Iron-fortified milk and noodle consumption is

Iron-fortified milk and noodle consumption is associated with lower risk of anemia among children aged 6–59 mo in Indonesia1–3 Richard D Semba, Regina Moench-Pfanner, Kai Sun, Saskia de Pee, Nasima Akhter, Jee Hyun Rah, Ashley A Campbell, Jane Badham, Martin W Bloem, and Klaus Kraemer

INTRODUCTION

Anemia is highly prevalent among children in developing countries, and it affects nearly 300 million preschool-aged children worldwide (1). Anemia adversely affects the cognitive and physical development of children and may have long-term consequences in terms of physical productivity and reproductive outcomes in adulthood (2). It is generally assumed that about onehalf of the cases of anemia are caused by iron deficiency, but the proportion may vary in accordance with local conditions (3). The main cause of iron deficiency among young children in developing countries is a lack of bioavailable iron in a diet that is largely plant based and low in animal foods. Although evidence is accumulating that improvement of iron status will confer large

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health benefits, progress has been extremely slow in the prevention of iron deficiency through public health interventions (4). Iron deficiency is most prevalent and severe during the weaning period. One of the major research priorities in the prevention of iron deficiency is the improvement of the nutritional quality of complementary foods. Fortified foods may provide iron and other micronutrients as infants make the transition from a diet of breast milk to a mixed diet that includes breast milk and other foods (5). A variety of approaches have been shown to decrease iron deficiency and anemia, and include in-home fortification with micronutrient powders and the use of commercially fortified foods such as cereals, sauces, and lipidbased spreads (5–7). Micronutrient-fortified powdered milk provided through a national complementary food program in Chile has been shown to improve iron status and decrease anemia in infants and young children (8, 9). Since the mid-1990s, fortification of powdered milk with vitamins and minerals, which includes iron, has been mandatory in Indonesia, and about onehalf of instant noodles have been fortified voluntarily. The use of fortified powdered milk is fairly common in Indonesia, but the use of fortified instant noodles is less common, especially among households in remote rural areas (10). The relation between the consumption of fortified powdered milk and fortified noodles and health outcomes has not been well characterized. We hypothesized that young children, aged 6–59 mo, who consumed iron-fortified powdered milk and/or iron-fortified noodles were at a lower risk of anemia. To address this hypothesis, we examined the relation between the use of fortified powdered milk and noodles and child anemia in a large populationbased sample of families from Indonesia.

1 From the Department of Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, MD (RDS, KS, and AAC); the Global Alliance for Improved Nutrition, Geneva, Switzerland (RM-P); the Nutrition Service, Policy, Strategy and Programme Support Division, World Food Programme, Rome, Italy (SdP and MWB); Helen Keller International Asia Pacific, Dhaka, Bangladesh (NA); Sight and Life, DSM, Basel, Switzerland (JHR and KK); and the JB Consultancy, Johannesburg, South Africa (JB). 2 Supported by the Lew R Wassermann Merit Award from Research to Prevent Blindness (to RDS). 3 Address correspondence to RD Semba, Johns Hopkins School of Medicine, 400 North Broadway, Suite 700, Baltimore, MD 21205. E-mail: [email protected]. Received January 22, 2010. Accepted for publication April 5, 2010. First published online May 5, 2010; doi: 10.3945/ajcn.2010.29254.

Am J Clin Nutr 2010;92:170–6. Printed in USA. Ó 2010 American Society for Nutrition

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ABSTRACT Background: Anemia is common among children in developing countries and is associated with decreased cognitive and physical development. Iron-fortified foods may decrease child anemia. Objective: The objective was to describe the association between iron-fortified milk and iron-fortified noodle consumption and anemia in children aged 6–59 mo. Design: Consumption of fortified milk and fortified noodles and child anemia were assessed in 81,885 families from rural and 26,653 families from urban slum areas in Indonesia. Results: The proportions of children who received fortified milk and noodles were 30.1% and 22.6%, respectively, in rural families and 40.1% and 48.9%, respectively, in urban families. The prevalence of anemia among children from rural families was 55.9% and from urban families was 60.8%. Children from rural and urban families were less likely to be anemic if they received fortified milk [odds ratio (OR): 0.76; 95% CI: 0.72, 0.80 (P , 0.0001) and OR: 0.79; 95% CI: 0.74, 0.86 (P , 0.0001), respectively] but not fortified noodles [OR: 0.98; 95% CI: 0.93, 1.09 (P = 0.56) and OR: 0.95; 95% CI: 0.88, 1.02 (P = 0.16), respectively] in multiple logistic regression models with adjustment for potential confounders. In rural families, the odds of anemia were lower when the child who consumed fortified milk also consumed fortified noodles or when the child who consumed fortified noodles also consumed fortified milk. Conclusions: In Indonesia, consumption of fortified milk and noodles was associated with decreased odds of child anemia. Iron-fortified milk and noodles may be a strategy that could be applied more widely as an intervention to decrease child anemia. Am J Clin Nutr 2010;92:170–6.

IRON-FORTIFIED MILK AND NOODLES AND CHILD ANEMIA SUBJECTS AND METHODS

data collection round were calculated based on the months in which data were collected for each round. Expenditure and price variables in US dollars per round were created and calculated with the use of the exchange rates by round. The study protocol complied with the principles enunciated in the Helsinki Declaration (15). The field teams were instructed to explain the purpose of the nutrition surveillance system and data collection to each child’s mother or caretaker, and, if present, the father and/or household head; data collection proceeded only after written informed consent was obtained. Participation was voluntary, no remuneration was provided to subjects, and all subjects were free to withdraw at any stage of the interview. The protocol of the NSS in Indonesia was approved by the Ministry of Health, Government of Indonesia. The plan for secondary data analysis was approved by the Institutional Review Board of the Johns Hopkins University School of Medicine. Rural and urban areas were analyzed separately because of differences in sampling methods and because the availability of fortified foods would be expected to differ between urban slums and rural areas. The study was limited to children aged 6–59 mo because the interpretation of low hemoglobin in children age ,6 mo is difficult. For families with more than one child aged 6–59 mo, the analysis was limited to the youngest child only (ie, families were not counted more than once because anemia tends to cluster within families). Anemia was defined as hemoglobin ,11 g/dL in children and ,12 g/dL in nonpregnant women, in accordance with World Health Organization criteria (1). Maternal age was divided into quartiles. Maternal and paternal education was categorized as 0, 1–6 (primary), 7–9 (junior high), and 10 y (high school or greater). The proportion of mothers and fathers who had achieved .12 y (high school graduate) was 2.3% and 3.8%, respectively, and was thus included in the category 10 y. Maternal smoking was not included as a covariate because ,0.1% of women were smokers. Weighting was used to adjust for urban as well as rural population size, by city and province, respectively, and all results were weighted. Weekly per capita household expenditure was used as the main indicator of socioeconomic status. Crowding was defined as households where .4 individuals ate from the same kitchen. Chi-square tests were used to compare categorical variables between groups. Analysis of variance (ANOVA) was used to compare the adjusted prevalence of anemia across groups by expenditure. Multiple logistic regression models were used to examine the relation between child anemia and the use of fortified milk and the use of fortified noodles. Variables were included in the multivariate models if significant in univariate analyses. P , 0.05 was considered significant. Covariance matrices were used to examine for multicollinearity among independent variables in the models. Data analyses were conducted with the use of SAS Survey (SAS Institute, Cary, NC). RESULTS

Of 81,885 families from rural areas and 26,653 families from urban slum areas, the proportion of children who consumed fortified milk was 30.1% and 40.1%, respectively. In families from rural and urban areas, the proportion of children who consumed fortified noodles was 22.6% and 48.9%, respectively. The prevalence of anemia among children aged 6–59 mo from rural and urban slum families was 55.9% and 60.8%, respectively.


The study subjects consisted of families from rural areas who participated in the Nutritional Surveillance System (NSS) in Indonesia from March 1999 to August 2003 and families from urban slum areas who participated in the NSS from January 1999 to July 2003. The NSS was established by the Ministry of Health, Government of Indonesia, and Helen Keller International in 1995 (11). The NSS was based on United Nations International Children’s Fund’s conceptual framework on the causes of malnutrition (12) with the underlying principle to monitor public health problems and guide policy decisions (13). The NSS used stratified multistage cluster sampling of households in subdistricts of administrative divisions of the country in rural and slum areas of large cities. During the study period, there were 17 rounds of data collection, from an average of ’4800 rural households and 1560 urban households per round. Data collection involved 5 major urban poor populations from slum areas in the cities of Jakarta, Surabaya, Makassar, Semarang, and Padang, and rural population from the provinces of Lampung, Banten, West Java, Central Java, East Java, the island of Lombok (West Nusatenggara), and South Sulawesi. New households were selected every round and data were collected by 2-person field teams. A structured, coded questionnaire was used to record data on children aged 0–59 mo; the questionnaire included anthropometric measurements, date of birth, and sex. The mother of the child or other adult member of the household was asked to provide information on the household’s composition, parental education, and weekly household expenditures, along with other socioeconomic, environmental sanitation, and health indicators. For each child in the family, data were collected on whether the child had received a vitamin A capsule and/or a deworming medication in the previous 6 mo. For each child in the family, data were collected on whether the child had consumed industrially produced milk products in the previous week, the commercial brand of the product, and how much money was spent on the milk product in the previous week. Similar data were collected on whether the child had consumed instant noodles in the previous week, the commercial brand of the product (which allowed classification of noodles as fortified or not), and how much was spent on the noodles in the previous week. Data on consumption of meat and poultry by the child in the previous week were also collected. Hemoglobin was measured in mothers and children in the family with the use of a HemoCue instrument (HemoCue AB, Angelholm, Sweden). Birth dates of the children were estimated with the use of a calendar of local and national events and were converted to the Gregorian calendar. The participation rate of families in the surveillance system was .97% in both urban slum and rural areas, and the main reason for nonresponse was that the family had moved out of the area or was absent at the time the interviews were conducted. Nonresponse because of refusal to participate in the surveillance system was very low (,1%). In each household, data were gathered regarding the expenditures in the previous week. Expenditure and price variables were collected in Indonesian rupiah. For this analysis, expenditures are presented in US dollars to control for the fluctuation of the Indonesian rupiah. In Indonesia, monthly exchange rates from 2000 to 2003 were established with the use of historic data available publicly through the Bank of Canada (14). Mean exchange rates by

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TABLE 1 Demographic and other factors related to anemia in children aged 6–59 mo from families in rural and urban slum areas of Indonesia Rural Variable1

n

Child with anemia

Urban P value2

n

%

P value2

%

24,638 57,078

47.4 59.7

,0.0001

9987 14,899

56.1 64.2

,0.0001

18,497 63,384

53.2 56.8

,0.0001

13,031 13,620

59.1 62.4

,0.0001

16,419 26,406 18,908 12,656 7493

75.4 65.7 47.6 37.8 30.8

,0.0001

4957 8427 6290 4445 2534

75.6 68.8 56.5 47.5 39.3

,0.0001

42,127 39,758

58.3 53.5

,0.0001

13,973 12,679

62.4 59.0

,0.0001

24,096 20,525 17,713 19,462

60.8 56.0 53.9 51.8

,0.0001

7138 6816 5901 6798

65.4 60.6 59.3 57.6

,0.0001

4,713 44,040 16,520 16,191

61.7 57.3 56.0 50.5

,0.0001

1373 12,516 6119 6565

62.3 62.7 61.0 56.7

,0.0001

10,188 56,988 12,241 2035

62.4 56.4 50.5 46.7

3310 16,768 5179 1129

65.8 61.8 56.0 54.1

19,082 58,674

66.8 52.8

,0.0001

7087 17,742

69.3 57.6

,0.0001

3435 38,940 14,982 21,817

62.8 57.2 55.5 52.3

,0.0001

632 9635 6385 9375

63.4 63.1 61.3 57.9

,0.0001

43,970 37,815

64.8 35.2

,0.0001

13,005 13,598

70.8 51.2

,0.0001

14,051 66,821

49.4 57.6

,0.0001

5482 21,136

58.0 61.5

,0.0001

48,381 31,224

52.7 61.1

,0.0001

15,455 10,210

58.4 64.5

,0.0001

6,099 73,974

53.6 56.3

,0.0001

2404 24,049

55.3 61.4

,0.0001

17,134 63,192

51.7 57.3

,0.0001

8745 17,799

58.5 62.0

,0.0001

59,726 20,387

56.7 53.6

,0.0001

18,974 7212

61.6 58.6

,0.0001

,0.0001

,0.0001

(Continued)


Child consumed fortified milk Yes No Child consumed fortified noodles Yes No Child age 6–11 mo 12–23 mo 24–35 mo 36–47 mo 48–59 mo Child sex Male Female Maternal age 24 y 25–28 y 29–32 y 33 y Maternal education None 1–6 y 7–9 y 10 y Maternal BMI ,18.5 kg/m2 18.5 to ,25 kg/m2 25 to ,30 kg/m2 30 kg/m2 Mother was anemic Yes No Paternal education None 1–6 y 7–9 y 10 y Child currently breastfeeding Yes No Child received deworming medication Yes No Child received vitamin A in past 6 mo Yes No Child consumed beef in past week Yes No Child consumed poultry in past week Yes No Father is a smoker Yes No

Child with anemia

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IRON-FORTIFIED MILK AND NOODLES AND CHILD ANEMIA TABLE 1 (Continued ) Rural Variable1 No. of household members eating from same kitchen 2–4 .4 Weekly per capita household expenditure3 Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5

Urban

n

Child with anemia

P value2

n

Child with anemia

P value2

33,203 40,147

% 54.8 56.4

,0.0001

13,824 12,475

% 60.6 61.5

,0.0001

14,672 14,672 14,674 14,670 14,672

61.0 57.7 55.9 53.0 50.6

,0.0001

5293 5295 5293 5293 5294

63.2 61.9 60.4 60.8 58.2

,0.0001

1 Missing data for the following numbers of participants (rural, urban): fortified milk (69, 1717); fortified noodles (4, 2); child age (3, 0); child sex (0, 1); maternal age (89, 0); maternal education (421, 80); maternal BMI (433, 267); maternal anemia (4129, 1824); paternal education (3711, 626); child breastfeeding (100, 50); deworming (1013, 35); vitamin A (2280, 988); paternal smoking (1772, 467); number of household members (8531, 354); and weekly per capita household expenditure (8525, 185). 2 Chi-square tests were used to compare categorical variables. 3 Quintiles 1 and 5 represent the lowest and the highest per capita household expenditure, respectively.

urban families, vitamin A supplementation was not significantly associated with anemia. Current breastfeeding was associated with higher odds of child anemia in the same multiple logistic regression models. Families were divided into 4 categories on the basis of weekly expenditure per child on fortified milk (Figure 1) and fortified noodles (Figure 2). The prevalence of child anemia decreased across the 4 categories of expenditure in both rural and urban families, when adjustment was made for the same covariates as in Table 2 (P , 0.0001). DISCUSSION

The present study shows that children aged 6–59 mo who consumed iron-fortified milk were less likely to be anemic than children who did not consume iron-fortified milk. To our knowledge, this is the first population-based study to show an association between consumption of fortified milk and decreased risk of anemia in children aged 6–59 mo. The findings in the study were consistent for children from families from rural areas and those from urban slums. The present study did not show that children who consumed fortified noodles alone had a lower risk of anemia; however, among rural families, children who consumed both fortified noodles and fortified milk had lower odds of anemia than if they consumed fortified milk alone. Less than one-half of families had children who consumed fortified milk and/or fortified noodles, but it should be noted that uptake of these products is passive because there is no active program for the provision of fortified milk or fortified noodles in Indonesia. Whether the consumption of fortified milk is causally related to lower anemia cannot be definitively concluded from these results, because the observation is based on cross-sectional associations from a nutritional surveillance program. However, such a conclusion seems reasonable. Previous interventional studies have shown that fortified milk decreases anemia in children (8, 9). A recent controlled trial in India showed that fortified milk decreased infectious disease morbidity in children aged 1–3 y (16). Diarrheal disease and infections are factors that also contribute to anemia in children in developing countries, and reduction of infectious disease morbidity by fortified milk would


The relation of demographic and other characteristics of families from rural areas and urban slum areas with child anemia is shown in Table 1. Factors associated with higher odds of child anemia were younger child age, male sex, lower maternal age, lower maternal education, maternal underweight, maternal anemia, lower paternal education, current breastfeeding, paternal smoking, .4 household members eating from the same kitchen, and lower weekly per capita household expenditure. Factors associated with lower odds of child anemia were consumption of fortified milk, consumption of fortified noodles, deworming, vitamin A supplementation, consumption of beef, and consumption of poultry. These findings were consistent for families from both rural and urban slum areas. The relation between consumption of fortified milk and fortified noodles and child anemia was examined in separate multiple logistic regression models for families from rural areas and urban slum areas (Table 2). In rural and urban families, consumption of fortified milk was associated with lower odds of child anemia in separate multiple logistic regression models, with adjustment for child age; child sex; maternal age, education, and body mass index; maternal anemia; current breastfeeding; deworming; vitamin A supplementation; beef consumption; poultry consumption; paternal smoking; household size; weekly per capita household expenditure; and location. In rural and urban families, consumption of fortified noodles was not significantly associated with lower odds of child anemia in separate multiple logistic regression models, when adjustment was made for the same covariates as above. An interaction was observed between the consumption of fortified milk and fortified noodles (P = 0.028) in rural families but not among urban families (P = 0.39). In rural families, the consumption of fortified milk was associated with lower odds of child anemia when the child who consumed fortified milk also consumed fortified noodles (odds ratio: 0.70; 95% CI: 0.63. 0.76; P , 0.0001). The consumption of fortified noodles was associated with lower odds of child anemia when the child who consumed fortified noodles also consumed fortified milk (odds ratio: 0.92; 95% CI: 0.84, 0.99; P = 0.04). Vitamin A supplementation was associated with lower odds of anemia in children from rural families. In the separate model for

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SEMBA ET AL

TABLE 2 Multiple logistic regression models for consumption of both fortified milk and fortified noodles and child anemia in families from rural and urban areas of Indonesia1 Rural

Urban

Variable

OR

95% CI

P value

OR

95% CI

P value

Child consumed fortified milk Child consumed fortified noodles Child age 6–11 mo 12–23 mo 24–35 mo 36–47 mo 48–59 mo P value for trend Male child Maternal age 24 y 25–28 y 29–32 y 33 y P value for trend Maternal education 0y 1–6 y 7–9 y 10 y P value for trend Maternal BMI ,18.5 kg/m2 18.5 to ,25 kg/m2 25 to ,30 kg/m2 30 kg/m2 P value for trend Mother was anemic Child currently breastfeeding Child received deworming medication in past 6 mo Child received vitamin A in past 6 mo Child consumed beef in past week Child consumed poultry in past week Father is a smoker More than 4 individuals eating from same kitchen Weekly per capita household expenditure2 Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5 P value for trend

0.76 0.98

0.72, 0.80 0.93, 1.04

,0.0001 0.50

0.79 0.95

0.74, 0.86 0.88, 1.02

,0.0001 0.16

1.00 0.72 0.41 0.29 0.21

— 0.68, 0.77 0.38, 0.45 0.27, 0.32 0.19, 0.24 ,0.0001 1.18, 1.29

— ,0.0001 ,0.0001 ,0.0001 ,0.0001

1.00 0.76 0.57 0.43 0.30

— ,0.0001 ,0.0001 ,0.0001 ,0.0001

,0.0001

1.21

— 0.69, 0.85 0.51, 0.65 0.37, 0.49 0.26, 0.35 ,0.0001 1.13, 1.29

1.24

,0.0001

— 0.91, 1.02 0.88, 1.00 0.78, 0.88 ,0.0001

— 0.20 0.04 ,0.0001

1.00 1.01 0.99 0.85

— 0.92, 1.11 0.89, 1.09 0.76, 0.94 0.0003

— 0.80 0.81 0.002

1.38 1.21 1.17 1.00

1.23, 1.56 1.14, 1.28 1.09, 1.25 — ,0.0001

,0.0001 ,0.0001 ,0.0001 —

1.32 1.31 1.20 1.00

1.11, 1.57 1.21, 1.43 1.09, 1.32 — ,0.0001

0.001 ,0.0001 0.0003 —

1.15 1.00 0.99 0.87

1.08, 1.23 — 0.94, 1.06 0.76, 0.98 0.86 1.69, 1.88 1.09, 1.13 0.94, 1.06 0.88, 0.97 0.92, 1.10 0.90, 1.01 0.97, 1.06 1.03, 1.13

,0.0001 — 0.97 0.03

1.06 1.00 0.90 0.85

0.24 — 0.02 0.05

,0.0001 ,0.0001 0.93 0.001 0.89 0.09 0.57 0.002

1.68 1.12 1.02 1.02 0.91 0.93 1.01 1.09

0.96, 1.18 — 0.83, 0.98 0.71, 1.00 0.01 1.55, 1.81 1.09, 1.16 0.93, 1.11 0.95, 1.09 0.81, 1.03 0.86, 1.00 0.94, 1.09 1.01, 1.18

— 0.33 0.28 0.84 0.55

1.00 0.97 1.03 1.05 1.02

1.79 1.11 0.99 0.92 1.01 0.95 1.01 1.08 1.00 0.97 1.04 0.99 0.98

— 0.90, 1.04 0.97, 1.11 0.92, 1.07 0.90, 1.06 0.62

— 0.87, 1.08 0.92, 1.15 0.94, 1.19 0.90, 1.16 0.43

,0.0001 ,0.0001 0.72 0.58 0.12 0.05 0.76 0.03 — 0.57 0.61 0.38 0.73

1 OR, odds ratio. Separate multiple logistic regression models were analyzed for rural and urban participants. All models were adjusted for location (province for rural model, city for urban model). 2 Quintiles 1 and 5 represent the lowest and the highest per capita household expenditure, respectively.

be expected to lower anemia of infection. Although the present study did not show a significant association between consumption of fortified noodles and child anemia in Indonesia, a previous study showed that iron-fortified noodles decreased iron-deficiency anemia in a controlled trial among school children aged 6–8 y in rural Vietnam (17). The strengths of this study are the large population-based sample size, the consistency of the results between rural and urban slum areas, and data that allowed analyses to be controlled for potential confounding factors. In epidemiologic studies, it is not possible to control for all factors, and unmeasured factors

may have influenced the relation between use of fortified milk and child anemia. The present study is limited in that hemoglobin alone was measured in children, with no measurement of biomarkers of iron status or other micronutrients that could contribute to anemia, such as vitamin A, folate, and vitamin B-12. The identification of specific micronutrient deficiencies through laboratory analyses was not an aim of the surveillance program and would have been difficult with a sample size of .100,000 children. Iron deficiency is usually considered to be the cause of about one-half of the cases of anemia in children (3). In Indonesia, iron deficiency is the main cause of anemia among


1.00 0.96 0.94 0.83

IRON-FORTIFIED MILK AND NOODLES AND CHILD ANEMIA

children in the community (18). Although malaria can cause anemia, the only study location that was endemic for malaria was Lombok. In the present study, children who were still breastfeeding at 6 to 59 mo of age were at higher risk of anemia. Although the proportion of infants who were exclusively breastfeeding at 6 mo of age was low, these findings are consistent with previous studies of anemia in breastfeeding infants aged .6 mo. In Mexico, the risk of anemia was increased among infants who were exclusive breastfeeding after 6 mo of age (19). A study in Argentina showed that iron-deficiency anemia was higher in exclusively breastfed infants up to 9 mo (20). In Malaysia, prolonged breastfeeding for .6 mo was associated with an increased risk

FIGURE 2. Prevalence of anemia in children aged 6–59 mo from families in rural (gray bars) and urban slum (black bars) areas of Indonesia by expenditure per child on fortified noodles, adjusted for child age, child sex, maternal anemia, current breastfeeding, deworming, vitamin A supplementation, beef consumption, poultry consumption, paternal smoking, household size, weekly per capita household expenditure, location, and maternal age, education, and BMI. P , 0.0001 by ANOVA across the 4 categories for both rural and urban areas.

of iron deficiency and iron-deficiency anemia (21). By the age of 6 mo, exclusive breastfeeding is not sufficient to meet the nutritional requirements for iron; therefore, complementary foods that contain iron are needed to meet the needs of infants (22). The results of the present study do not apply to children ,6 mo old who are breastfeeding. The prevalence of anemia among preschool-aged children in Indonesia, as in most of south and southeast Asia, is extremely high. The prevalence of anemia fits the World Health Organization’s definition of anemia as a severe health problem, because the prevalence is 40% (1). Although there are known interventions to decrease iron deficiency anemia, progress has been slow (4). The results of the present study suggest that compulsory fortification of milk with micronutrients in Indonesia has helped decrease child anemia. Use of fortified milk and noodles was higher in urban slum areas compared with rural areas, as would be expected based on their availability. Further work is needed to determine whether wider use of fortified milk and noodles for children aged 6–59 mo can decrease the high prevalence of child anemia in Indonesia. The authors’ responsibilities were as follows—KK and RDS: study design and analysis; KS: data analysis; MWB: design and establishment of the Nutrition Surveillance System in Indonesia; and all authors: interpretation of data and writing and editing of the manuscript. None of the authors had a conflict of interest.

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FIGURE 1. Prevalence of anemia in children aged 6–59 mo from families in rural (gray bars) and urban slum (black bars) areas of Indonesia by expenditure per child on fortified milk, adjusted for child age, child sex, maternal anemia, current breastfeeding, deworming, vitamin A supplementation, beef consumption, poultry consumption, paternal smoking, household size, weekly per capita household expenditure, location, and maternal age, education, and BMI. P , 0.0001 by ANOVA across the 4 categories for both rural and urban areas.

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