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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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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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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.

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).

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.

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.

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.

34

Discussion

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

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.

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

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

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.

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,

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).

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

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.

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

-

( ) 94 51

:

: ........................................................

..................................................... :

: : -1

: ......................................................................................................................... -

..................................................................................................................... : .. -

: ........................................ - .91: ....../....../........ -

: -2

4 3 2 1 : -3 4 3 2 1: -4

4 3 2 1 : -5 8 7 6 5

.: ......................... -6

(: ) -7

: .: ............................. -8

: .............................. -01 .: .................................... -9

2 1: -11

25

:

.: .......................... -21

3 2 1: -31 : .............................................................. " " " " -41

: -51

2 1: -61

/ : " " -71

:

2 1: -81

: - 91

: -02

3 2 1: -12

: " " -22

: -32

2 1: -42

:

2 1: 6 -52

: ......................................................................... " " -62

35

2 1: 6 -72

....................................: .......................................... " " -82

3 2 1: -92 3 2 1: " " -03

: ........................................................ 4

2 1: -13

..................................................................: ..................." " -23

2 1: -33

..........................................: ............................................." " -43

2 1: -53 ...................: ...................................................................." " -63

2 1: -73 : ......................................................................................." " -83

: ................................................................................................ -93

45

: 2 1 : 04 : ................................................................... " " -14

2 1: -24 : ............................................................................ " " -34 : ............................................................................... -44 2 1 : -54

: .............................................................................................." " -64 : -74

()

/

: ....................................................................

55

References

56

References

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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