The Potential of Various Foods to Serve As a Carrier for Micronutrient Forti®Cation, Data from Remote Areas in Indonesia

Home , Micronutrient

The potential of various foods to serve as a carrier for micronutrient forti®cation, data from remote areas in Indonesia

A Melse-Boonstra1*, S de Pee1, E Martini1, S Halati1, M Sari1, S Kosen2, Muhilal3 and MW Bloem3

1Helen Keller International=Indonesia and HKI Asia-Paci®c Regional Of®ce, Jakarta, Indonesia; 2National Institute for Health Research and Development, Jakarta Indonesia; and 3Nutrition Research and Development Centre, Bogor, Indonesia

Objective: To estimate the potential of various industrially produced foods, to serve as a carrier for micronutrient forti®cation based on the frequency of their consumption in different socio-economic strata; to determine the role of forti®ed instant noodles as a source of micronutrients; to assess the contribution of plant foods, animal foods and forti®ed foods to vitamin A intake. Setting: A survey was conducted in rural South Sulawesi and urban South Kalimantan between November 1996 and January 1997. Subjects: Households (1500 in South Sulawesi; 2112 in South Kalimantan) were selected randomly by multi- stage cluster sampling. From each household, data were collected from the mother and her youngest child (0 ± 5 y). Data collection: Mothers were interviewed on various topics, including socio-economic status, food consumption, receipt of high-dose vitamin A capsules, health and nutritional status. Results: Monosodium glutamate and salt were consumed daily in almost all households in both areas, and consumption was not associated with socio-economic status. Instant noodles were consumed in nearly all households in both areas, but consumption of forti®ed noodles was related to socio-economic status; it was highest among households of government employees and private investors, and lowest among farmers and share- croppers. Vegetables were the most important source of vitamin A in rural South Sulawesi, while foods of animal origin were the most important source in urban South Kalimantan. Conclusions: The results support double or triple forti®cation of salt and=or monosodium glutamate with iodine, vitamin A and=or iron. Efforts to overcome associated technical and logistical dif®culties are urgently needed. Sponsorship: Opportunities for Micronutrient Interventions (OMNI); United States Agency for International Development (USAID). Descriptors: food consumption; forti®cation; vitamin A; iron; iodine; salt; monosodium glutamate; instant noodles; Indonesia European Journal of Clinical Nutrition (2000) 54, 822±827

Introduction A de®ciency can also cause nutritional anemia (Bloem, 1995). Iron de®ciency is highly prevalent in Indonesia. The Micronutrient malnutrition is one of the major health household survey of 1995 found a prevalence of anemia problems in developing countries. Vitamin A, iron and among pregnant women of 50.9% and among pre-school iodine de®ciencies all have severe health consequences children of 40.5% (Department of Health, Republic of for mothers and children. According to Indonesia's national Indonesia, 1995). Iron de®ciency has severe consequences vitamin A survey in 1992, more than 50% of the under-®ve for health, work productivity and general well-being (Edg- children had a marginal vitamin A status (Muhilal et al, erton et al, 1979; Untoro et al, 1998). Lack of iodine can 1994). Children with vitamin A de®ciency are at increased lead to mental retardation, miscarriages and stillbirth. In the risk of blindness and death, and illness is generally more early 1990s, the total goiter prevalence among school severe and lasts longer (Sommer et al, 1984; Beaton et al, children in Indonesia due to iodine de®ciency was 32% 1993; Ghana VAST Study Team, 1993). Recently, a study and the visible goiter rate was 5% (Pandav, 1994). in Nepal found that maternal mortality was reduced by 40 ± Due to Indonesia's economic crisis that started mid- 50% when women were supplemented with a weekly low 1997, the prevalence of anemia, vitamin A de®ciency and dose of vitamin A or b-carotene (West et al, 1999). Vitamin wasting, among mothers as well as children, is increasing (de Pee et al, 2000). The situation is worse in urban slums *Correspondence: S de Pee, Helen Keller International=Indonesia, P.O. than in rural areas. Box 4338, Jakarta Pusat, Indonesia. Indonesia has an extensive history of combating micro- E-mail: [email protected] nutrient de®ciencies. In the early 1970s, distribution of Guarantor: Saskia de Pee. Contributors: AMB carried out the data analysis and had the main part in vitamin A capsules to under-®ves, iron pills to pregnant writing the manuscript; SdP was involved in designing the survey and in women, and iodized oil injections and capsules in speci®c editing and commenting on the manuscript; EM, SH and MS were areas was started (Bloem, 1995; Pandav, 1994; Schultink, involved in the design of the study, coordinated the data collection, and 1996). Other strategies, such as home gardening, nutrition wrote the Subjects and methods section of the manuscript; SK, M and education and food forti®cation, are also used. MWB had the ®nal responsibility for the survey and gave overall comments on the manuscript. With respect to food forti®cation, an effort has been Received 6 october 1999; accepted 10 August 2000 made since 1974 to iodize salt with 40 ± 50 ppm potassium Carriers for micronutrient forti®cation in Indonesia A Melse-Boonstra et al 823 iodate. By 1996, salt consumed was found to be adequately holds with at least one child younger than ®ve years. From iodized in 50% of the households (BPS=UNICEF, 1996). this list, 25 households were selected by interval sampling, In the last 5 y, some manufactures have started fortifying using a random start. In total, data were collected from instant noodles with vitamin A, iron and B-vitamins. 1500 households. In urban South Kalimantan, households Powdered and condensed milk and some brands of marga- were selected from all 50 subareas of Banjarmasin and rine are forti®ed with vitamins A and D and other micro- from the most-urban subareas of Martapura, 31 out of 58. nutrients, and in January 1999 iron-forti®cation of wheat From each subarea, a list was obtained of households with ¯our became mandatory. at least one child younger than 5 y. From this list, house- Food forti®cation can be a good and sustainable strategy holds were selected by interval sampling, using a random to deliver needed micronutrients to the population. The start. The number of households selected per subarea was dif®culty of food forti®cation however is to select a suitable proportional to their population size. In total, data were food vehicle that meets the following criteria: (1) the food collected from 2112 households. is widely consumed by subjects at risk; (2) the manufactur- Data were analyzed for one child per household, the ing process is suitable for forti®cation; (3) the variation in youngest, and their mother. While the social marketing per capita consumption of the food is limited; (4) the campaign and the survey for its evaluation were considered forti®ed food is stable and organoleptically acceptable; part of the local government's activities and were approved and (5) forti®cation does not greatly affect the food's as such, the Ethical Committee of the Indonesian Ministry price. Certainly during a period of in¯ation, this last point of Health approved procedure for blood taking that was is very important. conducted among a subsample. The purpose of this paper was to assess what industrially produced foods could be potential vehicles for further Baseline data collection micronutrient forti®cation in Indonesia based on consump- Graduates of Academies of Nutrition and Agricultural tion frequencies in different socio-economic strata. In this Universities, who had been trained for this purpose for 4 respect, the role of forti®ed instant noodles as a source of days, conducted the data collection. In urban South Kali- micronutrients was also determined. Further, we assessed mantan, 16 ®eld-workers were in charge of data collection the contribution that plant foods, animal foods and forti®ed and in rural South Sulawesi 10. All mothers were inter- foods already make to vitamin A intake. Data used for this viewed at home on various topics, such as socio-economic analysis were collected among households in urban South status, food consumption, receipt of high-dose vitamin A Kalimantan and rural South Sulawesi between November capsules, health and nutritional status. Anthropometric 1996 and January 1997. measurements were taken from all subjects and blood was collected from a subsample.

Subjects and methods Anthropometry. The weight of mothers and children was measured, without shoes and with minimal clothing, to the The data presented here were collected during a baseline nearest 0.1 kg (UNICEF Mother and Child Weighing survey for the evaluation of a social marketing campaign, Scale). Height without shoes was determined using which promoted the consumption of dark-green leafy a microtoise; for children under 2 y old a length board vegetables and eggs (LocalVita), between November was used. Mid-upper-arm circumference (MUAC) was 1996 and January 1997. The aim of the campaign was to measured to the nearest 0.1 cm using an insertion tape improve maternal and child survival through promotion of (Department of Health, Indonesia). vitamin A-rich foods. South Sulawesi was chosen as a project site for this campaign because the 1992 National Blood collection. Venous blood (3 ml) was collected from Vitamin A Survey identi®ed the province as one among a subsample of approximately 100 mother ± child pairs in three provinces of Indonesia where xerophthalmia was still each district. The subsample was taken by random selection a public health problem. South Kalimantan was chosen as of 10 households per village, from a total of 10 randomly it is one of the less developed provinces of Indonesia and selected villages. After an explanation of the purpose of the it is a USAID (United States Agency for International blood collection, the mothers signed an informed consent Development) Priority Area. form. The blood collection took place in the health centers of the sub-districts. Hemoglobin concentrations using Project sites venous blood were assessed directly in the ®eld, using the In rural South Sulawesi, Goa district was chosen as the area HemoCue device (Angelholm, Sweden). for the campaign, and in urban South Kalimantan, Banjarma- sin district. For the evaluation of changes after the social Frequency of food consumption. Food consumption was marketing campaign, data were also collected from control assessed with a food-frequency questionnaire. Mothers districts. In rural South Sulawesi, this was done in Bulukumba were asked how many times per week they and their district, and in urban South Kalimantan in Martapura sub- child usually consumed certain food items, including district, Banjar. Geological characteristics and living condi- green leafy vegetables, fruits, eggs, fresh ®sh, salted ®sh, tions of the control districts resemble those of the intervention powdered or condensed milk, cooking oil, soy sauce, sugar, area closely. For the present paper, the data of the intervention salt, monosodium glutamate, cookies, snacks and sweets. and the control districts were pooled per province. For instant noodles, the weekly consumption in the household was asked for. In case noodles were consumed, brand Subjects names were recorded in order to be able to distinguish Households were selected by multi-stage cluster sampling. between forti®ed and unforti®ed noodles. In rural South Sulawesi, a total of 30 villages were selected per district by probability-proportional-to-size sampling. Vitamin A intake. Vitamin A intake was estimated using From each selected village a list was obtained of house- the 24-VASQ method (24 h recall for Vitamin A, Semi-

European Journal of Clinical Nutrition Carriers for micronutrient forti®cation in Indonesia A Melse-Boonstra et al 824 Quantitative; de Pee et al, 1999). In short, a 24 h recall showed the strongest, positive, correlation with consump- questionnaire is administered and the foods containing tion frequency of powdered or condensed milk (Table 3), vitamin A are assigned a food code and a vitamin A content among mothers as well as children in both areas. No, or code. The food code indicates whether the ingredient is a only very weak, correlation coef®cients were found in all vegetable, fruit, forti®ed food or animal food, and the groups for salt and monosodium glutamate. In other words, vitamin A content code indicates the vitamin A content of its consumption was not related to socio-economic status. the amount of the ingredient consumed (<20 retinol equi- In rural South Sulawesi, 98% of the households con- valents (RE), 20 ± 100 RE, 100 ± 250 RE, 250 ± 500 RE, sumed instant noodles and in urban South Kalimantan, 500 ± 1000 RE > 1000 RE). Vitamin A intake was calculated 99%. Forti®ed instant noodles were consumed in 29% of semi-quantitatively for each of the four food groups. the households in rural South Sulawesi, and in 65% in urban South Kalimantan. Maternal education showed a Data analysis weak positive correlation with household consumption of For the analysis of food consumption patterns presented in forti®ed noodles: Spearman rank-order correlation coef®- this paper, data were only analyzed for mothers, n1500 cients were 0.15 in rural South Sulawesi and 0.22 in urban for rural South Sulawesi, and n2112 for urban South South Kalimantan. Consumption of forti®ed noodles tended Kalimantan, and for children 12 ± 60 months old, n1033 to be lower in households where education of both parents and n1553, respectively. For the analysis of vitamin A was primary school or lower (consumption rates were intake from certain food groups, data were analyzed for 22.5% in rural South Sulawesi and 51.4% in urban South children aged 18 months and older, n796 for rural South Kalimantan) and higher where education of both parents Sulawesi and n1279 for urban South Kalimantan, and for was secondary school or higher (41.2% in rural South mothers. Sulawesi; 76.2% in urban South Kalimantan). In rural The data were entered into a computerized database by South Sulawesi, consumption of forti®ed noodles was experienced data-entry typists. Frequencies and descriptive highest ( > 40%) among households of government statistics were obtained using SPSS for Windows (version employees, private investors and drivers, and lowest 7.5, SPSS Inc., Chicago). Spearman rank-order correlation (<25%) among households of farmers, share-croppers, coef®cients were calculated between consumption fre- becak riders (bicycle taxi) and boatmen. In urban South quency of various food items and years of maternal educa- Kalimantan, consumption of forti®ed noodles was highest tion, which is a good indicator for socioeconomic status in ( > 70%) among households of traders, government this population (de Pee et al, 1998c). employees and=or private investors, average (50%) among households of casual laborers, becak riders, boat- Results men, carpenters and handicrafts salesmen, and lowest (<30%) among households of farmers, share-croppers Characteristics of mothers and children are presented in and ®shermen. Forti®ed noodle consumption was distrib- Tables 1 and 2, respectively. The proportion of mothers uted equally among households with 0 ± 4, 5 ± 8, or 8 with a BMI <18.5 kg=m2 or with a BMI > 27 kg=m2 was family members in both rural South Sulawesi and urban 12.1% and 5.5%, respectively, in rural South Sulawesi, and South Kalimantan. 16.9% and 9.1%, respectively, in urban South Kalimantan. Of the households in rural South Sulawesi of whom Figure 1 presents the proportion of subjects consuming mothers had a BMI > 25 kg=m2, 40 ± 50% consumed for- certain foods 4 times per week. The number of years of ti®ed noodles, while of the households where the mothers maternal education, an indicator for socio-economic status, had a lower BMI, 27.5% consumed forti®ed noodles. The

Figure 1 Proportion of mothers and children (12±60 mo old) in rural South Sulawesi and urban South Kalimantan that consumed particular foods 4 times per week.

European Journal of Clinical Nutrition Carriers for micronutrient forti®cation in Indonesia A Melse-Boonstra et al 825 proportion of households that consumed forti®ed noodles in 1999 and should ensure that all products containing ¯our South Sulawesi was not different among households that will be forti®ed with iron. Flour is not forti®ed with vitamin had or did not have a wasted or stunted child. However, A because of the higher costs. only 24% of the Sulawesi households with an anemic child Another recent initiative, launched by the Government consumed forti®ed noodles, while this was 36% among the of Indonesia and supported by UNICEF, is the Rapid households where the child was not anemic. The proportion Response Complementary Food Initiative (CFI). The initia- of households that consumed forti®ed noodles was not tive aims to safe children from (crisis-induced) malnutri- different among households where the mother was or was tion, by providing a low-price, micronutrient-forti®ed, not anemic. For urban South Kalimantan similar relation- energy-dense, complementary food for children 6 ± 24 ships between household consumption of forti®ed noodles months old. The food is called `Vitadele', can be purchased and nutritional status of mother and child were found. from the Posyandu (local health clinic), and is so far In rural South Sulawesi, median vitamin A intake was available to poor communities in West, Central and East 870 RE=day among women and 470 RE=day among Java, West and East Nusa Tenggara, and East Timor. children. In urban South Kalimantan this was 520 With respect to increasing vitamin A intake, consump- RE=day for women and 350 RE=day for children. In rural tion of fruits and eggs, both good sources of vitamin A with South Sulawesi, 35 ± 40% of mothers and children had a relatively high bioavailability (de Pee et al, 1998a), could vitamin A intake lower than the recommended dietary be increased in both areas. For young children, an increase allowances (RDA; for adults 600 RE=day and for under- of the consumption of green leafy vegetables should also ®ves 350 RE=day; Muhilal, 1998). In urban South Kali- be promoted. In fact, in March 1997, a social marketing mantan, 50 ± 60% of mothers and children had intakes campaign promoting the consumption of green leafy vege- below the RDA. As shown in Table 4, vegetables were tables and eggs started in both areas. Such a campaign in the most important source of vitamin A in rural South Central Java in 1996 had been found successful in increas- Sulawesi, while foods of animal origin were the most ing vitamin A intake as well as vitamin A status (de Pee important source in urban South Kalimantan. For a propor- et al, 1998b). However, because of Indonesia's economic tion of the children in urban South Kalimantan, forti®ed crisis, which started in July 1997, the impact expected of foods were also an important source of vitamin A. the social marketing campaigns in South Sulawesi and South Kalimantan is very small. Looking at the potential of food vehicles for micronu- Discussion trient forti®cation, as assessed in this paper, only salt and monosodium glutamate consumption appear insensitive to Salt and monosodium glutamate would be the preferred socio-economic status. Products that had penetrated well in carriers for micronutrients because of a high consumption both areas were instant noodles, powdered or condensed frequency and the absence of a relationship with socio- milk, and cookies. In particular, noodles were consumed in economic status. These products were consumed 4 times nearly every household. However, forti®ed noodles are per week by 86 ± 100% of mothers and children in both slightly more expensive than unforti®ed noodles and the rural South Sulawesi and urban South Kalimantan. Instant households that consumed forti®ed noodles were those that noodles were also consumed in nearly every household in had a higher socio-economic status and in which mother both areas, but the forti®ed ones were consumed less and child had a better nutritional status. Because Indone- frequently and primarily by households with a higher sia's crisis has increased food prices by 2 ± 3 times, there socio-economic status. Nevertheless, noodles are a high- has been an enormous decline of the consumption of potential micronutrient vehicle. In rural South Sulawesi, relatively luxury foods. Therefore, the only foods eligible green leafy vegetables were consumed more frequently for food forti®cation in the current economic situation are than in urban South Kalimantan and they were the most foods of which the consumption is not related to socio- important dietary source of vitamin A for this population. economic status; namely monosodium glutamate and salt. In urban South Kalimantan, most vitamin A was obtained Pilot projects for fortifying monosodium glutamate with from animal foods and forti®ed products. vitamin A had already been conducted by Muhilal and This survey found that nightblindness was virtually colleagues in the 1980s. Within 5 and 11 months after the absent in rural South Sulawesi, but present in 1.3% of the introduction of monosodium glutamate forti®ed with vita- women in urban South Kalimantan. This is in accordance min A (810 RE=g) in a number of communities in West with recent ®ndings of a higher prevalence of nightblind- Java, retinol concentrations in serum and breast milk had ness in urban than in rural areas (unpublished observations increased markedly, linear growth had improved, hemoglo- of the GOI=HKI Nutrition Surveillance System). Approxi- bin concentrations had increased, and mortality among mately 14% of the non-pregnant women and 30 ± 35% of preschool children had decreased (Muhilal et al, 1988a, the children aged 12 ± 60 months in both areas were b). In one of the papers, a rough outline for a nationwide anemic. While these levels were already high, especially monosodium glutamate forti®cation program is given in children, the crisis has further worsened this situation (Muhilal et al, 1988a). Although it has already been tried (unpublished observations of the GOI=HKI Nutrition Sur- to put forti®ed monosodium glutamate on the market, veillance System). This has further increased the need for technical problems associated with forti®cation on a large strategies to combat micronutrient de®ciencies. scale, long shelf-life requirements, and varying storage The strategies that must be used now should be feasible conditions have not yet been solved. given the current economic situation. Iron and vitamin A Salt is already a well-known forti®cation agent as it is supplementation of the population should be maintained used worldwide as a vehicle for iodine. The percentage of and expanded, and the costs of food forti®cation should be households that used adequately iodized salt ( > 30 ppm) as very low. A good example of the latter is the forti®cation of assessed by the use of a test-kit was 16% in rural South wheat ¯our with iron, which started in Indonesia in January Sulawesi and 82% in urban South Kalimantan. This

European Journal of Clinical Nutrition Carriers for micronutrient forti®cation in Indonesia A Melse-Boonstra et al 826 Table 1 Characteristics of mothers in rural South Sulawesi (n1500) Table 2 Characteristics of children ( 12 mo old) in rural South and urban South Kalimantan (n2112) Sulawesi (n1033) and urban South Kalimantan (n1553).

South Sulawesi South Kalimantan South Sulawesi South Kalimantan

Age (y)1 27.4Æ 5.7 28.3Æ 5.9 Age (mo)1 29.5Æ 12.6 32.5Æ 13.7 Lactating (%) 62.0 55.4 Breastfed (%) 48.3 43.3 <3 y education (%) 13.0 9.7 Height for age Z score 46.8 42.1 BMI (kg=m2)1 21.7Æ 3.2 21.9Æ 3.7 < 2s.d. (%) MUAC (cm)1 25.2Æ 2.8 25.7Æ 3.7 Weight for height Z score 10.5 15.2 Hb (g=L)1,2 131Æ 13 129Æ 13 < 2s.d. (%) Hb <120 g=L1,2 14.3 13.7 Weight for age Z score 47.1 49.1 Nightblind (%) <0.01 1.3 < 2s.d. (%) Diarrhea on day of interview (%) 0.5 0.2 MUAC <12.5 cm (%) 3.7 1.7 Diarrhea in previous 7 days (%) 1.3 1.0 Hb (g=L)1,2 113.Æ 12 115.Æ 12 Postpartum VAC distribution (%)3 1.6 14.3 Hb <110 g=L (%)2 35.6 30.9 Proportion of pregnant women 84.6 67.1 Nightblind (%) 0 0.1 receiving iron pills (%)4 Diarrhea on day of interview (%) 3.5 2.7 Diarrhea in previous 7 days (%) 8.8 6.6 1MeanÆ s.d. Runny nose=coughing 25.3 44.6 2Subsample of non-pregnant women (n242 in rural South Sulawesi and on day of interview (%) n233 in urban South Kalimantan). Measles during previous 12 16.3 15.3 3Women with a child <12 mo (n446 in rural South Sulawesi and months (%) n549 in urban South Kalimantan) who received a vitamin A capsule Coverage of vitamin A 85.7 81.4 within 40 days of delivery of that child. capsule distribution (%) 4Pregnant women (n54 in rural South Sulawesi and n 79 in urban South Kalimantan). 1MeanÆ s.d. 2Subsample (n191 in rural South Sulawesi and n181 in urban South indicates that salt iodization has yet been successful for Kalimantan). urban South Kalimantan but not so much for rural South Sulawesi. dropped from 53.7% to 19.4% among the boys and from Husaini conducted an intervention trial with salt forti®ed 15.5% to 3.0% among the girls (Nadiger et al, 1980). A with vitamin A in 1982 (Husaini, 1982). The study was ®eld trial conducted later by the same investigators showed carried out with 600 preschool children, living on rubber a signi®cant improvement of Hb and a signi®cant reduction plantations in West Java. Clinical signs of xerophthalmia in the prevalence of anemia in all areas (Report of The were signi®cantly reduced after using forti®ed salt for 6 Working Group on Forti®cation of Salt with Iron, 1982). months. The percentage of children with serum retinol Our conclusions with respect to salt and monosodium <10 mg=dl. decreased from 13.5% at baseline to 1.6% glutamate being the best potential carriers for micronutrient after 6 months, while the percentage with serum retinol forti®cation are based on data that were obtained in rural between 10 and 19 mg=dl decreased from 54% at baseline to South Sulawesi and urban South Kalimantan. These areas 38% after the intervention. Muhilal and Karyadi found that represent the poorer areas of the country and the ®ndings the bioavailability of vitamin A from forti®ed salt used in would apply to the situation that existed in most areas of cooking was very high, 97.3% (personal communication). Indonesia before the onset of the crisis. Since the onset of In 1980, Nadiger et al described an intervention trial the crisis, the relationship between purchasing power and with salt forti®ed with iron (ferric orthophosphate, consumption of relatively luxury foods has only become 3500 mg=kg) in India. The forti®ed salt was found to be stronger throughout the country. Therefore, we are con- acceptable with respect to its colour and taste when ®dent that our conclusions are applicable to most of incorporated into diets cooked according to traditional Indonesia and are also valid in the current economic methods. An intervention trial with 314 boys and 232 situation. girls showed a signi®cant increase of Hb, 14 g=l in boys In conclusion, the current results support double or triple and 11 g=l in girls. The proportion with Hb <120 g=l forti®cation of salt or monosodium glutamate with iodine,

Table 3 Spearman rank-order correlation coef®cients between the consumption frequency of the various food items and the number of years of maternal education for mothers and children 12 mo

Mothers Children

Food items South Sulawesi (n1500) South Kalimantan (n2112) South Sulawesi (n1033) South Kalimantan (n1553)

Green Leafy Vegetables 0.12** 0.18** 0.08** 0.06* Fruit 0.14** 0.18** 0.14** 0.16** Eggs 0.25** 0.14** 0.25** 0.10** Fresh ®sh 0.15** 0.07** 0.13** 0.02 Salted ®sh 0.15** 0.05* 0.14** 0.05* Salt1 0.01 0.01 0.01 0.0 MSG1 0.02 0.05* 0.01 0.07** Sugar1 0.13** 0.05* 0.13** 0.08** Oil1 0.17** 0.01 0.16** 0.05 Soy sauce1 0.24** 0.05* 0.24** 0.05 Milk1 0.30** 0.20** 0.33** 0.26** Snacks1 0.06* 0.02 0.04 0.12** Sweets1 0.05 0.08** 0.05 0.04 Cookies1 0.22** 0.12** 0.16** 0.09**

*,** Statistically signi®cant, * P<0.05 (2-tailed) or ** P<0.01 (2- tailed). 1Foods considered to be potentially forti®able.

European Journal of Clinical Nutrition Carriers for micronutrient forti®cation in Indonesia A Melse-Boonstra et al 827 Table 4 Vitamin A intake (RE=d) from vegetables, fruits, animal foods and forti®ed foods among mothers and children (18 ± 59 mo) in rural South Salawesi and urban South Kalimantan1

Mothers Children

Food items South Sulawesi (n1500) South Kalimantan (n2112) South Sulawesi (n796) South Kalimantan (n1279)

Vegetables 560 120 235 10 (120=1155) (20=395) (10=525) (0=100) Fruits 10 10 10 10 (0=175) (0=120) (0=30) (0=30) Animal foods 120 180 80 130 (30=180) (70=295) (20=180) (50=245) Forti®ed foods 0 0 0 0 (0=0) (0=0) (0=0) (0=175) Total 870 520 470 350 (425=1540) (270=940) (215=795) (150=590)

1Median (25=75 percentiles). vitamin A and=or iron, in addition to supplementation, as a means to combat micronutrient de®ciencies. This de Pee S, Bloem MW, Graciano F, Sari M, Soekarjo D, Tjiong R & Satoto measure will give all population groups access to a better (2000): Indonesia's crisis causes considerable weight-loss among nutritional status and will endure economic instability. The mother and adolescents. Nutr. Rev., (in press). Edgerton VR, Gardner GW, Ohira Y, Gunawardena KA & Senewiratne B organoleptic quality, stability and bioavailability of these (1979): Iron de®ciency anaemia and its effect on worker productivity micronutrients once added to salt or monosodium gluta- and activity patterns. Br. Med. J. 2, 1546 ± 1549. mate remain technical and logistic challenges that should Ghana VAST Study Team (1993): Vitamin A supplementation in northern urgently be addressed. Ghana: effects on clinic attendances, hospital admissions, and child mortality. Lancet 342, 7 ± 12. Husaini O (1982): Penggunaan garam forti®kasi untuk menanggulangi Acknowledgements ÐWe are grateful to all women and children who masalah kurang vitamin A. [The use of forti®ed salt to control vitamin participated in the survey. We also thank all the enumerators and the A de®ciency.] Doctoral dissertation. Bogor, Indonesia: Fakultas Pasca staff from the health laboratories for collecting all the data. Thanks also to Sarjana, Institut Pertanian. Eha Julaeha and Sugiatmi for entering all the data into a computerized Je Pee S, Bloem MW, Halati S, Soekarjo D, Sari M, Martini E, Kiess L, database. For all the help they gave us to make data collection possible, we Muita M, Davis D, Sakya N & Gorstein J (2000b): 24-VASQ method want to thank the following institutions: the Provincial Of®ces of the for estimating vitamin A intake: reproducibility and relationship with Ministry of Health and the Provincial Health Services in South Sulawesi vitamin A status. 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