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"Penelitian-penelitian terdahulu telah mengajukan beberapa faktor yang dapat menyebabkan mengapa suplementasi besi pada wanita hamil masih belum memuaskan hasilnya. Faktor-faktor tersebut adalah distribusi yang tidak memadai, hasil jangkauan dan ketaatan berobat yang rendah, dan juga penyerapan usus yang rendah. Penelitian ini bertujuan untuk mengukur status besi wanita hamil setelah konsumsi biskuit yang mengandung bubuk ikan dan preparat besi-folat. Penelitian ini dilakukan di Purworejo, Jawa Tengah, dari bulan Pebruari sampai Oktober 2002. Tujuh-puluh wanita hamil dalam trimester kedua-ketiga dengan umur kehamilan antara 2-3 bulan ikut dalam penelitian yang menggunakan randomized controlled trial (RCT). Sepuluh wanita mengundurkan diri dan sisanya dibagi dalam dua kelompok yang terdiri dari 28 wanita yang diberikan biskuit yang diperkaya dengan protein ? zat besi (kelompok PIEC) dan 32 wanita diberikan biskuit yang diperkaya dengan zat besi (kelompok IEC). Pemberian biskuit dilakukan selama 12 minggu. Dari hasil penelitian didapatkan peningkatan kadar hemoglobin (Hb) dan reseptor transferin serum (sTfR) pada kedua kelompok. Selain itu terdapat penurunan kadar serum feritin (SF) di kedua kelompok. Namun demikian, pada akhir penelitian, peningkatan kadar Hb dan sTfR kedua kelompok ini berbeda bermakna, sedangkan penurunan SF tidak berbeda bermakna. Protein hewani berupa bubuk ikan cendrung meningkatkan absorpsi zat besi non-heme sehingga dapat meningkatkan kadar Hb dan sTfR pada wanita hamil. (Med J Indones 2003; 12: 243-6)

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Previous studies have revealed that several factors influenced the relatively low success of iron supplementation for pregnant women. The factors included poor distribution, low coverage and compliance, as well as low absorption. The aim of this study is to measure the iron status of pregnant women after consuming crackers containing fish powder and iron-folate. This study was carried out in the Purworejo district (Central Java) from February through October 2002. Using a randomized controlled trial (RCT) design, 70 pregnant women in their second-third month of pregnancy were recruited, and divided into two groups. Ten women dropped out during the study. The first group consisted of 28 women were given protein ? iron enriched crackers (PIEC group), while the second group of 32 women were given iron?enriched crackers (IEC group) for a total of 12 weeks. The results showed that the hemoglobin (Hb) levels and serum transferrin receptors (sTfR) of both groups were increased. Serum ferritins (SF) of both groups were decreased. At the end of the study, the increase in Hb and sTfR levels between the two groups were significantly different, while the decrease in SF was not significantly different. Animal protein from fish powder tended to improve absorption of non-heme iron among pregnant women, resulting in improved Hb and sTfR levels. (Med J Indones 2003; 12: 243-6)"

"ABSTRACTAlthough iron supplementation exists for pregnant women, the prevalence of anemia during pregnancy remains high. The lack of compliance of the target group is one of the reasons which may reduce the efficacy of the supplementation program.Recent studies in preschool children and non pregnant women has been reported that the administration of intermittent iron supplement was equally effective in improving the iron status as daily supplement.This research was to investigate whether a weekly dose of 120 mg iron supplementation would improve the iron status in the same way as a daily dose of 60 mg iron supplementation in pregnant women.The effect of daily vs weekly iron supplementation was studied in pregnant women in non randomized experimental community trial. The subjects were pregnant women who attended the selected Health Centers for the first time in their current pregnancy. Of the 176 pregnant women enrolled, a complete data set were available for 139 (79 %). Duration of supplementation was 8 - 20 weeks.Three health centers each, matched with socioeconomic condition were allocated for control group and treatment group. Daily group served as control received 60 mg Fe + 0.25 mg folic acid daily (68 pregnant women), while weekly group received 120 mg Fe + 0.50 mg folic acid weekly (71 pregnant women).Hemoglobin concentration in both group increased significantly after supplementation (p < 0.001). Improvement of hemoglobin was influenced by initial hemoglobin level (p < 0.001), and hookworm infestation (p < 0.05).Serum ferritin level decreased in daily and weekly group (p > 0.05). Serum ferritin change was not influenced by initial hemoglobin level (p ] 0.05), however was influenced by hookworm infestation (p < 0.001).The duration of supplementation had no effect on hemoglobin changes (p > 0.05), but it influenced serum ferritin changes (p < 0.05).It was concluded that supplementation with 120 mg elemental iron on weekly basis had similar effects as daily dose of 60 mg on hematological status, but was not enough to improve iron stores in pregnant women. "

"ABSTRACTThe relationship between serum vitamin A level and protein-energy status of 61 children in Jakarta was studied. The children 1 - 6 years old either received vitamin A supplements at various times, or never received any vitamin A supplements at all. There was a high prevalence of PEM among the sample and their energy and vitamin A consumption were low, though protein intake was adequate. The serum vitamin A levels of PEM children who received vitamin A supplements tended to decline more rapidly with time after supplementation compared to their non-PEM counterparts. A positive correlation, though weak, was also observed between serum vitamin A level and Wt/Age of the children. It was thus concluded that the fast decline in serum vitamin A level of PEM children could predispose them to vitamin A deficiency despite vitamin A supplementation. It was also suggested that further investigation is needed on the relationship between Wt/age and serum vitamin A level, because if such a relationship is established, Wt/age could be a very useful index for identifying children who are "at risk" of developing vitamin A deficiency."

"This randomized double-blind placebo-controlled trial aimed to compare the efficacy of daily iron supplementation and multi-micronutrient supplementation both daily and weekly basis on increasing iron status among 284 apparently healthy Indonesian infants aged 6-12 mo. Infants were randomly assigned to receive either daily 1 RDA multi micronutrient supplement (n = 72), weekly 2 RDA multi micronutrient supplement (n = 70), daily ferrous sulphate 10 mg (n = 72), or placebo (n = 70) for wk. Blood hemoglobin, plasma ferritin, plasma zinc, and plasma C-reactive protein concentrations were measured prior to intervention and after 23 wk of supplementation. At baseline, 58.1% of subjects were anemic, 28.2% were iron deficient, and 11.2% were zinc deficient. After 23 wk of supplementation, both daily 1 RDA multi micronutrient and iron supplemented groups had significantly increased blood hemoglobin and plasma ferritin concentration, furthermore reducing the percentage of anemia and iron deficiency. However, the changes of hemoglobin were not significantly different among the treatment groups. Changes of hemoglobin were significantly higher in daily 1 RDA multi micronutrient group than in placebo group when initial blood hemoglobin was low. The change of plasma ferritin concentration in both daily 1 RDA multi micronutrient and iron groups was significantly higher than in other groups. Hemoglobin and ferritin concentrations of weekly 2 RDA multi micronutrient group were not significantly increase, but there were significantly increased in the subjects with low concentration of blood hemoglobin or plasma ferritin. Proportion of infants with zinc deficiency was increased significantly in iron group Daily I RDA multi micronutrient and daily iron supplementation are efficacious in improving the concentration of blood hemoglobin and plasma ferritin and reducing the percentage of infants with anemia and iron deficiency of Indonesian infants aged 6-12 months in a rural community. However, there was an increasing proportion of infants with zinc deficiency in daily iron supplementation. The efficacy of daily 1 RDA multi micronutrient supplementation was higher among the children with blood hemoglobin < 110 g/L Efficacy of weekly 2 RDA multi micronutrient supplementation on the concentration of blood hemoglobin and plasma ferritin of all subjects was not found, but it affected in children with low concentration of blood hemoglobin or plasma ferritin."

"Prevalensi anemia di negara berkembang masih tetap tinggi meskipun program suplementasi tablet besi-asam folat telah dilaksanakan dalam skala besar. Dampak suplementasi dipengaruhi oleh berbagai faktor seperti rendahnya kepatuhan minum tablet, efek samping yang kurang disukai, persediaan tablet kurang, rendahnya jangkuan program, status vitamin A yang rendah dan hambatan asorpsi zat besi karena suplementasi zat besi setiap hard.Strategi yang mungkin dapat dilakukan untuk menurunkan prevalensi dan mengatasi masalah operasional adalah pemberian suplemen multi-vitamin mineral selama masa remaja dengan dosis lebih rendah dan frekuensi pemberian yang lebih jarang/tidak setiap hari.Suatu penelitian kros-seksional telah dilakukan untuk mendapatkan informasi dasar tentang status gizi dan kesehatan remaja laki-laki serta putri yang telah mendapat haid pada tiga buah sekolah menengah yang dipilih secara acak di Jakarta Timur. Usia rata-rata remaja laki-laki adalah 14,8 tahun dan remaja putri 15,6 tahun. Para remaja tersebut berasal dari keluarga golongan sosial ekonomi mengengah. Prevalensi "thinness" lebih tinggi pada laki-laki (43%) daripada yang putri (10,2%) dan kelebihan berat badan lebih banyak pada remaja putri (32,9%). Prevalensi "stunting" pada remaja laki-laki dan putri (22%). Prevalensi anemia lebih tinggi pada remaja putri (21%) daripada laki-laki (2,5%).Setelah penelitian kros-seksional, dilakukan intervensi/suplementasi dengan tujuan menentukan pengaruh multivitamin-mineral dalam berbagai dosis pada hemoglobin, feritin plasma dan status vitamin A remaja putri. Tiga ratus enam puluh tiga subyek dipilih secara acak yaitu remaja putri yang telah mendapat haid, dengan kisaran usia 14-18 tahun dan tidak menderita clamant, infeksi saluran nafas, atau penyakit "gastro intestinal". Pengelompokan subjek menjadi 4 kelompok perlakuan (tiga kelompok mendapat suplemen dan sate mendapat plasebo) dilakukan secara "double-blind". Pil suplemen yang mengandung: 60 mg zat besi el, 2500 SI vitamin A, 250 ug asam folat, dan 60 mg vitamin C diberikan kepada kelompok dosis harian (DD); 60 mg zat besi el, 20 000 SI vitamin A, 500 g g asam folat dan 60 mg vitamin C untuk kelompok setiap minggu dosis rendah (WLD); ] 20 mg zat besi el , 20 000 SI vitamin A, 500 lag asam folat dan 60 mg vitamin C untuk kelompok setiap minggu-dosis tinggi (WHD), dan kelompok terakhir diberi pil plasebo (PL). Pil multi-vitamin dan mineral tidak dapat dibedakan dari pil plasebo secara kasat mata. Sebelum suplementasi didapati prevalensi anemia yang tinggi (21%), feritin plasma rendah (37%), dan retinol plasma rendah (31%).Suplementasi selama 8 minggu menaikkan secara bermakna kadar hemoglobin (Hb), feritin plasma (FP), retinol plasma (RP), tinggi badan dan skor tes prestasi sekolah, semua kelompok yang mendapat suplemen. Kenaikan kadar FP kelompok dosis harian (DD) lebih besar (bermakna) daripada kelompok dosis setiap minggu.Penambahan vitamin A dalam pd suplemen meningkatkan kadar RP dan rupanya berpengaruh pada penggunaan zat besi secara efisien untuk erythropoiesis. Peningkatan pada kelompok plasebo (PL) tidak jelas sebabnya, tetapi ada kemungkinan pengaruh obat cacing.Peningkatan prestasi sekolah dapat disebabkan oleh peningkatan penyediaan zat besi dalam otak dan distribusinya ke sel-sel otak yang penting untuk kelancaran fungsi neuron "dopaminergic". Suplementasi multi-vitamin dan mineral dapat memacu pertumbuhan linier tetapi tidak mengkompensasi kehilangan awal. Bertambahnya tinggi badan karena suplemen multivitamin-mineral dapat dikaitkan Dengan perbaikan status zat, besi yang meningkatkan oksidasi dan penyediaan energi untuk propliferasi sal. Prevalensi "stunting", "thinness" dan kelebihan berat tidak berkurang. Berat badan rupanya tidak dipengaruhi oleh suplementasi multi- vitamin dan mineral.Peningkatan masa suplementasi sampai 12 minggu tidak menghasilkan peningkatan Hb dan RP pada kelompok multi-vitamin dan mineral, tetapi memberikan waktu yang lebih lama untuk meningkatkan (bermakna) FP pada kelompok dosis mingguan..Pada kelompok dosis harian (DO) kadar FP bertambah tetapi tidak berbeda bermakna darn kadar pads minggu ke 8.Tidak ada perbedaan efek dosis-frekuensi dari berbagai komposisi pil multi-vitamin dan mineral untuk seluruh rnasa suplementasi kecuali kenaikan FP yang menyolok kelompok dosis harian (DD) pada minggu ke-8.Selama masa 12 minggu, "individual lobe counts" dari granulosit (gejala defisiensi asam folat) setiap kelompok dalam kisaran normal sedangkan subjek penelitian tidak menderita demam, infeksi saluran pernafasan dan infeksi saluran pencernaan. Dengan demikian penyebab anemia dalam penelitian i:ni disebabkan oleh kelcurangan zat besi dan/atau kekurangan vitamin A.Pada minggu ke 36 (24 minggu atau 6 bulan setelah akhir suplementasi) subyek yang sama diperiksa lagi untuk menilai sisa (retention) pengaruh suplementasi multivitamin-mineral pada kadar Hb, FP, RP dan pertumbuhan badan.Semua kelompok yang mendapat suplemen, kadar RP dan tinggi badannya tetap lebih tinggi secara bermakna. Kadar Hb yang lebih tinggi (bermakna) hanya terdapat pada kelompok mingguan-dosis-rendah (WLD), sedangkan kadar FP yang lebih tinggi ditemukan pada kedua kelompok mingguan (WLD, WHD). Kadar Hb dan FP cenderung menurun mulai akhir suplementasi sampai minggu ke 36 sesudahnya.Oleh sebab itu suplementasi mingguan dengan pit dosis rendah (WLD) yang mengandung 60 mg zat besi el, dan 20 000 SI vitamin A, 500 μg asam folat dan 60 mg vitamin C selama 12 minggu, dapat dipertimbangkan sebagai strategi pencegahan untuk meningkatkan kesehatan, status gizi, dan skor tes prestasi belajar para remaja sebelum hamil. Suplementasi berkala perlu dilakukan setiap 6 bulan. Namun demikian perencana program perlu memperhatikan bahwa meskipun program suplementasi besi adalah jalur utama untuk menanggulangi anemia, di dalamnya harus ada pendidikan gizi antara lain tentang petunjuk aturan minum pil suplemen . Suatu strategi campuran yang seimbang yang terdiri dari strategi jangka menengah yang berhubungan dengan fortifkasi pangan dan strategi jangka panjang yang bertujuan mengubah kebiasaan makan melalui pendidikan gizi harus menjadi bagian program suplementasi zat besi untuk memastikan kesinambungan dari program.Penelitian lebih lanjut dengan jumlah subyek yang lebih besar perlu dilakukan untuk menunjang/menegaskan basil penelitian ini dan mengetahui peranan kekurangan zat gizi lain yang berkaitan dengan anemia seperti protein, Cu, vitamin B2, vitamin B6, dan vitamin B12. Kadar RP yang tidak berubah pada minggu ke 12 perlu diteliti lebih lanjut. Dosis vitamin yang lebih rendah (10.000 SI) mungkin cukup untuk meningkatkan kadar retinal. Selain itu karena keterbatasan waktu penelitian ini perlu dilakukan penelitian longitudinal suplementasi multi-vitamin-mineral mingguan dosis rendah (WLD). Penelitian operasional tentang sistem penyampaian (delivery system) suplemen multi-vitamin-mineral di sekolah-sekolah juga penting dipertimbangan.

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Prevalence of anemia (IDA) in pregnant women in Indonesia as well as in other developing countries is still high despite of large scale iron supplementation program. Reasons of ineffectiveness are poor compliance, law coverage, occurrence of iron dosage blockage, and law vitamin A status.

A cross-sectional study was conducted to obtain information on the health and nutritional status of randomly selected 118 males and 805 female school-going adolescents in three randomly selected high schools in East Jakarta. The prevalence of IDA was higher in females (21%) than in males (2.5%). Stunting was prevalent in both sexes (22%). The prevalence of thinness was higher in males (43%) than in females (10.2%), overweight was higher (32.9%) in females than in males (9.3%).

An intervention study for 12 weeks followed the cross-sectional study. This was to determine the effects of different regimens of multi-nutrient supplements on iron and vitamin A status of randomly selected 363 females in one randomly selected school .Allocation to 4 treatment groups were double-blind and all pills were similar on sight. Supplements contained 60 mg el iron, 2 500 IU vitamin A, 250 pg folic acid, and 60 mg vitamin C for the daily dose (DD); 60 mg el iron, 20 000 IU vita min A, 500,ag folic acid and 60 mg vitamin C for the weekly law dose (WLD); 120 mg el iron, 20 000 IU vitamin A, 500/,g folic acid and 60 mg vitamin C for the weekly high dose (WHD); and the last group was the Placebo (FL).

Supplementation significantly increased Hb, plasma ferritin (PF), and plasma retinol levels (PR) at the end of 8 weeks in all multi-supplemented groups. DD had significantly higher PF than the weekly doses. Other benefits were increased linear growth and test scores. The PL had significant decreased Hb and PF but increased PR.

Extending the supplementation period for 12 weeks resulted in no greater benefit in Hb and PR levels in the multi-nutrient supplemented groups but further significant increases in PF only in the weekly groups. All groups had further increased height.

At 36 weeks, a follow-up study was done to assess the retention of effects of multi-nutrient supplements on iron and vitamin A status of females as basis for the interval of supplementation. Remaining number of samples were: DD=37, WLD-45, WHD=40, PL =50. Hb, PF, PR and height in the WLD; PF, PR, and height in the WHD; PR and height in the DD remained significantly higher than baseline values.

The WLD supplement for 12 weeks every 6 months can be a possible preventive strategy to improve the iron status of female adolescents."

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

"Iron deficiency anemia among under live children is highly prevalent in Indonesia and is considered as a public health problem. Iron supplementation seems to be the most appropriate way to control iron deficiency in relatively short period of time. Children consume less food than adult and their diet often consists of foods with little iron content and poor iron bioavailability. Additional iron to food for children is therefore necessary. One possible food chosen as alternative vehicle to prevent iron deficiency among children is bread. This study gave iron supplementation using bread as vehicle which provided 25% of daily iron requirement of preschoolers to address iron deficiency problem in relatively short period of time.The study report is arranged and divided into three parts- Part I includes the background of the study, problem statement, rationale of the study, literature review, hypotheses, objectives and variable-indicator matrix.Part 2 is the manuscripts for publication. The manuscript ?The efficacy of iron supplementation using bread as vehicle of preschoolers in Surabaya, East Java? is written for submission to Asia Pasific Journal. This pan consists of abstract, introduction, materials and methods including study and subjects, sample size, study design, data collection, statistical analysis, ethical consideration, results, discussion, conclusion and references.Part 3 describes the questionnaire used for 'the data collection, detailed methodology and important results that have not been presented in the manuscript, ethical consideration, grant approval, references and curriculum vitae."

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