5, pp. 301-6. Jus'at, I, Achadi, EL, Galloway, R, Dyanto, A, Zazri, A, Supraktito, G, Zizic, L & Elder, L 2000, 'Reaching young Indonesian women through marriage registries: an innovative approach for anemia control', J Nutr, vol. 130, pp. 456S-8S. Kurniawan, YAI, Muslimatun, S, Achadi, EL & Sastroamidjojo, S 2006, 'Anaemia and iron deficiency anaemia among young adolescent girl from peri rban coastal area of Indonesia', Asia Pac j Clin Nutr, vol. 15, no. 3, pp. 350-6. Kurz, KM 1994, 'Adolescent Growth', SCN News, vol. 11, pp. 6-11. Latham, MC 1997, Human nutrition in the developing country, Food and Agriculture Organization of The United Nations, Rome. Soekarjo, DD, de Pee, S, Bloem, MW, Tjiong, R, Yip, R, Schreurs, WH & Muhilal 2001, 'Socioeconomic status and puberty are the main factors determining anaemia in adolescent girls and boys in East Java, Indonesia', Eur J Clin Nutr, vol. 55, no. 11, pp. 932-9. Wethington, E 2005, 'An overview of the life course perspective: implications for health and nutrition', J Nutr Educ Behav, vol. 37, no. 3, pp. 115-20. Whitney, E & Rolfes, SR 2010, Understanding Nutrition, 12th edn, Cengage Learning, Wadsworth.

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