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Kingdom of Bahrain World Health Organization Ministry of Health
Regional Office (EMRO) Public Health Directorate Cairo - Egypt
Nutrition Section
Impact of the National Flour Fortification Program
on the Prevalence of Iron Deficiency and Anemia
among Women at Reproductive Age in the
Kingdom of Bahrain
(First Monitoring Study)
Dr. Zuhair Salman Al-Dallal Senior Nutritionist
Dr. Khairya Moosa Hussain Chief, Nutrition Section
2003
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Table of Contents
Acknowledgment .... 6 Abstract ..... 7 Introduction . 9 Study
Rationale 11 Objectives of the Study . 11 Specific Objectives ...
11 Material and Methods: The Settings .. 13 Study Population .. 13
Study Design . 13 Sample Size ... 13 Pulling out the Sample .. 14
Official Procedure . 14 Teams . 14 Package .. 14 Questionnaire . 15
Data Collections . 15 Duration of Data Collections 16 Data Entry .
16 Data Analysis . 16 Sponsorship ... 17 Results: Main
Characteristics of the Participants . 19 Iron Status .. 22
Socio-Demographic Risk Factors for Iron Deficiency Anemia .. 28
Current Study vs. National Nutrition Survey .. 30 Awareness
Regarding Fortification Program . 31 Discussion: Introduction . 35
Iron Status 37 Impact of Fortification on the Prevalence of Iron
Deficiency and Anemia 39 Fortification and Public Awareness .. 44
Conclusion .. 47 Recommendations .... 49 Appendix (1): Study
Questionnaire ... 51 References ... 56
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List of Tables Table (1): Main Characteristics of the
participants 19 Table (2): Distribution of the participants
according to their Geographical Region 20 Table (3):
Socio-Demographic Characteristics of the participants ... 21 Table
(4): Hematological and Biochemical Analysis of the participants ..
22 Table (5): Distribution of the participants according to their
Hb level and Age .. 25 Table (6): Distribution of the participants
according to their Hb level and Hemoglobin Groups .. 25 Table (7):
Relationship between the participants Serum Ferritin level and
Hemoglobin Groups ...... 26 Table (8): Classification of Iron
Status using Hemoglobin Concentration and Serum Ferritin Levels ...
27 Table (9): Relationship between the participants Folic Acid
level and Hemoglobin groups ... 27 Table (10): Relationship between
the participants Vitamin B12 and Hemoglobin groups . 28 Table (11):
Correlation Coefficient between the participants Hb Concentration
and some risk factors related to iron status 29 Table (12):
Correlation Coefficient between the participants SF Concentration
and some risk factors related to iron status . 29 Table (13):
Correlation coefficient between the participants various Blood
Indices ... 30 Table (14): Comparison of the level by Age group
between the Current Study and the National Nutrition Survey 30
Table (15): Comparison of the low Hb level (< 12 g/dl) between
the Current Study and the National Nutrition Survey .. 31 Table
(16): Participants Knowledge about the flour Fortification Program
32 Table (17): Types and Frequency of consumed Bread by the
Participants .... 33
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List of Figures Figure (1): Frequency distribution of hemoglobin
level with a normal Curve of the Participants .. 23 Figure (2):
Frequency distribution of Serum Ferritin level with a normal Curve
of the Participants ... 24
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Acknowledgment The successful implementation of this report
would not have been possible without
the active dedicated efforts of number of organizations and
individuals.
First of all, we would like to express our special thanks and
gratitude to the Ministry
of Health, Kingdom of Bahrain and World Health Organization
Regional Office
(EMRO), Egypt, for kindly supporting the conduct of this
study.
We would like to record our indebtedness to the Director of the
Central Statistics
Organization for pulling out the sample.
We wish to thank Mrs. Layla Al-Nashemi, Head of Health Centers
Laboratories, for
her assistance in recruiting the investigators.
We would also like to extend our gratitude and thanks to Mrs.
Manal A Al-Sairafi,
nutritionist, for her valuable comments on the final report.
Thanks to Mrs. Ghada Al-Raees, nutritionist, for her suggestions
and input at early
stages prior to conducting the study.
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Abstract Impact of the National Flour Fortification Program on
the Prevalence of Iron
Deficiency and Anemia among Women at Reproductive Age in the
Kingdom of
Bahrain (First Monitoring Study) By: Zuhair Salman Al-Dallal and
Khairya Moosa Hussain
Iron deficiency anemia is the most common nutritional deficiency
in the developing world, and it affects almost 30% of the world
population. Women of childbearing age are at greatest risk because
of the effects of menstruation and pregnancy. In the Kingdom of
Bahrain, iron deficiency anemia is considered as a major public
health concern, where it affects about 37.7% of females at
reproductive age. Flour fortification program was implemented in
the country as a part of large scale program to reduce the
incidence of the disease. A cross-sectional study among Bahraini
females at childbearing age (14 49 years) was carried out almost
six months post to the implementation of the fortification program.
The main objective of the study was to explore the impact of the
iron and folic acid fortified flour on hemoglobin and the iron
status of this population group. A total of 393 females were
selected randomly by the Central Statistics Organization and
recruited for the purpose of this monitoring study. They were
interviewed by qualified and well trained laboratory technicians
using a pre- prepared questionnaire designed specially for this
study. All the participants agreed to give blood samples for
hematological and biochemical analysis. The data was computerized
and analyzed using the SPSS package (version 11.0 for Windows). The
mean Hb and SF levels were 11.9 g/dl and 30.4 g/L respectively.
Participants from Muharraq region found to had higher Hb level than
participants from other regions with a statistically significant
difference. A statistically significant association (P < 0.05)
was found between Hb groups and SF level. Participants with low Hb
concentration tend to had lower SF level and verse versa. Using
dual criteria; Hb and SF, it was found that the prevalence of iron
deficiency anemia among the participants is 24.5%, while 51.3% of
them were anemic and 10.9% were at risk to develop iron deficiency
anemia . Correlation coefficient between both Hb and SF and some
risk factors related to iron status showed that Hb was positively
correlated with SF of the participants. Among anemic participants,
Hb was positively correlated (P < 0.05) with the occupation,
while there was a significant correlation between SF and marital
status of iron deficit participants. Although, no obvious
difference was found in the prevalence of anemia between the
current study and the National Nutrition Survey (pre-fortification
study), however, mean Hb among anemic participants in the current
study was significantly higher (P < 0.05). Unexpectedly, the
majority of the participants (85.5%) were unaware about the
fortification program. Despite the short period between the
implementation of the fortification program and this study, a
slight improvement was found in the anemic status of the
participants. In conclusion, it is early to draw up a sound
conclusion about the impact of the fortification program on the
prevalence of the iron deficiency anemia among this population
group. Though, further monitoring studies and investigations will
be done in future.
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Introduction
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Introduction
Anemia is common throughout the world. Its main cause, iron
deficiency which is the
most common known form of nutritional deficiency affecting more
than 700 million
persons all over the world (WHO, 1993).
Simply stated an iron deficiency occurs when an insufficient
amount of iron is
absorbed to meet the bodys requirements. This in-sufficiency
might be attributed to
inadequate dietary iron intake, reduced bioavailability of
dietary iron, increased needs
of iron, or to chronic blood loss. When prolonged, iron
deficiency leads to iron
deficiency anemia.
This nutritional disorder has profound effects on psychological
and physical
development, behavior, and work performance and eventually on
productivity and
socioeconomic development (WHO, 1998). During pregnancy it
increases maternal
morbidity, and mortality as well as prenatal mortality, and
increases the risk of low
birth weight (WHO, 1989).
Its prevalence is highest among young children and women of
childbearing age
because of the effects of menstruation and pregnancy. Women of
childbearing age
usually require additional iron to compensate for menstrual
blood loss (an average of
0.3 0.5 mg daily during their productivity years), and for
tissue growth during
pregnancy and blood loss at delivery and postpartum (an average
3 mg daily over 280
days gestation) (CDC, 1998).
In the countries of the Eastern Mediterranean Region. Iron
deficiency anemia affects
between 30% and 60% of women of childbearing age and young
children (WHO,
1999). In the Kingdom of Bahrain, results of National Nutrition
Survey revealed that
37.3 % of women aged 19 years and above having low hemoglobin
(Hb < 12 gm/dl)
which means they were anemic (Moosa, 2002).
As a National strategy to control and prevent iron deficiency
anemia, the Ministry of
Health in the Kingdom of Bahrain adopted a National flour
fortification program in
collaboration with World Health Organization Regional Office for
Eastern
Mediterranean Countries, which was lunched in November 2001,
in-line with other
strategies such as nutrition education and supplementation
program mainly for
pregnant women.
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The fortification program have contributed to increased dietary
iron intake and
reductions in iron deficiency anemia in many developed countries
which is considered
as the most effective preventive tool (Whittaker et al.,
2001).
However, continuous monitoring on both the effectiveness and
safety of fortification
practices has proven necessary for improving quality and for
advocacy purposes.
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Study Rationale The fortification program of flour with iron and
folic acid was implemented as a
continuous program for the first time in the Kingdom of Bahrain
in November 2001.
This program was performed as a part of enormous national
program to reduce the
prevalence of iron deficiency anemia (IDA) among the Bahraini
population. On the
other hand, there was an intention to establish a long-tem
monitoring system to
evaluate the feasibility of the fortification program. However,
this study was carried
out almost six months after the program implementation. In
general, six months is an
adequate period to improve the iron status of a person with low
hemoglobin if iron
fortified food or supplementation was introduced on regular
basis (Stolzfuss and
Dreyfuss, 1998). Therefore, this study could be considered as
the first monitoring
stage of the entire program.
Objectives of the study This study was undertaken with these two
main objectives:
1- Monitoring the flour fortification program.
2- Establishing a baseline data for monitoring program in
future.
Specific objectives 1- To explore the impact of the iron and
folic acid fortified flour on the Hb status
of Bahraini females at child- bearing age.
2- To assess the knowledge and awareness of Bahraini females
about the fortified
flour program.
3- To explore the public attitudes towards the fortified
flour.
4- To assess the current prevalence of IDA among Bahraini
females at
childbearing age.
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Materials & Methods
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Materials and Methods
The Setting The Kingdom of Bahrain which is situated 20 km east
of the Saudi Arabia, consists of
several islands in the Arabian Gulf with a total area of 706 sq.
km. The population of
the kingdom according to the published report of the Central
Statistics Organization
(CSO) in 2001 was 650,604 of whom 37.6% were expatriates.
Females at
childbearing age (14 49 years) represents about 55.6% of the
whole Bahraini
females. The health services are organized into primary,
secondary, and tertiary health
care, including high technology medicine. Health services are
provided free of charge
to the population. The Kingdom of Bahrain is divided into five
main Governorates,
and there are 4 5 health centers in each governorate, each
health center serves
population according to their catchments area and with a view to
making geographical
access to health services equitable and easier.
Study Population The study population from which the
participants were selected consist of Bahraini
females at childbearing age (14 49 years). This age group
represents the most
vulnerable group to iron deficiency anemia. Non-Bahraini females
were excluded
from this study.
Study Design This study was designed as a cross-sectional study
among Bahraini females.
Sample Size The total sample size was calculated using the
following equation:
N = Z P (1-P)/ d where;
N = the total population.
Z = the standard normal deviate at confidence level (CI )
95%.
P = the prevalence of iron deficiency anemia (IDA).
d = absolute precision.
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Based on 50% prevalence of IDA, and absolute precision of 5%
with 95% confidence
interval, the sample size was calculated to be 378. This number
was multiplied by
10%, allowing for expected drops out, therefore, the number was
increased to 416.
Pulling out the Sample In order to select a representative
sample from all over the kingdom, an official letter
was sent to the Director of the Central Statistic Organization
(CSO) to pull out the
sample. A list of 538 names were obtained from the CSO as they
were randomly
selected by computer from different ages and areas as required
for this study.
Official Procedures As the researchers were asked to visit the
participants in their resident, each of them
was provided with a special identification card (ID) and an
official letter signed by the
Head of Nutrition Section describing the research
objectives.
A special form was also designed in order to obtain the written
consent of the subject
or their parents prior to the interview and withdrawing the
blood sample.
Teams The researchers were divided into teams, each team
consists of two persons, one to
interview the subject and extract the information while the
other is to take the body
measurements and collect the blood sample. Each team was
assigned to a particular
area in the country. In general, we had three teams of surveyors
whom were
responsible to collect the data from the participants from all
areas in the Kingdom.
Package Each team was provided with a research package which
consist of:
1- Name lists of the selected participants with their full
addresses.
2- Questionnaires.
3- Weighing scale (Soehnle).
4- Stadiometer (Seca).
5- Ice box.
6- Needles, vacutainer, vacutainer EDTA, and tourniquet.
7- Cotton, gloves, sterile alcohol swap, and plastic strap
box.
8- Full blood count and immunoassay forms.
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Questionnaire A special questionnaire was developed and prepared
for the purpose of this study. The
questionnaire was divided into four main sections as follow:
Section 1: This section covered the socio-demographical data;
such as date of birth,
educational level, marital status, geographical area, and
monthly family income.
Section 2: This section includes the anthropometrical data.
Weight and height were
recorded in this section, while the body mass index (BMI) was
calculated later and
recorded as well.
Section 3: This section was prepared to collect the personal and
health related data ,
such as: menstrual data, pregnancy, and number of children. In
addition, medical
history such as; previous disease, hereditary diseases,
bleeding, drugs and vitamin
taken.
Section 4: This section was designed to collect data related to
fortification
knowledge, type of flour used at home, dishes made by the flour,
origin country of the
flour, and frequency of consumption of certain types of bread
and food prepared by
the flour.
Data Collection The data collection part was divided into four
main phases as follow:
Phase One (Recruitment phase): Because in this study we aimed to
extract a blood
sample from our participants, we searched for laboratory
technicians to be recruited
for this purpose. In addition, as our participants are females,
the laboratory technician
needed were females as well. As this is more culturally
accepted.
However, in order to select a professional team, a circular was
distributed in the all
health centers introducing the research importance and
describing its objectives and
the needs for professional female laboratory technicians.
Phase Two (Training phase): After the laboratory technicians
were selected (6
laboratory technicians), a special training session was
conducted by a Senior
Nutritionist for all the whole group. The training program was
focused mainly on
taking body measurements (weight and height), interviewing
techniques using the
questionnaire and extracting the information from the
participants, and using the
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address guideline to identify the subjects addresses. Therefore,
the researchers were
the laboratory technicians themselves.
Phase Three (Field work): Interviews were held at the
participants residence. A
special questionnaire was designed and developed for this
purpose, and filled at the
time of the interview by the researchers.
Phase Four (Blood Sampling): A blood sample was obtained from
each subject
participant in the study at the end of the interview. The blood
samples were
transported in sterile container directly to the laboratory in
Salmaniya Medical
Complex in iceboxes for analysis. These were stored at 4C
overnight and analyzed
the next working day.
Duration of Data Collection The data collection part started on
the 1st. of May 2002 and lasted for almost four
months as it was completed on the 20th. of August 2002.
Data Entry All the data were entered and stored on a computer
data base file using SPSS package
(version 11.0 for Windows) by a senior Nutritionist on daily
basis. The blood results
were added to the data as soon as they were received from the
laboratory using ID
number.
Data Analysis Data were analyzed using the same statistical
package (SPSS). Comparison of mean
values between groups was done using the analysis of variance
(ANOVA). For all
tests of statistical significance, a p value < 0.05 was
considered as statistically
significant.
Age of the participants was classified into four groups; < 20
years, 20 29 years, 30
39 years, and 40 years and above.
Hemoglobin concentration (Hb) was categorized into three groups;
< 11.0 g/dl, 11.0
11.9 g/dl, and > 11.9 g/dl. In some parts of the study, and
for certain purpose, the Hb
was classified into two groups; < 12 and 12 g/dl, and the
participants were classified
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as anemic if their Hb level was less than 12 g/dl based on the
World Health
Organization criteria (WHO, 1989).
Blood samples taken from the participants were used for the
measurements of several
biochemical indices including hematologic profile; serum
ferritin, folic acid, vitamin
B12, blood hemoglobin concentration, red blood cell, MCV, MCH,
and MCHC.
The cut-off point used for identification of participants with
anemia was hemoglobin
concentration below 12.0 g/dl. participants were classified as
iron deficient when
serum ferritin concentration was lower than 15.0 g/L based on
the WHO criteria
(WHO, 1998).
Sponsorship This study was partially funded by the World Health
Organization Regional Office
(EMRO), Cairo Egypt as well as by the Ministry of Health,
Kingdom of Bahrain.
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Results
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Results 1- Main Characteristics of the Participants The total
number of the interviewed subjects was 416 participants, however,
23
questionnaires were excluded from the study during data cleaning
and analysis as they
did not meet the study criteria. Therefore, this brought up the
total number into 393
participants in this study.
In table (1) the main characteristics of the participants were
demonstrated. The mean
age was found 30.7 years, while the mean weight and height of
the participants were
77 16.6 kg and 158 6.5 cm respectively. Mean age at menarche was
12.6 1.5
years with a minimum of 9 years and maximum of 20 years.
Table (1): Main characteristics of the Participants
Variable Mean SD Minimum Maximum Age (yrs) 30.7 10.2 14 49
Weight (kg) 77.0 16.6 37 140 Height (cm) 158 6.5 140 195 BMI 27.2
6.4 14.8 48.4 Age at menarche (yrs) 12.6 1.5 9 20 Distribution of
the participants according to their geographical region is
described in
table (2). The percentage of the participants involved in this
study is shown in the
middle column of table (2), whereas the actual proportion of
population in each region
is shown in the last column. However, our participants
represents almost the actual
proportion of population from each region in the Kingdom
according to the CSO
statistics (2001), except the participants from the Riffa area.
In fact, our investigators
faced some difficulties in interviewing the participants from
Riffa as most of them
refused to participate in the study. Therefore, there was a big
difference between the
percentage of the participated participants (3.6%) and the
actual percentage of the
population in Riffa area (10.0%).
Age group, educational level, occupation, marital status, and
family income were
demonstrated in table (3).
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The majority of the participants had education of high school or
below (63.5%) while
28.6% had higher education, and this was expected as 22.9% of
the participants were
less than 20 years of age, mainly at school age. According to
the occupation of the
participants, it was found that most of the participants were
housewives (37.4%),
where students represents 25.4% of the participants. Whereas,
married participants
consist 58% of our participants as shown in table (3). On the
other hand, 54.2% of the
participants belong to low income families (less than BD 300 per
month).
The majority of the participants do not have children or had
never been pregnant
before (47.1%), this could be attributed to the fact that 40.2%
of the participants were
single, as 11.0% of the married participants had no children or
had never been
pregnant.
Table (2): Distribution of the participants according to their
geographical region
Region No. % % (of population)*
Hidd 7 1.8 1.8 Muharraq 62 15.8 15.2 Manama 56 14.2 11.0 Jidhafs
49 12.5 11.3 Northern region 28 7.1 8.0 Sitra 39 9.9 8.0 Isa Town
26 6.6 8.4 Central Region 50 12.7 8.9 Riffa 14 3.6 10.0 Western
Region** 62 15.8 17.3 Total 393 100.0 100.0 * According to CSO
(2001). ** Western region includes Hamad Town.
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Table (3): Socio-demographic characteristics of the
participants
Variable No. % Age: < 20 years 90 22.9 20 29 years 96 24.4 30
39 years 102 26.0 40 years 105 26.7 Total 393 100.0 Educational
Level: Illiterate 30 7.9 High School 242 63.5 > High School 109
28.6 Total 381 100.0 Occupation: Housewife 143 37.4 Employed 102
26.7 Student 97 25.4 Unemployed 40 10.5 Total 382 100.0 Marital
Status: Single 158 40.2 Married 228 58.0 Divorced 4 1.0 Widow 3 0.8
Total 393 100.0 Family Income: Low (< 300 BD) 195 54.2 Medium (
300 700 BD) 129 35.8 High ( > 700 BD) 36 10.0 Total 360 100.0
Parity: None 185 47.1 1 4 126 32.0 5 and more 82 20.9 Total 393
100.0
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2- Iron Status Blood sample was extracted from each subject for
hematological and biochemical
analysis and the results were summarized in table (4). For
hematological analysis,
only hemoglobin concentration was found to be lower than the
cut-off point with a
mean of 11.9 1.2, while all other results were within the normal
range. Figure (1)
shows the distribution and frequency of hemoglobin among our
participants.
Serum Ferritin level of the participants in this study shows
vast variations; the
minimum found to be 0.5 g/L while the maximum was 311 g/L with a
mean of 30.4
and standard deviation 32.7. However, figure (2) shows the
distribution and
frequencies of SF.
Table (4): Hematological and Biochemical Analysis of the
participants
Variable No. Mean SD Min. Max. Normal range Hb (g/dl) 393 11.9
1.2 7.8 15.4 12 14.5 RBC ( x 10^12/1) 392 4.7 0.5 2.8 - 6.5 3.9 5.2
MCV (fl) 392 76.6 8.9 6.8 95.0 82 97 MCH (pg) 392 25.6 4.1 17.0
72.1 27 33 MCHC (g/dl) 392 33.1 1.4 22.3 50.4 32 36 SF (g/L) 384
30.4 32.7 0.5 311 7 282 Folic Acid (nmol/L) 381 24.7 7.2 7.0 45.3
6.6 28.1 Vitamin B12 (pmol/l) 384 290 160 39 - 1475 133 - 835 In
order to explore the hemoglobin concentration among different age
group, the
participants were grouped into four groups and correlated with
the hemoglobin
concentration (table 5). The mean hemoglobin for most age groups
were almost
similar (11.9 1.1), however, this result confirm that among
females from different
age groups, the hemoglobin status is need to be corrected as it
is still low.
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Hemoglobin Level (g/dl)
15.5015.00
14.5014.00
13.5013.00
12.5012.00
11.5011.00
10.5010.00
9.509.00
8.508.00
Hemoglobin Level (g/dl)
Freq
uenc
y
80
60
40
20
0
Std. Dev = 1.18 Mean = 11.92
N = 393.00
Figure (1): Frequency distribution of hemoglobin level with a
normal curve of the participants
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Serum Ferritim Level (ug/L)
300.0280.0
260.0240.0
220.0200.0
180.0160.0
140.0120.0
100.080.0
60.040.0
20.00.0
Serum Ferritim Level (ug/L)
Freq
uenc
y
100
80
60
40
20
0
Std. Dev = 32.69 Mean = 30.4
N = 384.00
Figure (2): Frequency distribution of Serum Ferritin level with
a normal curve of the participants
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Table (5): Distribution of the participants according to
their
Hb level and age group Age group No. Hb (g/dl)
Mean SD*
Minimum Maximum
< 20 years 90 11.9 1.2 8.2 14.3 20 29 years 96 11.9 1.1 9.0
14.1 30 39 years 102 11.9 1.1 8.3 14.9 40 years 105 12.0 1.3 7.8
15.4 Total 393 11.9 1.2 7.8 15.4 * No significant differences
between the different groups. The participants were distributed
according to their geographical region as shown in
table (6). The hemoglobin level of the participants was
correlated according to the
geographical region. Participants from Muharraq region showed a
significantly higher
mean hemoglobin concentration (12.3 1.4) than Manama, Jidhafs,
Northern region,
Sitra, Central region, Riffa, and Hamad town (P value <
0.05). There were no
significant differences between other regions. There was no
significant difference
among other regions (Table 6).
Table (6): Distribution of the participants according to
their
Hb level and geographical region Region No. Hb (g/dl)
Mean SD
Minimum Maximum
Hidd 7 11.8 1.5 9.4 13.6 Muharraq 62 12.3* 1.4 9.0 14.9 Manama
56 11.9 1.0 9.2 14.5 Jidhafs 49 11.9 1.2 8.5 14.3 Northern Region
28 11.7 0.7 9.8 13.0 Sitra 39 11.7 1.1 9.4 13.7 Isa Town 26 12.0
1.0 9.5 13.5 Central Region 50 11.8 1.3 7.8 15.4 Riffa 14 11.5 1.7
8.1 13.7 Hamad Town 48 11.8 1.0 8.2 14.2 Western Region 14 12.1 1.3
10.3 13.5 Total 393 11.9 1.2 7.8 15.4 * The mean difference is
significant at P < 0.05 than Manama, Jidhafs, Northern region,
Sitra, Central region, Riffa, and Hamad Town.
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In addition, in order to explore the relationship between the
hemoglobin and serum
ferritin levels of the participants, both were correlated as
shown in table (7). It was
found that there is a significant statistical difference (P <
0.05) between the
hemoglobin group and serum ferritin level. Participants with low
hemoglobin had
lower serum ferritin level, as hemoglobin level increases the
serum ferritin increase.
The impact of this result emphasis on the contribution of iron
deficiency on anemia
status.
Table (7): Relationship between the participants Serum Ferrtin
level and Hemoglobin groups
Hb group No. SF (g/L)
Mean SD
Minimum Maximum
< 11.0 g/dl 73 24.7 34.4 0.5 217.0 11.0 11.9 g/dl 124 26.2
28.0 0.7 203.0 12.0g/dl 187 35.1* 34.3 1.3 311.0 Total 384 30.3
32.7 0.5 311.0 * The mean difference is significant at P < 0.05
than Hb groups < 11.0 g/dl and 11.0 11.9 g/dl.
In table (8) iron status of the participants was analyzed using
dual criteria;
hemoglobin and serum ferritin. It shows the prevalence of iron
deficiency measured
by serum ferritin concentration and the prevalence of anemia
measured by
hemoglobin concentration. The cut-off point used for low
hemoglobin concentration
was set to < 12 g/dl and for low serum ferritin was < 15
g/L according to the WHO
recommendation. Consequently, it was found that 24.5% of the
participants were
suffering from iron deficiency anemia (low in both hemoglobin
and serum ferritin
concentrations). On the other hand, the majority of the
participants (51.3%) were
classified as anemic (low hemoglobin concentration), whereas
35.4% of them were
iron deficient (Serum ferritin lower than 15 g/L).
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Table (8): Classification of Iron Status using Hemoglobin
concentration and Serum Ferritin level
Hb Category Serum Ferritin level
< 15 g/L 15 g/L
Total
Hb < 12 g/dl 94 (24.5%) 103 (26.8%) 197 (51.3%) Hb 12g/dl 42
(10.9%) 145 (37.8%) 187 (48.7%) Total 136 (35.4%) 248 (64.6%) 384
(100%)
The folic acid status of the participants was correlated with
the hemoglobin
concentration as shown in table (9). There was a statistically
significant difference (P
< 0.05) between the low hemoglobin and folic acid status.
Participants with
hemoglobin concentration 11.0 g/dl had lower folic acid than
participants with
hemoglobin concentration 11.0 11.9 g/dl. Furthermore,
participants with
hemoglobin concentration 12 g/dl had higher vitamin B12 level
than participants
with lower hemoglobin at P value < 0.05 (Table 10).
Table (9): Relationship between the participants Folic acid
level and Hemoglobin groups Hb group No. Folic Acid (nmol/L)
Mean SD
Minimum Maximum
< 11.0 g/dl 73 23.0 7.6 8.5 44.1 11.0 11.9 g/dl 123 25.5* 7.1
9.3 45.0 12.0g/dl 185 24.8 7.2 7.0 45.3 Total 381 24.7 7.2 7.0 45.3
* The mean difference is significant at P < 0.05 than Hb group
< 11.0 g/dl.
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28
Table (10): Relationship between the participants Vitamin B12
level and Hemoglobin groups
Hb group No. Vit. B12 (pmol/l)
Mean SD
Minimum Maximum
< 11.0 g/dl 72 279.8 196.7 49 1475 11.0 11.9 g/dl 125 269.0
144.1 39 921 12.0g/dl 187 307.5* 155.6 64 992 Total 384 289.7 160.2
39 1475 * The mean difference is significant at P < 0.05 than Hb
group 11.0 11.9 g/dl. 3- Socio-Demographic Risk Factors for Iron
Deficiency and Anemia Socio-demographic factors that may considered
as risk factors of iron deficiency and
anemia such as age, educational level, occupation, marital
status, education, family
income, and parity among our participants, were correlated with
the hemoglobin
concentration and serum ferritin level are shown in tables (11)
and (12).
The hemoglobin concentration was positively correlated with
serum ferritin
concentration in the participants with different iron status
(Table 11). Among anemic
participants, hemoglobin concentration is significantly
correlated with the occupation
of the subject at level < 0.05.
Serum ferritin concentration was correlated with some risk
factors to develop iron
deficiency anemia (Table 12). Marital status was found
positively correlated with the
serum ferritin concentration among iron deficient participants
at level < 0.05.
Moreover, in anemic participants, occupation and parity were
significantly correlated
with the serum ferritin concentration at level < 0.01 and
< 0.05 respectively.
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29
Table ( 11): Correlation coefficient between the participants Hb
concentration and some risk factors related to Iron
Status Factor Iron Deficient Anemic Non-Anemic Serum Ferritin
0.251* - 0.432** 0.178* Age 0.019 0.129 0.002 Occupation 0.048 -
0.182* - 0.002 Marital status 0.002 0.107 0.063 Education 0.196
0.058 0.019 Family Income 0.18 0.032 0.005 Parity - 0.114 - 0.041
0.09 * Correlation is significant at the 0.05 level (2-tailed). **
Correlation is significant at the 0.01 level (2-tailed).
Table ( 12): Correlation coefficient between the participants SF
concentration and some risk factors related to Iron
Status Factor Iron Deficient Anemic Non-Anemic Age 0.169 0.014
0.154 Occupation - 0.072 0.199* - 0.015 Marital status 0.282* 0.014
0.074 Education 0.195 - 0.158 - 0.295* Family Income 0.011 - 0.032
- 0.081 Parity 0.142 0.166** 0.085 * Correlation is significant at
the 0.01 level (2-tailed). ** Correlation is significant at the
0.05 level (2-tailed).
In order to explore the relationship between different blood
indices and their effect on
the iron status, blood indices of the participants were
correlated using 2-tailed correlation coefficient analysis (Table
13). Serum ferritin was significantly correlated
with hemoglobin concentration at level 0.01, but was not
correlated with folic acid
and vitamin B12. Furthermore, hemoglobin concentration was
positively correlated
with vitamin B12 at the 0.05 level.
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30
Table (13): Correlation coefficient between the participants
various blood indices
Variable Serum Ferritin Hemoglobin Folic Acid Vitamin B12 Serum
Ferritin 1 0.206* - 0.053 0.041 Hemoglobin 0.206* 1 0.015 0.133**
Folic Acid - 0.053 0.15 1 0.138* Vitamin B12 0.041 0.113** 0.138* 1
*Correlation is significant at the 0.01 level (2-tailed). **
Correlation is significant at the 0.05 level (2-tailed). 4- Current
Study vs. National Nutrition Survey (NNS)
The data related to the hemoglobin concentration collected in
this monitoring study
was compared with the data from the NNS (Moosa, 2002). Table
(14) summarize the
comparison between both studies according to hemoglobin
concentration among
different age groups. It was found that the data from both
studies were almost similar,
however, there was no significant difference in hemoglobin
concentration between
them.
Table (14): Comparison of Hb level by age group between the
current study and the NNS*
Age group Current Study**
No. % Mean SD NNS*
No. % Mean SD 19 29 yrs 122 37.1 11.9 1.1 195 33.4 11.7 1.3 30
39 yrs 102 31.0 11.9 1.1 205 35.1 12.0 1.6 40 49 yrs 105 31.9 12.0
1.3 184 31.5 11.9 1.5 Total 329 100 11.9 1.2 584 100 11.8 1.5 *
NNS: National Nutrition Survey (Moosa, 2002). ** Participants aged
less than 19 years were excluded.
Furthermore, low hemoglobin concentration in both studies were
compared, although
the prevalence of low hemoglobin in the current study was higher
than in NNS, but
the mean of low hemoglobin in the current study was
statistically different than mean
hemoglobin in NNS at P value < 0.05 (Table 15).
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31
Table (15): Comparison of low Hb level (< 12 g/dl) between
the current study and the NNS
Study No. % Mean SD* Minimum Maximum Current study 202 51.4 11.0
0.8 7.8 11.9 NNS 262 34.6 10.7 0.9 7.0 11.9 * The mean difference
is significant at P < 0.05 between both studies.
5- Awareness Regarding Flour Fortification Program The
participants were asked if they know the meaning of fortification
or if they have
any information about the flour fortification program or had
heard about it.
Unfortunately, the majority of the participants (85.5%) stated
that they do not know
the meaning of fortification is and had never heard about the
fortification program
(table 16). On the other hand, with reference to the most
consumed type of flour at
home, 68.4 % of the participants stated that the multipurpose
flour (extraction rate
75%) is the most consumed type of flour, while 17.8% reported
that they do not know
the type of flour they use.
About 62% of the participants knew the country of origin of the
flour purchased or
consumed at home, as the majority reported that Bahrain is the
country of origin
(88.4%). When participants were asked about the most type of
dishes prepared at
home by the flour, they reported that the most dishes were
sweets, cakes, and pastries
(57.5%, 22.1%, and 17.1% respectively).
Table (17) demonstrates the most frequent types of bread and
derivatives consumed
by the participants. The majority of the participants (62.6%)
consume the Tanoor
bread (the traditional bread) on daily basis (this type of bread
is mostly prepared by
flour No. 1 which is extracted by 78% and fortified by iron and
folic acid). On the
other hand, 47.3% of the participants consume the Western bread
type (mainly sliced
bread) on daily basis. Moreover, 30.8 % consume pizza once a
week, 17.8% for both
Arabic bread and rusks, while 14% and 10.9% consume Chappatti
(Indian bread) and
Turkish bread once a week.
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32
Table (16): Participants Knowledge about the Flour Fortification
Program
Variable No. %
Knowledge about the Program: Know 57 14.5 Do not Know 336 85.5
Total 393 100.0 Type of most used Flour: Multipurpose 269 83.3
Flour No. 2* 26 8.0 Flour No. 1** 9 2.8 Others*** 19 5.9 Total 323
100.0 Country of Origin: Yes 242 61.6 No 151 38.4 Total 393 100.0
Name of the Country: Bahrain 214 88.4 Saudi (KSA) 12 5.0 Kuwait 10
4.1 USA 6 2.5 Total 242 100.0 Dishes Made by Flour: Sweets 172 57.5
Cakes 66 22.1 Pastries 51 17.1 Others 10 3.3 Total 299 100.0 *
Flour No. 2 with extraction rate of 86% ** Flour No. 1 with
extraction rate of 78% *** Others includes: American flour, Kuwaiti
flour, Saudi flour, and flour 1&2 together.
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33
Table (17): Types and Frequency of Consumed Bread by the
participants
Type of Bread Frequency No. %
Tanoor Bread* Daily 246 62.6 Western Bread Daily 186 47.3 Pizza
Once a week 121 30.8 Arabic Bread Once a week 70 17.8 Rusks Once a
week 70 17.8 Chappatti** Once a week 55 14.0 Turkish Bread Once a
week 43 10.9 *Tanoor Bread is the traditional bread consumed in
Bahrain. ** Chapptti is the Indian type of bread.
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34
Discussion
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35
Discussion Introduction Iron deficiency with or without anemia
is the most common nutrient deficiency in the
developing world, whereas women of childbearing age are at
greatest risk because of
the effects of menstruation and pregnancy (Patterson et al.,
2001)
Furthermore, micronutrient deficiencies especially iron; still
represent significant
problems in the Kingdom of Bahrain among women of reproductive
age. An
estimated 40% of the pregnant mothers attending MCH suffer from
iron deficiency
anemia and/or iron deficient (Moosa and Zein, 1996).
Important risk factors for iron deficiency and anemia among
Bahraini women of
childbearing age are mainly dietary habits, noncompliance of
women in taking the
iron supplements, infections, and hereditary diseases.
Overall, the prevalence of iron deficiency anemia in the Kingdom
of Bahrain is
relatively high compared to the international rates and
standards, especially among
women of reproductive age. Among adult women, iron deficiency
was found to be
responsible for lost productivity and premature death (Wu et
al., 2002). It is also
implicated as a cause of perinatal complications such as low
birth weight and
premature delivery in affected mothers (CDC, 2002).
Therefore, in order to prevent, control and compact this health
problem and its series
consequences, Nutrition Section (Ministry of Health) initiated a
National Program
to reduce the prevalence rate of anemia and iron deficiency
anemia by flour
fortification with iron and folic acid (according to the WHO
recommendations).
Along with this study, we are attempting to set up a
surveillance system by
implementing a national survey (system) to monitor the flour
fortification program
and track the micronutrients status of targeted population. Our
participants; females at
childbearing age, represents the most vulnerable group in the
community to develop
anemia and /or iron deficiency anemia.
The flour fortification program was implemented in the Kingdom
of Bahrain in
November 2001, while this study was carried out almost six
months later. However, it
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36
could be considered as the first monitoring study for the
planned surveillance system.
In general, six months period could be an adequate period to
improve the iron status
in the body of a person with iron deficiency if the intake of
supplements and fortified
foods was on a regular basis (Stolzfus and Dreyfuss, 1998; WHO,
1989). However, in
very severe cases of iron storage depletion, recovery may take
longer period and it
may need further intervention with certain iron supplementation.
Conversely, in
Venezuela, Garcia-Casal and Layrisse (2002) found a striking
reduction in the
prevalence of iron deficiency and anemia after 2 years of
fortification.
One of the most common and important strategies for the control
of iron deficiency
anemia worldwide is fortification. Fortification of an
appropriate food vehicle with
specific nutrients has been practiced in numerous industrialized
countries for many
years with considerable success (Darnton-Hill et al., 1999).
Fortification efforts have
in the past been less effective, in term both of start-up and of
sustainability, in
developing countries compared with the more industrialized world
( Hurrell, 1997).
Fortification of staples (e.g., wheat flour) is a cost-effective
and feasible strategy, but
regular monitoring is required to demonstrate effectiveness and
ensure quality (Yip
and Ramakrishnan, 2002).
Darnton-Hill et al. (1999) demonstrated that fortification has
also been identified as
one of the most cost-effective and sustainable approaches to
controlling iron
deficiency anemia. With improved iron status, gain in
productivity have been shown
to increase by 10% to 30% (Darnton-Hill et al., 1999).
It was well known, since the late 40s of the last century, that
fortification of cereal
flour is one of the most useful public health strategies to
control certain deficiencies.
In addition, flour fortification with iron and other vitamins
was also reported to be of
great impact on reducing the incidence of iron deficiency
(Beinner and Lamounier,
2003).
Moreover, Yip and Ramakrishnan (2002) reported that
fortification is probably the
most efficient method to improve the iron status even though it
is not specific for
women; men and children will also benefit.
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37
The elemental iron powders have been used for cereal
fortification for more than 50
years and continue to be the most widely used iron compound for
this purpose
(Hurrell, 2002). On the other hand, Uauy et al. (2002) argued
that elemental iron
despite being very compatible with most food matrixes is very
poorly absorbed and,
thus, is not useful even at high levels of fortifications
Nevertheless, for successful iron fortification, it is important
to select food vehicles
that are consumed daily, to choose an iron compound that is well
absorbed, and to
maintain control of the enrichment (INACG, 1993; INACG,
1982).
In the Kingdom of Bahrain, all the above premises have been
fulfilled for the
fortification program. The flour was fortified with 60 ppm of
elemental iron and
15 ppm of folic acid based on the WHO recommendation. Therefore,
we selected the
elemental iron because it is most stable form at a very high
temperature and humidity.
Consequently, the entire population (except infants) consumes
the bread made by the
fortified flour. On the other hand, many authors have
demonstrated the iron
bioavailability restrictions of the elemental iron (Hurrell,
2002; Uauy et al. 2002).
Conversely, the industrialized process of fortifying flour
allows full control of the
ingredients.
Furthermore, there are some major technical constrains when
cereals are selected as
vehicles for fortification: high levels of phytic acid was
considered as a main
constrain. However, to overcome this obstacle in Bahrain, it was
recommended to
fortify the flour with extraction rate less than 80% (i.e. less
phytate).
Although, Martorell (2002) argued that in the Middle East, it is
well-established that
most of the anemia is due to iron deficiency. Yip and
Ramakrishnan (2002) showed
that in most industrialized areas, iron deficiency among women
of reproductive age is
more likely to be due to increased blood loss than to poor
diet.
Iron Status Based on our results, table (8) shows the results of
the survey carried out on the
prevalence of iron deficiency measured by serum ferritin
concentration and the
prevalence of anemia measured by hemoglobin concentration.
Accordingly, the
prevalence of IDA among our population group did not show any
changes when it is
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38
compared with previous studies (Moosa, 2002). However, the
prevalence of IDA
raised by 16.8%. Conversely, the iron status reflected by mean
serum ferritin showed
slight progress.
As indicated by Fleming et al. (2001), hemoglobin concentration
is the last iron index
to change in uncomplicated iron deficiency, and thus it may not
provide information
about early stage of iron storage depletion, which is reflected
by decreased serum
ferritin concentration.
In Venezuela, according to Garcia-Casal and Layrisse (2002),
they found that there
was a striking reduction in the prevalence of iron deficiency
and anemia after two
years of fortification program implementation. Therefore, we
believe it is still early
and very unlikely to drop out a conclusion about the effect and
feasibility of the
fortification program in Bahrain.
In Sweden, at least 25% of the decline in prevalent of iron
deficiency was attributed to
iron fortification (Martorell, 2002), while the reminder was
attributed to greater
prescription of iron tablets, and use of ascorbic acid
supplements, highlighting the
need for multiple strategies to prevent iron deficiency.
Therefore, we should not
depend entirely on the fortification program to eradicate or
reduce the incidence of
anemia or iron deficiency. Moreover, where other strategies must
be implemented in
line with fortification like routine screening, supplementation
programs, and dietary
diversification program.
Nevertheless, anemia of this type in this population group
(females of childbearing
age) was diagnosed to be due to iron deficiency. It is therefore
possible to conclude
that the amount of iron is not the limiting factor causing IDA;
rather its absorption is
the problem.
An analysis of the diet of Bahraini population (Moosa, 2002),
revealed that indeed the
main sources of iron were meat and fish, with negligible
participation of fruits and
vegetables and other foods of animal source. In fact, these
foods are considered as
good sources of quality iron and iron absorption enhancers.
However, it was found
that the consumption rate of these foods were not high enough in
our community.
Furthermore, Bahrainis dietary behavior consists of a lot of bad
habits, as it contains
many iron absorption inhibitors such as phytic acid and
polyphenols. The influence of
the diet composition on enhancing or inhibiting iron absorption
has been well
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39
documented and summarized by Hernnandez et al., (2003) and
Layrisse and Garcia-
Casal (1997).
Hallberg and his colleagues (1998) have analyzed the influence
of diet composition in
iron absorption and storage in the liver. They estimated that
vegetarian diet with large
amounts of cereals and legumes limit iron bioavailability to 25
g/kg of food per day.
Comparatively, they also estimated that in the primitive diet of
early humans, which
was mainly based on meat and fish, iron absorption was 15%,
which caused liver
storage of 500 mg (Hallberg et al., 1998).
Other important conclusions included that the steady-state level
or iron storage is
determined by iron bioavailability, and that any change in the
quality of the diet
affects this parameter within the first year. Therefore, any
effectiveness evaluation of
a food fortification program should be monitored mainly during
its first year (Dary,
2002b).
The diagnosis of iron deficiency is often prompted by historical
features and aided by
specific clinical and laboratory data. Thorough history taking
is an essential part of
discovery and management. Dietary history may provide evidence
supporting iron
deficiency. Specific dietary practices such as consume less rich
iron sources, consume
more iron absorption inhibitors, and lack of iron
supplementation. On the other hand,
Wu et al. (2002), suggest that history alone neither confirms
nor rules out the
presence of iron deficiency but may help to identify those at
low risk, thus avoiding
unnecessary screening.
Impact of Fortification Program on the Prevalence of Iron
Deficiency and Anemia
The amount of fortified flour consumed by target individuals at
the household level is
an important issue. Do women at reproductive age, the group at
highest risk of iron
deficiency anemia, eat enough processed wheat products at
regular intervals to justify
a fortification intervention? In general, low socioeconomic
status remains a predictor
of community rates for iron deficiency, even in countries where
iron fortification is
widespread and has been successful in reducing iron deficiency.
Members of the
poorer socioeconomic strata generally consume fewer meat
products.
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40
The second issue is the consumption of iron absorption
enhancers. Among this
population the consumption of meat and fruits found to be very
low as found in the
NNS findings (Moosa, 2002), especially among those who belong to
low
socioeconomic group and to large families usually do not get
their iron requirements.
It was well documented by many investigators, that in
lower-income groups,
reduction in the quality and quantity of food consumption,
characterized by a lower
intake of meat, vegetables, fruits, as well as cereals, grains,
and tubers may lead to
decrease in dietary iron intake.
Wheat flour and its products are the most frequent fortified
foods, mainly with
reduced iron, which has low bioavailability (Fritz et al., 1970;
Forbes et al., 1989).
Whereas, studies in Venezuela (Layrisse and Garcia-Casal, 1997;
Layrisse et al.,
1996) have reported that fortification of wheat and corn flour
with ferrous fumarate is
more successful than with other iron sources.
Our results confirmed the findings reported by others that
ferrous sulfate is well
utilized when added to wheat flour (Fritz et al., 1975).
However, it is not a suitable
sources of iron fortification because it easily oxidizes the
food matrix, affecting its
shelf-life and acceptability in storage (Hurrell et al.,
1989).
This finding is contradictory to those reported by others who
found a better iron
availability from diets with high iron content.
In Bahrain, the fortified flour (with iron and folic acid)
supplies the body with only
25% of its daily iron requirements. However, this means that the
other 75% of the
body iron requirements should be supplied by other sources,
especially animal
sources. Consequently, the intention of fortification was not to
overcome the problem
of anemia and iron deficiency, but as a part of a multi-national
program to reduce the
magnitude of the problem. On the other hand, the diet in Bahrain
based on rice, meat,
fish, and bread, with a very small proportion of foods from
vegetable origin. Based on
the composition of this diet, it is possible to estimate that
the amount of iron supplied
is sufficient to cover the recommended nutrient intake
(RNI).
For example, by analyzing the consumption and nutritional
composition of the daily
micronutrient intakes of the Bahraini adult females' diet, it is
calculated that on
average their diet provides between 83.8% to 117.2% of the RNI
for iron (Moosa,
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41
2002). It is therefore difficult to explain through a dietary
analysis why iron
deficiency anemia is so prevalent and extended in Bahrain.
Consequently, there is
only one explanation for this, it could be attributed to the low
iron bioavialability.
However, Dary (2002b) showed that in this case the improvement
of iron status owing
to the consumption of iron-fortified flours was not determined
either.
In spite of all efforts done before, during, and after the flour
fortification with iron and
folic acid program including education and marketing, the
Bahraini population is still
suffering from iron deficiency anemia. There are many reasons to
explain this
situation, including of course that the implemented
fortification program is still in
progress as the results are considered as provisional outcome,
and because of the short
period between the implementation and conducting this study.
Moreover, it is obvious
that large sectors of the population are not consuming
sufficient amount of the
fortified foods as well as iron absorption enhancers, and other
iron rich sources. In
addition, it might also be that the bioavailability of iron in
the food they most
consume is low.
Darnton-Hill (1998) explained this as there are two main issues
regarding
consumption of wheat flour. One is the larger question of
whether wheat flour
products are consumed, and to what extent, by a target
population. In our study, it was
shown that most of the participants (62.6%) consume the
traditional bread (Tanoor)
which is made by fortified flour on daily basis, even though the
prevalence of IDA
still high. Consequently, this finding confirm the fact that
consuming fortified
products by itself without giving little concern to consume
other rich iron sources
and/or enhancers, will never correct the iron status among all
age groups in the
community.
A very important point, since the fortification program was not
intended for a specific
group of population; in fact small children do not eat staple
foods (bread) in sufficient
amount. Hence, they will continue to be at risk of suffering
IDA, despite the existence
of food fortification programs with good coverage and good iron
quality. This
problem, however, could be overcome easily by introducing a good
screening
program for this age group along with iron supplementation
(Nutrition Section future
plans).
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42
In addition, it is worth mentioning that the bioavailability of
elemental iron in its best
form (electronic iron) is usually half that of ferrous sulfate
(Dary, 2002b). Therefore,
in the Kingdom of Bahrain it is used in double the amount, which
was recommended
by the WHO for ferrous sulphate (ferrous sulphate 30 ppm while
ferric sulphate 60
ppm).
Furthermore, it is well known that iron fortification of staple
foods would benefit
large segments of the population, but it would be very difficult
to solve iron
deficiency entirely, mainly owing to levels of iron that these
foods allow (Dary,
2002b).
The flour fortification program implementation with elemental
iron and folic acid in
Bahrain did not cause any kind of adverse complications, such as
taste, texture, color,
smell, and even the price of the bread did not affected as the
flour is subsidized by the
government.
Although in our study we concluded that the prevalence of IDA
was higher than in the
NNS (Moosa, 2002), it was clear that, the implementation and
consumption of the
fortified flour gave a small but statistically significant
increase in the hemoglobin
concentration (0.3 g/dl) after only six months of
implementation. Elwood and
colleagues (1971) support our finding. In their study, Elwood et
al. (1971) found that
neither trial provided conclusive evidence of any beneficial
effect of wheat
fortification on iron status, even though the reduced
iron-fortified bread gave a small
but statistically significant increase in hemoglobin (0.24 g/dl)
after nine months of
intervention.
Unfortunately, there is only one published study reporting
improved iron status in a
population fed regularly with an elemental iron-fortified
cereal, this study was
conducted among infants in Chile (Walter et al., 1993). Walter
and his colleagues
(1993) concluded that cereal fortified with electrolytic iron
could contribute
substantially to preventing IDA. Whereas this is true, it should
be emphasized that
IDA was not eradicated completely in Chile according to Walter
and colleagues' study
even though the cereal provided an extra 14 to 17 mg iron per
day.
Moreover, the Central American population is still suffering
from IDA in spite of all
efforts in food fortification with iron (Dary, 2002a). He argued
that, there are many
reasons to explain this situation, including of course that the
implemented fortification
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43
programs have been unsuccessful. Dary (2002a) also reported
that, it is obvious that
large sectors of the Central American population are not
consuming sufficient amount
of the fortified food, but it might also be that the
bioavailability of iron in those foods
is low.
Ultimately, the usefulness of elemental iron for food
fortification depends on the
ability of the fortified food, when consumed as part of the
normal diet, to prevent iron
deficiency in at-risk population group (Hurrell et al.,
2002).
The bioavailability or efficacy of this product, however, has
not been tested in
Bahrain. Bioavailability and/or efficacy tests of the fortified
products will be
important in guiding policy on these products.
Strengthening of both program monitoring and evaluation is
required to generate
proper data for decision makers, in terms of both policy and
program improvement,
and to assess the effectiveness of intervention strategies
(Winichagoon, 2002).
The result of this study suggests that dietary treatment of iron
deficiency is feasible
for women of childbearing age. It also emphasizes on the fact
that flour fortification
program somehow improved the iron status for a certain limit of
the population of this
study after six months only of the implementation of flour
fortification program.
Therefore, this may lead us to conclude that continuity of the
fortification program
with continuous monitoring may help to reduce the prevalence of
IDA among this age
group. In fact, the findings of this study are supported by
Darys (2002a) assumption that iron deficiency in many developing
countries is usually a problem of iron quality
rather than iron quantity.
Hurrell et al. (2002) argued that the elemental iron powders are
less well absorbed
than soluble iron compounds and they vary in their absorption
depending on
manufacturing method and physiochemical characteristics. This
argument emphasizes
on the importance of educating the people not to depend merely
on the fortified flour
to correct their iron status. Therefore, encouraging them to
consume more iron
absorption enhancers and to give up the bad dietary habits which
are considered as a
crucial technique.
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44
Fortification and Public Awareness Although a condensed national
educational and marketing campaign was conducted
for the public prior to and after the implementation of the
fortification program, it
seems from this study that this campaign did not achieve its
goals and objectives.
Based on our results, awareness of fortification and the
importance of avoiding iron
absorption inhibitors were very low among our population.
Whereas, the results
acquired from this study show that only 15% of the study
population are aware of the
fortification program, or the meaning of the word
"fortification" itself.
Moreover, the majority of them knew very little about the
consequences of anemia or
even IDA. In the United States (CDC, 1998), the public health
approaches of
education and iron fortification had a great success in reducing
the prevalence of
anemia in women at reproductive age. Consequently, this could
put on our burden
more obligations to condense and spread the education for the
whole population
groups.
Iron deficiency and anemia occur in this population group within
a dietary context
that is much constrained by dietary habits, economic and
environmental conditions
that limit proper iron intake and absorption.
Another issue relating to fortification, as described by Yip and
Ramakrishnan (2002),
is the concern that people in the target population may not
consume enough of the
fortified food, such as iron-fortified wheat flour. However,
even a low consumption of
fortified wheat flour is likely to provide a significant
increase in iron intake. Whereas,
in such small population like Bahraini population, the iron
fortified flour is consumed
by almost all the population sectors for a very simple reason.
This is because in
Bahrain there is only one Mill Company, this company is
responsible for supplying
almost 80% of the bakeries in the country with the fortified
flour for different uses
and purposes. Recently, HE Minister of Trade issued a resolution
stated that All
imported flour should be fortified with iron, otherwise, it well
be rejected.
Therefore, this means that we are quite confident that all the
flour used in Bahrain for
preparing the bread and its derivates (products) is fortified.
Therefore, this fact
confounds the above assumption.
Overall, in the Kingdom of Bahrain, the apparent lack of effect
of the fortification
program on anemia prevalence has several reasons: first is the
short period between
-
45
the monitoring study and the implementation of the fortification
program, and second
is the lack of awareness, high intake of iron absorption
inhibitors, and continuity of
certain dietary habits.
-
46
Conclusion
-
47
Conclusion
The fortification of flour with iron and folic acid in the
Kingdom of Bahrain is
considered as a big challenge for many reasons. Actually, it
went through various
stages and faced several difficulties and barriers. These
barriers were within the
Ministry of Health and other related governmental organizations;
mainly convincing
policy makers as well as convincing the millers about the
importance and urgent
needs for the fortification program. Therefore, the
implementation of the program by
itself could be considered as a huge victory for the Nutrition
Section. In fact, the
process of iron fortification was introduced with a multiphase
system in order to
check for its efficacy and effectiveness by the time.
Fortification is the beginning
phase of this system, which will be an ongoing system.
However, the results of this monitoring study showed for a
certain extent a slight
improvement in the hemoglobin concentration and iron status of
the population
investigated. Although, there were some unexpected or
frustrating findings, these
could be translated as positive results to be used in future for
planning of more
effective and accurate programs and studies.
On the other hand, to really overcome iron deficiency, any
fortification program
should be complemented with the implementation of other
interventions. In this
context, most of the reviewed articles, emphasized on the
importance of the
monitoring program during the first year of fortification. In
addition, it is very
difficult to come up with a conclusion from this first stage,
which is actually six
months period of post fortification implementation as it is too
short to draw up a
conclusion.
In general, the monitoring program will be continued and the
data of this study will be
used as a reference to evaluate the entire program.
-
48
Recommendations
-
49
Recommendations
In order to overcome the barriers facing the fortification
program to achieve its
intended purpose of reducing the prevalence of IDA and improve
the iron status of the
Bahraini population, and according to the outcomes of this
study, we recommend the
following:
1- The composition of the natural diet must improve because the
presence of iron
inhibitors is the main constraint to enhancement of iron
absorption. Inclusion
of meat is very important in the diets of developing
countries.
2- Nutritional education is essential to achieve a good impact
of food fortification
programs, promoting simultaneously the composition of iron
absorption
enhancers (such as ascorbic acid and red meat) and avoiding iron
inhibitors
(tea and coffee, for example).
3- Strengthening other strategies to complement the
fortification program; such
as supplementation program for vulnerable groups as well as
screening
program and dietary diversification.
4- Further studies and investigations should be carried out in
the future.
5- One of the most important issues, regulatory monitoring is
required to
demonstrate effectiveness and ensure quality.
-
50
Appendices
-
15
eriannoitseuQ ydutS :)1( XIDNEPPA
-
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-
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-
35
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-
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-
55
References
-
56
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First Published 2003 by Ministry of Health Kingdom of
Bahrain
Impact of the National Flour Fortification Program on the
Prevalence of Iron Deficiency and
Anemia among Women at Reproductive Age in the Kingdom of Bahrain
(First Monitoring
Study).
1. Flour Fortification 2. Iron Deficiency Anemia 3. Monitoring
Study I. Title II. Al-Dallal, Z. S. III. Moosa, K. H. Bahrain
Public Library, 3752 / Dal Ain / 2003 ( . .3752 / 2003 ) ISBN 99901
18 - 09 - 4