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Abstrak :
Iron deficiency anemia is prevalent in Indonesia (38-71%), particularly among the pregnant women, despite of the large scale anemia control program launched by the government since 1970’s. The anemia control program included iron supplementation, nutrition education, food fortification, and parasite control. The results of the iron supplementation program is not yet as expected. Low compliance in taking iron pills was a reason suspected as the cause of the unexpected results. Several methods had been studied to increase the number of iron pills intake. However, the synthesis of hemoglobin is not only dependenton iron from the pills but also requires other blood forming nutrients from the diets. A two phase descriptive study was conducted to study the factors influencing the iron status of pregnant women in the second trimester participating in the National Anemia Control program in three subdistricts of Bogor district. The first phase was conducted for four weeks to obtain informations on hemoglobin and serum ferritin, socioeconomic condition, daily diet and nutrients intake, knowledge on anemia, on iron pills,and on Puskesmas Services, health behaviour, ante natal care attendance, and number of iron pills intake. The number of pregnant women joining the study was 456, they attended the ante natal care clinic of the Puskesmas of three subdistricts of the district of Bogor. The prevalence of anemia (Hb

Abstrak :
Insiden dan prevelansi penyakit ginjal kronik (PGK) meningkat dari tahun ke tahun baik di negara maju ataupun sedang berkembang. Malnutrisi energi protein (MEP) sering dijumpai pada penderita PGK dengan dialisis (PGK-D) ataupun sebelum mendapat terapi dialisis (PGK-ND). Malnutrisi energi protein pada PGK-ND dapat menurunkan kualitas hidup, meningkatkan morbiditas dan mortalitas serta merupakan prediktor yang kuat terhadap survival penderita PGK-D di kemudian hari. Tujuan penelitian untuk memperoleh parameter komposisi tubuh dan fungsi otot yang dapat mendeteksi kecenderungan terjadinya MEP pada penderita PGK-ND. Metode. Penelitian dilakukan di Bagian Penyakit Dalam RS Sumber Waras, RS PGI. Cikini, RS Islam Jakarta dan Universitas Tarumanegara dengan rancangan cross sectional. Subyek penelitian: 45 penderita PGK-ND (30 laki=laki, 15 perempuan) dan 45 subyek kontrol yang disepadankan jenis kelamin, usia (PGK-ND 48,2 ≠7,3 tahun, kontrol 47,7 + 6,2 tahun) tinggi badan (PGK-ND 159,4 ≠ 7,5 cm, kontrol 160,6 ≠ 7,6 cm) dan indeks massa tubuh (IMT) (PGK-ND 22,4 ≠ 3,4 kg/m2, kontrol 22,5 ≠ 3,1 kg/m2). Status nutrisi dikelompokkan dalam status nutrisi kurang, normal dan lebih berdasarkan IMT, WHO, 1995. Pada penderita dan subyek kontrol dilakukan penilaian asupan nutrisi (tanya ulang 2 X 24 jam dan pncatatan asupan makanan), pemeriksaan biokimiawi (darah dan urin), pengukuran komposisi tubuh (antropimetri dan bioelectric impedance analysis, BIA). dan fungsi otot (kekuatan genggam tangan). Hasil. Penderita dan subyek kontrol didapatkan 7 (15,6%) status nutrisi kurang, 28 (62,2%) normal dan 10 (22,2%) lebih. Rerata laju filtrasi glomerulus penderita PGK-ND sebesar 19,3 + 1,7 mL/men/1,73m2, 13 (28,9%) penderita stadium 3, 17 (37,8%) stadium 4 dan 15 (33,3%) stadium 5. Konsentrasi albumin, prealbumin dan insulin like growth factor-1 (IGF-1) penderita PGK-ND tidak berbeda bermakna berdasarkan status nutrisi dan stadium PGK. Konsentrasi transferin didapatkan lebih tinggi bermakna pada penderita PGK-ND status nutrisi lebih dibandingkan dengan status nutrisi kurang dan normal. Konsentrasi C reactive protein (CRP) lebih tinggi bermakna pada penderita PGK-ND status nutrisi kurang dibandingkan dengan status nutrisi baik. Derajat asidosis metabolik (konsentrasi HCO3) penderita PGK-ND tidak berbeda berdasarkan status nutrisi dan stadium PGK. Secara antropometri massa bebas lemak (MBL), indeks-MBL (I-MBL), massa lemak (ML) dan persen (ML penderita PGK-ND tidak berbada bermakna dengan subyek kontrol. Berdasarkan BIA didapatkan MBL, dan I-MBL, persen ML penderita PGK-ND lebih tinggi bermakna dibandingkan subyek kontrol (p < 0,05). Massa bebas lemak (MBL), I-MBL dan ML mempunyai linearitas dengan klasifikasi status nutrisi berdasarkan uji trend analysis. Massa bebas lemak dan I-MBL berkolerasi dengan IMT. Massa bebas lemak, I-MBL, ML dan PGK-ND tidak berbeda dengan subyek kontrol dan berdasarkan status nutrisi serta stadium PGK. Status (KGT) penderita lebih rendah bermakna dibandingkan dengan kontrol, dan KGT penderita dengan status nutrisi kurang lebih rendah bermakna dibandingkan dengan status nutrisi baik. Kekuatan genggam tangan mempunyai korelasi dengan I-MBL dan IMT. Terdapat kesesuaian yang baik antara I-MBL dan KGT dengan IMT untuk penilaian status nutrisi penderita PGK-ND. Dengan uji Receiver Operating Curve didapatkan titik potong I-MBL sebesar 14,23 kg/m2 dan titik potong KGT sebesar 9,7 kg untuk membedakan status nutrisi kurang dan baik. Kesimpulan. Penelitian ini menunjukkan protein viseral (albumin, prealbumin, transferin dan insulin like growth factor-1) merupakan parameter status nutrisi yang lemah untuk penderita PGK-ND. Indeks massa tubuh mempunyai kolerasi positif dengan I-MBL dan KGT. Indeks-MBL dan KGT dapat membedakan derajat status nutrisi penderita (PGK-ND stadium 3,4 dan 5, dan dapat digunakan sebagai prediktor untuk skrining status nutrisi pada penderita PGK-ND.

Abstrak :
Anemia is the main micronutrient deficiency problem among adolescent school girls in Indonesia. Anemia due to iron deficiency often coexists with zine deficiency. Iron and zinc have anlagonistic interaction. Therefore, it was appropriate ratio of iron-zinc supplementation. Objective The study was aimed to investigate the different ratios of iron-zinc supplementation Fe: Zn = 2: 1 and Fe: Zn = 4: 1 on improving the iron and zinc status and eventually reduction of the morbidity of anemic adolescent school girls compared to iron supplementation alone. Methodology A randomized, double blind community trial was conducted among anemic adolescent school girls (10-12 years old). Selection of subjects was conduted in two steps. Firstly, 238 girls (out of 1358 girls), with hemoglobin concentration level < 115 g/L using Hemocue were recruited and given antihelminthic drug (500 mg mebendazole as a single dose). Secondly, those who had hemoglobin concentration < 120 g/L using Cell Dyn from venous blood one week after deworming (n+133) were enrolled into the study. The 133 subjects were assigned randomly to one of the three groups for daily iron-zinc supplementation for 12 weeks with: Group 1 (n=45): iron (60 mg/day), Group 2 (n=45): iron and zinc (30 mg and 15 mg/day) or group 3 (n=43): iron and zinc (60 mg and 15 mg/day).Supplement intake was supervised at base line, weight and height were measured and the available iron and zinc intake from diet was estimated using a model modified from WHO/FAO and Murphy, based on the data 24-hour Food Recall and Food Frequency Questionnare. Iron (hemoglobin/Hb, serum ferritin/SF, serum transferrin receptor/TfR, zinc protoporphyrin/ZPP, Mean Corpuscular Volume/MCV, Red-cell Distribution Width/RDW, body iron/BI) and zinc (serum zinc/SZ) status and supplementation. Morbidity status of diarrhea and Acule Respiratory Infection (ARI) were recorded weekly. The phagocytes cell and Cell-Mediated Immunity were measured only for 50% of the subjects. Results and Discussion By the end of the supplementation, most indicators of iron status were increased significantly in all subjects both they took iron supplementation with or without zinc, and the proportion of iron deficiency anemia reduced. Iron supplementation alone or iron-zinc improved zinc status. The proportion of zinc deficiency was sinificantly reduced only among subjects who took iron-zinc supplementation with the ratio of Fe: Zn =2: 1. which was significantly lower compared to the other two groups at the end of supplementation. In iron/zinc 2 : 1 group, no subject had iron deficiency anemia and zinc deficiency after 12 weeks of supplementation, which suggested that iron-zinc supplementation with the ration of Fe: Zn = 2 : 1 had reduced both iron deficiency anemia and zinc deficiency. In this study, iron deficiency among anemic school girls was due to insufficiency of iron in red blood cell, and iron or iron-zinc supplementation for 12 weeks had less benefit to increase iron status. The possibility; of hemoglobinopathies such as thalassemia trait affecting adolescent girls in this study should be considered as several studies indicated that the prevalence of tlinlassemia trait among the same population in Indonesia is high. Iron deficiency also occurred at the storage level, which increased and reached the normal value with iron or iron-zinc supplementation. At the end of supplementation, the mean value of most indicators of iron status in all groups did not reach the normal value (such as Hb < 120 g/L, ZPP > 40 umol/mol heme, MCV <2 80 fL, RDW > l4%), perhaps the 12-weeks of iron supplementation was not long enough to fulfill iron for the 120 erythrocyte life cycle. lt seems, that the competition between iron and zinc occurred both at the storage level and the erythrocyte formation, and iron-zinc supplementation with the ratio of Fe: Zn = 2: 1 had minimal interaction as the improvement of both iron and zinc status was higher compared to the other groups. Most anemic adolescent school girls in this study had low available iron and zinc intake from the diet, with low intake of enhancers and high intake of inhibitors, which is not enough to promote either iron or zinc absorption from the supplements. The reduction of the proportion ol' subjects suffering from ARI was the highest among subjects who took either iron alone (3l.1% to 6.7%) compared to those who took iron- zinc supplement with ratio 2: 1 (1 7.3% to l1.l%) or iron-zinc supplement with ratio 4: 1(16.3 % to l4%), indicating that iron alone reduced morbidity status in tenn of Acute Respiratory Infection (ARI). However, adding zinc to iron supplements with ratio 2: 1 scents to improve the specific immune response of anemic adolescent school girls, as shown that the ratio of CD-4/CD-S was slightly increased among subjects who took iron-zinc supplement with the ratio of Fe: Zn= 2: 1. Conclusions and Recommendations lt was concluded, that both iron deficiency anemia (22%) and zinc deficiency (15.8%) were problems in the study area. Iron deficiency and hemoglobinopathies such as that assemia trait might be the causes of anemia among adolescent school girls. A daily 30 mg iron and 15 mg zinc supplementation among anemic adolescent schools girls for 12 weeks improved iron and zinc status and reduced iron deficiency anemia and zinc deficiency. Iron supplementation alone increased iron status, while adding zinc to iron supplementation protected the adverse effect of iron on decreasing zinc status. The competition between iron and zinc might occur in the role of both nutrients for erythrocytes formation as well-as at storage level, and supplementation with the ratio of Fe: Zn = 2: 1 had minimal interaction on improving bot.h iron and zinc status. As most of the anemic adolescent school girls had inadequate iron and zinc intake from the diet, the deficiencies of other micronutrients such as; vitamin A, folic acid and vitamin B12 should also be considered as the causes of anemia. Combined iron-zinc supplementation with the ratio of Fe: Zn = 2: 1 was appropriate on reducing the risk of anemic adolescent school girls suffering from Acute Respiratory Infection, however the mechanism of both iron and zinc on enhancing immune system could not clearly be shown from the results of this study. It is recommended to establish an iron-zinc supplementation program with ratio of 2: 1 through the existing channel of school health program to alleviate iron de iciency anemia and zinc deficiency 'among adolescent girls. Research cum action prioritized is to explain the contribution of bioavailability iron and zinc intake from the diet including increase the enhancers and minimize the inhibitors to the absorption of iron-zinc supplementation with ratio of Fe: Zn = 2: 1. The possibility of hemoglobinopathies such as thalassemia trait, as the cause of anemia needs further investigations.

Abstrak :
Anemia is the main micronutrient deficiency problem among adolescent school girls in Indonesia. Anemia due to iron deficiency often coexists with zine deficiency. Iron and zinc have anlagonistic interaction. Therefore, it was appropriate ratio of iron-zinc supplementation. Objective The study was aimed to investigate the different ratios of iron-zinc supplementation Fe: Zn = 2: 1 and Fe: Zn = 4: 1 on improving the iron and zinc status and eventually reduction of the morbidity of anemic adolescent school girls compared to iron supplementation alone. Methodology randomized, double blind community trial was conducted among anemic adolescent school girls (10-12 years old). Selection of subjects was conduted in two steps. Firstly, 238 girls (out of 1358 girls), with hemoglobin concentration level < 115 g/L using Hemocue were recruited and given antihelminthic drug (500 mg mebendazole as a single dose). Secondly, those who had hemoglobin concentration < 120 g/L using Cell Dyn from venous blood one week after deworming (n+133) were enrolled into the study. The 133 subjects were assigned randomly to one of the three groups for daily iron-zinc supplementation for 12 weeks with: Group 1 (n=45): iron (60 mg/day), Group 2 (n=45): iron and zinc (30 mg and 15 mg/day) or group 3 (n=43): iron and zinc (60 mg and 15 mg/day).Supplement intake was supervised at base line, weight and height were measured and the available iron and zinc intake from diet was estimated using a model modified from WHO/FAO and Murphy, based on the data 24-hour Food Recall and Food Frequency Questionnare. Iron (hemoglobin/Hb, serum ferritin/SF, serum transferrin receptor/TfR, zinc protoporphyrin/ZPP, Mean Corpuscular Volume/MCV, Red-cell Distribution Width/RDW, body iron/BI) and zinc (serum zinc/SZ) status and supplementation. Morbidity status of diarrhea and Acule Respiratory Infection (ARI) were recorded weekly. The phagocytes cell and Cell-Mediated Immunity were measured only for 50% of the subjects. Results and Discussion By the end of the supplementation, most indicators of iron status were increased significantly in all subjects both they took iron supplementation with or without zinc, and the proportion of iron deficiency anemia reduced. Iron supplementation alone or iron-zinc improved zinc status. The proportion of zinc deficiency was sinificantly reduced only among subjects who took iron-zinc supplementation with the ratio of Fe: Zn =2: 1. which was significantly lower compared to the other two groups at the end of supplementation. In iron/zinc 2 : 1 group, no subject had iron deficiency anemia and zinc deficiency after 12 weeks of supplementation, which suggested that iron-zinc supplementation with the ration of Fe: Zn = 2 : 1 had reduced both iron deficiency anemia and zinc deficiency. In this study, iron deficiency among anemic school girls was due to insufficiency of iron in red blood cell, and iron or iron-zinc supplementation for 12 weeks had less benefit to increase iron status. The possibility; of hemoglobinopathies such as thalassemia trait affecting adolescent girls in this study should be considered as several studies indicated that the prevalence of tlinlassemia trait among the same population in Indonesia is high. Iron deficiency also occurred at the storage level, which increased and reached the normal value with iron or iron-zinc supplementation. At the end of supplementation, the mean value of most indicators of iron status in all groups did not reach the normal value (such as Hb < 120 g/L, ZPP > 40 umol/mol heme, MCV <2 80 fL, RDW > l4%), perhaps the 12-weeks of iron supplementation was not long enough to fulfill iron for the 120 erythrocyte life cycle. lt seems, that the competition between iron and zinc occurred both at the storage level and the erythrocyte formation, and iron-zinc supplementation with the ratio of Fe: Zn = 2: 1 had minimal interaction as the improvement of both iron and zinc status was higher compared to the other groups. Most anemic adolescent school girls in this study had low available iron and zinc intake from the diet, with low intake of enhancers and high intake of inhibitors, which is not enough to promote either iron or zinc absorption from the supplements. The reduction of the proportion ol' subjects suffering from ARI was the highest among subjects who took either iron alone (3l.1% to 6.7%) compared to those who took iron- zinc supplement with ratio 2: 1 (1 7.3% to l1.l%) or iron-zinc supplement with ratio 4: 1(16.3 % to l4%), indicating that iron alone reduced morbidity status in tenn of Acute Respiratory Infection (ARI). However, adding zinc to iron supplements with ratio 2: 1 scents to improve the specific immune response of anemic adolescent school girls, as shown that the ratio of CD-4/CD-S was slightly increased among subjects who took iron- zinc supplement with the ratio of Fe: Zn= 2: 1 Conclusions and Recommendations lt was concluded, that both iron deficiency anemia (22%) and zinc deficiency (15.8%) were problems in the study area. Iron deficiency and hemoglobinopathies such as that assemia trait might be the causes of anemia among adolescent school girls. A daily 30 mg iron and 15 mg zinc supplementation among anemic adolescent schools girls for 12 weeks improved iron and zinc status and reduced iron deficiency anemia and zinc deficiency. Iron supplementation alone increased iron status, while adding zinc to iron supplementation protected the adverse effect of iron on decreasing zinc status. The competition between iron and zinc might occur in the role of both nutrients for erythrocytes formation as well-as at storage level, and supplementation with the ratio of Fe: Zn = 2: 1 had minimal interaction on improving bot.h iron and zinc status. As most of the anemic adolescent school girls had inadequate iron and zinc intake from the diet, the deficiencies of other micronutrients such as; vitamin A, folic acid and vitamin B12 should also be considered as the causes of anemia. Combined iron-zinc supplementation with the ratio of Fe: Zn = 2: 1 was appropriate on reducing the risk of anemic adolescent school girls suffering from Acute Respiratory Infection, however the mechanism of both iron and zinc on enhancing immune system could not clearly be shown from the results of this study. It is recommended to establish an iron-zinc supplementation program with ratio of 2: 1 through the existing channel of school health program to alleviate iron de iciency anemia and zinc deficiency 'among adolescent girls. Research cum action prioritized is to explain the contribution of bioavailability iron and zinc intake from the diet including increase the enhancers and minimize the inhibitors to the absorption of iron-zinc supplementation with ratio of Fe: Zn = 2: 1. The possibility of hemoglobinopathies such as thalassemia trait, as the cause of anemia needs further investigations.