Author: Nutrition Research and Development Centre
The magnitude of iron deficiency in Indonesia is such that no single intervention is enough to completely eliminate the problem. Wheat flour fortification is a highly feasible and cost-effective way to increase the dietary intake of iron as the consumption of wheat-based noodles is widespread in Indonesia. In January 1999, the Government of Indonesia, with support from UNICEF, and through an initial premix donated by MotherCare/USAID, started a program for fortifying wheat flour with iron. The implementation of this program provided an opportunity for fortification with multiple micronutrients. Subsequently, CIDA provided a grant to UNICEF for a multiple micronutrient flour fortification program. The in-kind component of the grant provided premix for the fortification of wheat flour with iron, zinc, thiamin, riboflavin and folic acid, as a temporary subsidy to consolidate the initiation of flour fortification in Indonesia. The cash component aimed to build capacities in quality control and monitoring systems, and ensure the sustainability of wheat flour fortification through appropriate legislation.
Purpose / Objective
- To evaluate iron intake of adolescent schoolgirls from iron-fortified wheat flour products and from other foods before fortification, 1 year and 3 years after beginning fortification
- To evaluate the contribution of iron intake from iron-fortified wheat flour products to the total iron intake of adolescent schoolgirls
- To evaluate the iron status (hemoglobin and ferritin concentration in blood) of adolescent schoolgirls before fortification, 1 year and 3 years after beginning fortification
- To estimate the prevalence of anemia among adolescent schoolgirls before fortification, 1 year and 3 years after beginning fortification
The evaluation was designed as a longitudinal study, with surveys conducted before project implementation, one year after beginning fortification, and three years after beginning fortification. Hemoglobin and ferritin were measured and compared between two groups of adolescent schoolgirls, one to represent population with high consumption and the other for low consumption of wheat flour products. The study took place in four locations: East Nusa Tenggara province (rural), Banten province (urban) and two sites in West Java province. From each site, 200 adolescent schoolgirls aged 11-17 were selected, thus amounting to a total of 800 girls for the study.
Anthropometric assessments were performed for height and weight. Hemoglobin was analyzed by cyanmethemoglobin method using hemoglobin kit. A food frequency questionnaire, which included 63 food items, was used to assess iron intake from wheat flour products and iron-rich foods. Iron intake was estimated based on frequency and standard portion size for which food models were used.
Key Findings and Conclusions
CIDA procured a total of 232,440 kilograms of fortificant premix with elemental iron, zinc as zinc oxide, thiamin, riboflavin and folic acid. This premix met industry needs for the fortification of 1,549,600 metric tons of wheat flour or one half of the yearly wheat flour production in Indonesia. The premix arrived in 2001. UNICEF arranged customs clearance for receiving the premix and facilitated the distribution among the various flour mills. The premix has been well accepted by both the flourmills and customers.
CIDA funds were used towards an evaluation to measure anemia, dietary patterns and the changes in iron status among schoolgirls over the course of the government's fortification program. Comparisons over time were made where there were baseline data. Tangerang shows a marked improvement over three years, with anemia prevalence dropping from 37 to 12 per cent. This showed a correlation with wheat flour consumption since these schoolgirls derived a substantial proportion of their iron intake from wheat products. However, no clear patterns are seen if ferritin is used as an indicator instead of hemoglobin. Kupang also showed an anomaly for hemoglobin in the third round of measurement. Malaria and worm infestation are possible confounding factors.
The evaluation results were useful in indicating a relationship between wheat flour consumption and reduced anemia, in calling attention to the severe problem and patterns of anemia in Indonesia, in revealing the different food consumption patterns, and in highlighting the need to address other factors known to be closely linked to anemia - such as malaria and worm infestation. Evaluation results were submitted to the Indonesian Fortification Coalition as an input for developing a Plan of Action for Indonesia.
The CIDA funds also led to strengthened capacities in quality control sampling and laboratory analysis of fortified wheat flour, and the initial development of a government quality control system for wheat flour fortification. CIDA funds also contributed to the establishment of the Indonesian Fortification Coalition, which will take the lead in coordinating food fortification efforts in Indonesia and moving forward the national agenda for fortification.
On the legislative and policy side, the CIDA-supported initiative contributed to the revision of the Indonesian National Standards for wheat flour. The revised standards became functional on 2 May 2001 with a Decree of the Ministry of Industry and Trade. The implementation of this Ministerial Decree was assigned to the Director General of Industry, Chemicals, Agriculture and Forestry.
In conclusion, CIDA support has been fundamental to promoting the wheat flour fortification program in Indonesia. Provision of the premix and related training enabled the flour milling industry to gain experience and acquire technical capacity for fortification. In fact, the sector is now buying its own premix to fortify flour in Indonesia. In addition, the CIDA support contributed to the development of a quality control system within the GoI for monitoring wheat flour fortification, although further work is still needed in this respect.
The results of the evaluations can, therefore, be used by UNICEF and its partners to advocate for the consumption of iron-fortified wheat flour products, but as a means to address anaemia within a more comprehensive strategy covering fortification, supplementation, dietary diversification and actions to control diseases causing iron-deficiency anaemia. UNICEF has submitted the evaluation results to the Indonesian Fortification Coalition (IFC) as an input for developing a Plan of Action for Indonesia.
A coordinated effort is needed between the Badan POM and the Ministry of Trade and Industry, in order to establish an effective quality control system for wheat flour fortification. UNICEF has assisted the government to develop a training module, with the assistance of a consultant from Tulane University, U.S.A., for monitoring and evaluation of fortification programs. Plans are underway by the IFC to initiate training among staff in the relevant Ministries and Departments. Building technical capacity within the government is a priority step for establishing a regulatory quality assurance system.
Overall, efforts to promote food fortification in Indonesia need better coordination. In particular, the development of a National Strategic Fortification Plan is not in line with the development of the ADB-sponsored Country Investment Plan for fortification. The two initiatives are taking place in parallel, with the latter in a more advanced stage. The country would benefit from one coherent plan for food fortification instead of different plans that are made to suit the requirements of specific parties. In this respect, the IFC is expected to take the lead in streamlining the various fortification programs in Indonesia. Thus, one of the results of the CIDA-funded program - the establishment of the IFC - is expected to contribute to future coordination in this sector.
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Health - Nutrition