Micronutrient deficiencies are widespread across the globe, especially in developing countries. The most vulnerable groups are those who experience fast growth and development, such as pregnant women, small children and adolescents. Pregnant women and children below 5 years of age have been the focus of most studies and intervention programs. However, limited data are available concerning female adolescents. There is, however, growing awareness that this is an important group to consider, not only for their growth and development, but also for future pregnancies. Indeed, one of the primary factors leading to micronutrient deficits during pregnancy is that many girls or women of reproductive age have poor micronutrient status prior to conception. Thus, improving micronutrient status of women during adolescence is likely to have multiple and long-lasting benefits. The GIRLS project was, therefore, designed to assess the impact of various strategies of improving iron and vitamin A status among female adolescents (aged 12-15 years) attending schools in rural and urban East Java, Indonesia.
Purpose / Objective
1. Test the effectiveness of iron-folate and vitamin A, given alone or in combination, on reducing anemia, vitamin A deficiency, and improving growth
2. Test the effectiveness of daily versus weekly multi-micronutrient supplements on reducing anemia, vitamin A deficiency, and improving growth
3. Test the effectiveness of a daily meal prepared to be either high or low in both iron and vitamin A on anemia, vitamin A deficiency, and growth
4. Determine the relative benefit of iron-folate or vitamin A supplementation in rural or urban settings
5. Determine the prevalence of anemia and vitamin A deficiencies among female adolescents in rural and urban communities
6. Assess the direct causes and underlying factors, as well as the processes, that lead to quantitative and qualitative micronutrient deficits in the habitual diets of female adolescents in rural and urban communities
7. Assess the appropriateness of the school as a channel to address the nutritional problems of female adolescents
During the three years of the GIRLS project, approximately 11,000 adolescents attending 34 schools received some form of supplementation or dietary intervention. In 24 junior high schools, approximately 6,000 were enrolled in each of the three years of randomized weekly supplementation trials. In the first year, 10,000 IU vitamin A and 60 mg iron with 250 ug folic acid was given either alone or in combination in 15 schools while the other 9 schools served as controls. In the second year, the trial used a placebo-controlled design and participants received either 20,000 IU vitamin A plus placebo, 60 mg iron with 250 ug folic acid plus placebo, 20,000 IU vitamin A plus 60 mg iron with 250 ug folic acid, or two placebos. In the third year, the impact of daily versus weekly multi-micronutrient supplementation was addressed. In addition, issues surrounding compliance and distribution of supplements were examined. Along with supplement-based interventions, over 400 girls in Islamic boarding schools (pondok pesantreri) were enrolled in a 6-month dietary intervention trial that assessed the impact on hemoglobin concentration of a daily meal containing iron-rich foods compared to a meal with a low iron content.
Key Findings and Conclusions
The prevalence of anemia found among adolescent girls (20-30%) and boys (10-25%) and of low serum retinol concentrations (35-55%) indicates that micronutrient deficiencies are an important problem among this population group (goal 5 of the project). Such information had not previously been available at this scale.
Supplementation with iron and vitamin A were effective in reducing deficiencies in these micronutrients in female and male adolescents. However, the results of the interventions with different kinds of supplements have been very limited, specifically in addressing goals 1, 2 and 4 of the project: Vitamin A supplementation had an impact on both hemoglobin and serum retinol concentration among boys in the first study. Vitamin A supplementation had no impact on hemoglobin and serum retinol concentration among boys in the second study. In the second study, vitamin A supplementation had an impact among girls but only on their hemoglobin concentration. Iron supplementation had no impact among girls, even in the third study, when supervision was maximized to an extent that would not be possible in a programmatic setting. Only boys complied and benefited from iron distributed with strict supervision (third study). No difference in impact on hemoglobin concentration was observed between multi-micronutrient supplements with a 12-fold difference of iron content.
This project also assessed whether schools could be a good channel for delivering different types of strategies for reducing micronutrient malnutrition among adolescents and examined the impact of the different strategies. Impact tended to be better among students at rural schools, which may indicate that their compliance with supplementation was better.
The most realistic shorter-term intervention is, therefore, supplementation with a single or multiple micronutrients. Another important observation was that the adolescents at the boarding schools that participated in the project tended to consume very little food; some only consumed one meal per day.
In summary, the GIRLS project has shown that, in order to be successful, interventions with dietary supplements need to have strong supervision and cooperation among all the partners involved. Much work still needs to be done to understand the behavior of adolescents in order to improve compliance.
Attention be given to micronutrient supplementation of both female and male adolescents.
In the design of supplementation intervention, special care be taken to investigate factors that negatively influence compliance and that ways are found to overcome these.
Schools are an appropriate channel for micronutrient supplementation to adolescents, where enrollment is sufficiently high.
More research be devoted to gain insight on the health status of adolescents, including the prevalence of micronutrient deficiencies.
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Health - Nutrition