Kingdom of Bahrain

World Health Organization

Ministry of Health
Public Health Directorate
Nutrition Section

Regional Office (EMRO)

Cairo - Egypt

Impact of the National Flour Fortification Program

on the Prevalence of Iron Deficiency and Anemia
among Women at Reproductive Age in the
Kingdom of Bahrain
(First Monitoring Study)

Dr. Zuhair Salman Al-Dallal

Senior Nutritionist

Dr. Khairya Moosa Hussain

Chief, Nutrition Section

2003
2

Table of Contents
Acknowledgment ....

Abstract .....

Introduction .

9
11
11
11

Study Rationale
Objectives of the Study .
Specific Objectives ...

Material and Methods:

The Settings ..
Study Population ..
Study Design .
Sample Size ...
Pulling out the Sample ..
Official Procedure .
Teams .
Package ..
Questionnaire .
Data Collections .
Duration of Data Collections
Data Entry .
Data Analysis .
Sponsorship ...

13
13
13
13
14
14
14
14
15
15
16
16
16
17

Results:
Main Characteristics of the Participants .
Iron Status ..
Socio-Demographic Risk Factors for Iron Deficiency Anemia ..
Current Study vs. National Nutrition Survey ..
Awareness Regarding Fortification Program .

19
22
28
30
31

Discussion:
Introduction .
Iron Status
Impact of Fortification on the Prevalence of Iron Deficiency and Anemia
Fortification and Public Awareness ..

35
37
39
44

Conclusion ..

47

Recommendations ....

49

Appendix (1): Study Questionnaire ...

51

References ...

56

List of Tables
Table (1): Main Characteristics of the participants

19

Table (2): Distribution of the participants according to their

Geographical Region

20

Table (3): Socio-Demographic Characteristics of the participants ...

21

Table (4): Hematological and Biochemical Analysis of the participants ..

22

Table (5): Distribution of the participants according to their Hb level

and Age ..

25

Table (6): Distribution of the participants according to their Hb level

and Hemoglobin Groups ..

25

Table (7): Relationship between the participants Serum Ferritin level

and Hemoglobin Groups ......

26

Table (8): Classification of Iron Status using Hemoglobin Concentration

and Serum Ferritin Levels ...

27

Table (9): Relationship between the participants Folic Acid level and
Hemoglobin groups ...

27

Table (10): Relationship between the participants Vitamin B12 and

Hemoglobin groups .

28

Table (11): Correlation Coefficient between the participants Hb

Concentration and some risk factors related to iron status

29

Table (12): Correlation Coefficient between the participants SF

Concentration and some risk factors related to iron status .

29

Table (13): Correlation coefficient between the participants various

Blood Indices ...

30

Table (14): Comparison of the level by Age group between the Current
Study and the National Nutrition Survey

30

Table (15): Comparison of the low Hb level (< 12 g/dl) between the
Current Study and the National Nutrition Survey ..

31

Table (16): Participants Knowledge about the flour Fortification

Program

32

Table (17): Types and Frequency of consumed Bread by the

Participants ....

33

List of Figures
Figure (1): Frequency distribution of hemoglobin level with a normal
Curve of the Participants ..

23

Figure (2): Frequency distribution of Serum Ferritin level with a normal

Curve of the Participants ...

24

Acknowledgment
The successful implementation of this report would not have been possible without
the active dedicated efforts of number of organizations and individuals.
First of all, we would like to express our special thanks and gratitude to the Ministry
of Health, Kingdom of Bahrain and World Health Organization Regional Office
(EMRO), Egypt, for kindly supporting the conduct of this study.
We would like to record our indebtedness to the Director of the Central Statistics
Organization for pulling out the sample.
We wish to thank Mrs. Layla Al-Nashemi, Head of Health Centers Laboratories, for
her assistance in recruiting the investigators.
We would also like to extend our gratitude and thanks to Mrs. Manal A Al-Sairafi,
nutritionist, for her valuable comments on the final report.
Thanks to Mrs. Ghada Al-Raees, nutritionist, for her suggestions and input at early
stages prior to conducting the study.

Abstract
Impact of the National Flour Fortification Program on the Prevalence of Iron
Deficiency and Anemia among Women at Reproductive Age in the Kingdom of
Bahrain (First Monitoring Study)
By: Zuhair Salman Al-Dallal and Khairya Moosa Hussain

Iron deficiency anemia is the most common nutritional deficiency in the developing
world, and it affects almost 30% of the world population. Women of childbearing age
are at greatest risk because of the effects of menstruation and pregnancy. In the
Kingdom of Bahrain, iron deficiency anemia is considered as a major public health
concern, where it affects about 37.7% of females at reproductive age. Flour
fortification program was implemented in the country as a part of large scale program
to reduce the incidence of the disease. A cross-sectional study among Bahraini
females at childbearing age (14 49 years) was carried out almost six months post to
the implementation of the fortification program. The main objective of the study was
to explore the impact of the iron and folic acid fortified flour on hemoglobin and the
iron status of this population group. A total of 393 females were selected randomly by
the Central Statistics Organization and recruited for the purpose of this monitoring
study. They were interviewed by qualified and well trained laboratory technicians
using a pre- prepared questionnaire designed specially for this study. All the
participants agreed to give blood samples for hematological and biochemical analysis.
The data was computerized and analyzed using the SPSS package (version 11.0 for
Windows).
The mean Hb and SF levels were 11.9 g/dl and 30.4 g/L respectively. Participants
from Muharraq region found to had higher Hb level than participants from other
regions with a statistically significant difference.
A statistically significant association (P < 0.05) was found between Hb groups and SF
level. Participants with low Hb concentration tend to had lower SF level and verse
versa. Using dual criteria; Hb and SF, it was found that the prevalence of iron
deficiency anemia among the participants is 24.5%, while 51.3% of them were anemic
and 10.9% were at risk to develop iron deficiency anemia .
Correlation coefficient between both Hb and SF and some risk factors related to iron
status showed that Hb was positively correlated with SF of the participants. Among
anemic participants, Hb was positively correlated (P < 0.05) with the occupation,
while there was a significant correlation between SF and marital status of iron deficit
participants. Although, no obvious difference was found in the prevalence of anemia
between the current study and the National Nutrition Survey (pre-fortification study),
however, mean Hb among anemic participants in the current study was significantly
higher (P < 0.05). Unexpectedly, the majority of the participants (85.5%) were
unaware about the fortification program. Despite the short period between the
implementation of the fortification program and this study, a slight improvement was
found in the anemic status of the participants. In conclusion, it is early to draw up a
sound conclusion about the impact of the fortification program on the prevalence of
the iron deficiency anemia among this population group. Though, further monitoring
studies and investigations will be done in future.

Introduction

Introduction
Anemia is common throughout the world. Its main cause, iron deficiency which is the
most common known form of nutritional deficiency affecting more than 700 million
persons all over the world (WHO, 1993).
Simply stated an iron deficiency occurs when an insufficient amount of iron is
absorbed to meet the bodys requirements. This in-sufficiency might be attributed to
inadequate dietary iron intake, reduced bioavailability of dietary iron, increased needs
of iron, or to chronic blood loss. When prolonged, iron deficiency leads to iron
deficiency anemia.
This nutritional disorder has profound effects on psychological and physical
development, behavior, and work performance and eventually on productivity and
socioeconomic development (WHO, 1998). During pregnancy it increases maternal
morbidity, and mortality as well as prenatal mortality, and increases the risk of low
birth weight (WHO, 1989).
Its prevalence is highest among young children and women of childbearing age
because of the effects of menstruation and pregnancy. Women of childbearing age
usually require additional iron to compensate for menstrual blood loss (an average of
0.3 0.5 mg daily during their productivity years), and for tissue growth during
pregnancy and blood loss at delivery and postpartum (an average 3 mg daily over 280
days gestation) (CDC, 1998).
In the countries of the Eastern Mediterranean Region. Iron deficiency anemia affects
between 30% and 60% of women of childbearing age and young children (WHO,
1999). In the Kingdom of Bahrain, results of National Nutrition Survey revealed that
37.3 % of women aged 19 years and above having low hemoglobin (Hb < 12 gm/dl)
which means they were anemic (Moosa, 2002).
As a National strategy to control and prevent iron deficiency anemia, the Ministry of
Health in the Kingdom of Bahrain adopted a National flour fortification program in
collaboration with World Health Organization Regional Office for Eastern
Mediterranean Countries, which was lunched in November 2001, in-line with other
strategies such as nutrition education and supplementation program mainly for
pregnant women.
9

The fortification program have contributed to increased dietary iron intake and
reductions in iron deficiency anemia in many developed countries which is considered
as the most effective preventive tool (Whittaker et al., 2001).
However, continuous monitoring on both the effectiveness and safety of fortification
practices has proven necessary for improving quality and for advocacy purposes.

10

Study Rationale
The fortification program of flour with iron and folic acid was implemented as a
continuous program for the first time in the Kingdom of Bahrain in November 2001.
This program was performed as a part of enormous national program to reduce the
prevalence of iron deficiency anemia (IDA) among the Bahraini population. On the
other hand, there was an intention to establish a long-tem monitoring system to
evaluate the feasibility of the fortification program. However, this study was carried
out almost six months after the program implementation. In general, six months is an
adequate period to improve the iron status of a person with low hemoglobin if iron
fortified food or supplementation was introduced on regular basis (Stolzfuss and
Dreyfuss, 1998). Therefore, this study could be considered as the first monitoring
stage of the entire program.

Objectives of the study

This study was undertaken with these two main objectives:
1- Monitoring the flour fortification program.
2- Establishing a baseline data for monitoring program in future.

Specific objectives
1- To explore the impact of the iron and folic acid fortified flour on the Hb status
of Bahraini females at child- bearing age.
2- To assess the knowledge and awareness of Bahraini females about the fortified
flour program.
3- To explore the public attitudes towards the fortified flour.
4- To assess the current prevalence of IDA among Bahraini females at
childbearing age.

11

Materials & Methods

12

Materials and Methods

The Setting
The Kingdom of Bahrain which is situated 20 km east of the Saudi Arabia, consists of
several islands in the Arabian Gulf with a total area of 706 sq. km. The population of
the kingdom according to the published report of the Central Statistics Organization
(CSO) in 2001 was 650,604 of whom 37.6% were expatriates. Females at
childbearing age (14 49 years) represents about 55.6% of the whole Bahraini
females. The health services are organized into primary, secondary, and tertiary health
care, including high technology medicine. Health services are provided free of charge
to the population. The Kingdom of Bahrain is divided into five main Governorates,
and there are 4 5 health centers in each governorate, each health center serves
population according to their catchments area and with a view to making geographical
access to health services equitable and easier.

Study Population
The study population from which the participants were selected consist of Bahraini
females at childbearing age (14 49 years). This age group represents the most
vulnerable group to iron deficiency anemia. Non-Bahraini females were excluded
from this study.

Study Design
This study was designed as a cross-sectional study among Bahraini females.

Sample Size
The total sample size was calculated using the following equation:

N = Z P (1-P)/ d
where;
N = the total population.
Z = the standard normal deviate at confidence level (CI ) 95%.
P = the prevalence of iron deficiency anemia (IDA).
d = absolute precision.

13

Based on 50% prevalence of IDA, and absolute precision of 5% with 95% confidence
interval, the sample size was calculated to be 378. This number was multiplied by
10%, allowing for expected drops out, therefore, the number was increased to 416.

Pulling out the Sample

In order to select a representative sample from all over the kingdom, an official letter
was sent to the Director of the Central Statistic Organization (CSO) to pull out the
sample. A list of 538 names were obtained from the CSO as they were randomly
selected by computer from different ages and areas as required for this study.

Official Procedures
As the researchers were asked to visit the participants in their resident, each of them
was provided with a special identification card (ID) and an official letter signed by the
Head of Nutrition Section describing the research objectives.
A special form was also designed in order to obtain the written consent of the subject
or their parents prior to the interview and withdrawing the blood sample.

Teams
The researchers were divided into teams, each team consists of two persons, one to
interview the subject and extract the information while the other is to take the body
measurements and collect the blood sample. Each team was assigned to a particular
area in the country. In general, we had three teams of surveyors whom were
responsible to collect the data from the participants from all areas in the Kingdom.

Package
Each team was provided with a research package which consist of:
1- Name lists of the selected participants with their full addresses.
2- Questionnaires.
3- Weighing scale (Soehnle).
4- Stadiometer (Seca).
5- Ice box.
6- Needles, vacutainer, vacutainer EDTA, and tourniquet.
7- Cotton, gloves, sterile alcohol swap, and plastic strap box.
8- Full blood count and immunoassay forms.
14

Questionnaire
A special questionnaire was developed and prepared for the purpose of this study. The
questionnaire was divided into four main sections as follow:
Section 1: This section covered the socio-demographical data; such as date of birth,
educational level, marital status, geographical area, and monthly family income.
Section 2: This section includes the anthropometrical data. Weight and height were
recorded in this section, while the body mass index (BMI) was calculated later and
recorded as well.
Section 3: This section was prepared to collect the personal and health related data ,
such as: menstrual data, pregnancy, and number of children. In addition, medical
history such as; previous disease, hereditary diseases, bleeding, drugs and vitamin
taken.
Section 4: This section was designed to collect data related to fortification
knowledge, type of flour used at home, dishes made by the flour, origin country of the
flour, and frequency of consumption of certain types of bread and food prepared by
the flour.

Data Collection
The data collection part was divided into four main phases as follow:
Phase One (Recruitment phase): Because in this study we aimed to extract a blood
sample from our participants, we searched for laboratory technicians to be recruited
for this purpose. In addition, as our participants are females, the laboratory technician
needed were females as well. As this is more culturally accepted.
However, in order to select a professional team, a circular was distributed in the all
health centers introducing the research importance and describing its objectives and
the needs for professional female laboratory technicians.
Phase Two (Training phase): After the laboratory technicians were selected (6
laboratory technicians), a special training session was conducted by a Senior
Nutritionist for all the whole group. The training program was focused mainly on
taking body measurements (weight and height), interviewing techniques using the
questionnaire and extracting the information from the participants, and using the

15

address guideline to identify the subjects addresses. Therefore, the researchers were
the laboratory technicians themselves.
Phase Three (Field work): Interviews were held at the participants residence. A
special questionnaire was designed and developed for this purpose, and filled at the
time of the interview by the researchers.
Phase Four (Blood Sampling): A blood sample was obtained from each subject
participant in the study at the end of the interview. The blood samples were
transported in sterile container directly to the laboratory in Salmaniya Medical
Complex in iceboxes for analysis. These were stored at 4C overnight and analyzed
the next working day.

Duration of Data Collection

The data collection part started on the 1st. of May 2002 and lasted for almost four
months as it was completed on the 20th. of August 2002.

Data Entry
All the data were entered and stored on a computer data base file using SPSS package
(version 11.0 for Windows) by a senior Nutritionist on daily basis. The blood results
were added to the data as soon as they were received from the laboratory using ID
number.

Data Analysis
Data were analyzed using the same statistical package (SPSS). Comparison of mean
values between groups was done using the analysis of variance (ANOVA). For all
tests of statistical significance, a p value < 0.05 was considered as statistically
significant.
Age of the participants was classified into four groups; < 20 years, 20 29 years, 30
39 years, and 40 years and above.
Hemoglobin concentration (Hb) was categorized into three groups; < 11.0 g/dl, 11.0
11.9 g/dl, and > 11.9 g/dl. In some parts of the study, and for certain purpose, the Hb
was classified into two groups; < 12 and 12 g/dl, and the participants were classified

16

as anemic if their Hb level was less than 12 g/dl based on the World Health
Organization criteria (WHO, 1989).
Blood samples taken from the participants were used for the measurements of several
biochemical indices including hematologic profile; serum ferritin, folic acid, vitamin
B12, blood hemoglobin concentration, red blood cell, MCV, MCH, and MCHC.
The cut-off point used for identification of participants with anemia was hemoglobin
concentration below 12.0 g/dl. participants were classified as iron deficient when
serum ferritin concentration was lower than 15.0 g/L based on the WHO criteria
(WHO, 1998).

Sponsorship
This study was partially funded by the World Health Organization Regional Office
(EMRO), Cairo Egypt as well as by the Ministry of Health, Kingdom of Bahrain.

17

Results

18

Results
1- Main Characteristics of the Participants
The total number of the interviewed subjects was 416 participants, however, 23
questionnaires were excluded from the study during data cleaning and analysis as they
did not meet the study criteria. Therefore, this brought up the total number into 393
participants in this study.
In table (1) the main characteristics of the participants were demonstrated. The mean
age was found 30.7 years, while the mean weight and height of the participants were
77 16.6 kg and 158 6.5 cm respectively. Mean age at menarche was 12.6 1.5
years with a minimum of 9 years and maximum of 20 years.

Table (1): Main characteristics of the Participants

Variable

Mean SD

Minimum

Maximum

Age (yrs)
Weight (kg)
Height (cm)
BMI
Age at menarche (yrs)

30.7 10.2
77.0 16.6
158 6.5
27.2 6.4
12.6 1.5

14
37
140
14.8
9

49
140
195
48.4
20

Distribution of the participants according to their geographical region is described in

table (2). The percentage of the participants involved in this study is shown in the
middle column of table (2), whereas the actual proportion of population in each region
is shown in the last column. However, our participants represents almost the actual
proportion of population from each region in the Kingdom according to the CSO
statistics (2001), except the participants from the Riffa area. In fact, our investigators
faced some difficulties in interviewing the participants from Riffa as most of them
refused to participate in the study. Therefore, there was a big difference between the
percentage of the participated participants (3.6%) and the actual percentage of the
population in Riffa area (10.0%).
Age group, educational level, occupation, marital status, and family income were
demonstrated in table (3).

19

The majority of the participants had education of high school or below (63.5%) while
28.6% had higher education, and this was expected as 22.9% of the participants were
less than 20 years of age, mainly at school age. According to the occupation of the
participants, it was found that most of the participants were housewives (37.4%),
where students represents 25.4% of the participants. Whereas, married participants
consist 58% of our participants as shown in table (3). On the other hand, 54.2% of the
participants belong to low income families (less than BD 300 per month).
The majority of the participants do not have children or had never been pregnant
before (47.1%), this could be attributed to the fact that 40.2% of the participants were
single, as 11.0% of the married participants had no children or had never been
pregnant.

Table (2): Distribution of the participants according to their

geographical region
Region

No.

% (of population)*

Hidd
Muharraq
Manama
Jidhafs
Northern region
Sitra
Isa Town
Central Region
Riffa
Western Region**

7
62
56
49
28
39
26
50
14
62

1.8
15.8
14.2
12.5
7.1
9.9
6.6
12.7
3.6
15.8

1.8
15.2
11.0
11.3
8.0
8.0
8.4
8.9
10.0
17.3

Total

393

100.0

100.0

* According to CSO (2001).

** Western region includes Hamad Town.

20

Table (3): Socio-demographic characteristics of the

participants
Variable

No.

< 20 years
20 29 years
30 39 years
40 years

90
96
102
105

22.9
24.4
26.0
26.7

Total

393

100.0

Illiterate
High School
> High School

30
242
109

7.9
63.5
28.6

Total

381

100.0

Housewife
Employed
Student
Unemployed

143
102
97
40

37.4
26.7
25.4
10.5

Total

382

100.0

Single
Married
Divorced
Widow

158
228
4
3

40.2
58.0
1.0
0.8

Total

393

100.0

Low (< 300 BD)

Medium ( 300 700 BD)
High ( > 700 BD)

195
129
36

54.2
35.8
10.0

Total

360

100.0

185
126
82

47.1
32.0
20.9

393

100.0

Age:

Educational Level:

Occupation:

Marital Status:

Family Income:

Parity:
None
14
5 and more

Total

21

2- Iron Status
Blood sample was extracted from each subject for hematological and biochemical
analysis and the results were summarized in table (4). For hematological analysis,
only hemoglobin concentration was found to be lower than the cut-off point with a
mean of 11.9 1.2, while all other results were within the normal range. Figure (1)
shows the distribution and frequency of hemoglobin among our participants.
Serum Ferritin level of the participants in this study shows vast variations; the
minimum found to be 0.5 g/L while the maximum was 311 g/L with a mean of 30.4
and standard deviation 32.7. However, figure (2) shows the distribution and
frequencies of SF.

Table (4): Hematological and Biochemical Analysis of the

participants
Variable

No.

Mean SD

Min. Max.

Normal range

Hb (g/dl)
RBC ( x 10^12/1)
MCV (fl)
MCH (pg)
MCHC (g/dl)
SF (g/L)
Folic Acid (nmol/L)
Vitamin B12 (pmol/l)

393
392
392
392
392
384
381
384

11.9 1.2
4.7 0.5
76.6 8.9
25.6 4.1
33.1 1.4
30.4 32.7
24.7 7.2
290 160

7.8 15.4
2.8 - 6.5
6.8 95.0
17.0 72.1
22.3 50.4
0.5 311
7.0 45.3
39 - 1475

12 14.5
3.9 5.2
82 97
27 33
32 36
7 282
6.6 28.1
133 - 835

In order to explore the hemoglobin concentration among different age group, the
participants were grouped into four groups and correlated with the hemoglobin
concentration (table 5). The mean hemoglobin for most age groups were almost
similar (11.9 1.1), however, this result confirm that among females from different
age groups, the hemoglobin status is need to be corrected as it is still low.

22

Hemoglobin Level (g/dl)

80

60

Frequency

40

20
Std. Dev = 1.18
Mean = 11.92
N = 393.00

0
8.00

9.00

8.50

10.00 11.00 12.00 13.00 14.00 15.00

9.50

10.50 11.50 12.50 13.50 14.50 15.50

Hemoglobin Level (g/dl)

Figure (1): Frequency distribution of hemoglobin level with a normal

curve of the participants

23

Serum Ferritim Level (ug/L)

100

80

60

Frequency

40

20

Std. Dev = 32.69

Mean = 30.4
N = 384.00

0
0.
30 0
0.
28 .0
0
26 .0
0
24 0
0.
22 .0
0
20 0
0.
18 .0
0
16 .0
0
14 .0
0
12 0
0.
10
.0
80
.0
60
.0
40
.0
20
0
0.

Serum Ferritim Level (ug/L)

Figure (2): Frequency distribution of Serum Ferritin level with a

normal curve of the participants

24

Table (5): Distribution of the participants according to their

Hb level and age group
Age group

No.

Hb (g/dl)

Minimum

Maximum

8.2
9.0
8.3
7.8
7.8

14.3
14.1
14.9
15.4
15.4

Mean SD*
< 20 years
20 29 years
30 39 years
40 years
Total

90
96
102
105
393

11.9 1.2
11.9 1.1
11.9 1.1
12.0 1.3
11.9 1.2

* No significant differences between the different groups.

The participants were distributed according to their geographical region as shown in

table (6). The hemoglobin level of the participants was correlated according to the
geographical region. Participants from Muharraq region showed a significantly higher
mean hemoglobin concentration (12.3 1.4) than Manama, Jidhafs, Northern region,
Sitra, Central region, Riffa, and Hamad town (P value < 0.05). There were no
significant differences between other regions. There was no significant difference
among other regions (Table 6).

Table (6): Distribution of the participants according to their

Hb level and geographical region
Region

No.

Hb (g/dl)

Minimum

Maximum

9.4
9.0
9.2
8.5
9.8
9.4
9.5
7.8
8.1
8.2
10.3
7.8

13.6
14.9
14.5
14.3
13.0
13.7
13.5
15.4
13.7
14.2
13.5
15.4

Mean SD
Hidd
Muharraq
Manama
Jidhafs
Northern Region
Sitra
Isa Town
Central Region
Riffa
Hamad Town
Western Region
Total

7
62
56
49
28
39
26
50
14
48
14
393

11.8 1.5
12.3* 1.4
11.9 1.0
11.9 1.2
11.7 0.7
11.7 1.1
12.0 1.0
11.8 1.3
11.5 1.7
11.8 1.0
12.1 1.3
11.9 1.2

* The mean difference is significant at P < 0.05 than Manama, Jidhafs, Northern region, Sitra, Central
region, Riffa, and Hamad Town.

25

In addition, in order to explore the relationship between the hemoglobin and serum
ferritin levels of the participants, both were correlated as shown in table (7). It was
found that there is a significant statistical difference (P < 0.05) between the
hemoglobin group and serum ferritin level. Participants with low hemoglobin had
lower serum ferritin level, as hemoglobin level increases the serum ferritin increase.
The impact of this result emphasis on the contribution of iron deficiency on anemia
status.

Table (7): Relationship between the participants Serum

Ferrtin level and Hemoglobin groups
Hb group

No.

SF (g/L)

Minimum

Maximum

Mean SD
< 11.0 g/dl
11.0 11.9 g/dl
12.0g/dl

73
124
187

24.7 34.4
26.2 28.0
35.1* 34.3

0.5
0.7
1.3

217.0
203.0
311.0

Total

384

30.3 32.7

0.5

311.0

* The mean difference is significant at P < 0.05 than Hb groups < 11.0 g/dl and 11.0 11.9 g/dl.

In table (8) iron status of the participants was analyzed using dual criteria;
hemoglobin and serum ferritin. It shows the prevalence of iron deficiency measured
by serum ferritin concentration and the prevalence of anemia measured by
hemoglobin concentration. The cut-off point used for low hemoglobin concentration
was set to < 12 g/dl and for low serum ferritin was < 15 g/L according to the WHO
recommendation. Consequently, it was found that 24.5% of the participants were
suffering from iron deficiency anemia (low in both hemoglobin and serum ferritin
concentrations). On the other hand, the majority of the participants (51.3%) were
classified as anemic (low hemoglobin concentration), whereas 35.4% of them were
iron deficient (Serum ferritin lower than 15 g/L).

26

Table (8): Classification of Iron Status using Hemoglobin

concentration and Serum Ferritin level
Hb Category

Serum Ferritin level

< 15 g/L

Total

15 g/L

Hb < 12 g/dl
Hb 12g/dl

94 (24.5%)
42 (10.9%)

103 (26.8%)
145 (37.8%)

197 (51.3%)
187 (48.7%)

Total

136 (35.4%)

248 (64.6%)

384 (100%)

The folic acid status of the participants was correlated with the hemoglobin
concentration as shown in table (9). There was a statistically significant difference (P
< 0.05) between the low hemoglobin and folic acid status. Participants with
hemoglobin concentration 11.0 g/dl had lower folic acid than participants with
hemoglobin concentration 11.0 11.9 g/dl. Furthermore, participants with
hemoglobin concentration 12 g/dl had higher vitamin B12 level than participants
with lower hemoglobin at P value < 0.05 (Table 10).

Table (9): Relationship between the participants Folic acid

level and Hemoglobin groups
Hb group

No.

Folic Acid (nmol/L)

Minimum

Maximum

Mean SD
< 11.0 g/dl
11.0 11.9 g/dl
12.0g/dl

73
123
185

23.0 7.6
25.5* 7.1
24.8 7.2

8.5
9.3
7.0

44.1
45.0
45.3

Total

381

24.7 7.2

7.0

45.3

* The mean difference is significant at P < 0.05 than Hb group < 11.0 g/dl.

27

Table (10): Relationship between the participants Vitamin

B12 level and Hemoglobin groups
Hb group

No.

Vit. B12 (pmol/l)

Minimum

Maximum

Mean SD
< 11.0 g/dl
11.0 11.9 g/dl
12.0g/dl

72
125
187

279.8 196.7
269.0 144.1
307.5* 155.6

49
39
64

1475
921
992

Total

384

289.7 160.2

39

1475

* The mean difference is significant at P < 0.05 than Hb group 11.0 11.9 g/dl.

3- Socio-Demographic Risk Factors for Iron Deficiency and Anemia

Socio-demographic factors that may considered as risk factors of iron deficiency and
anemia such as age, educational level, occupation, marital status, education, family
income, and parity among our participants, were correlated with the hemoglobin
concentration and serum ferritin level are shown in tables (11) and (12).
The hemoglobin concentration was positively correlated with serum ferritin
concentration in the participants with different iron status (Table 11). Among anemic
participants, hemoglobin concentration is significantly correlated with the occupation
of the subject at level < 0.05.
Serum ferritin concentration was correlated with some risk factors to develop iron
deficiency anemia (Table 12). Marital status was found positively correlated with the
serum ferritin concentration among iron deficient participants at level < 0.05.
Moreover, in anemic participants, occupation and parity were significantly correlated
with the serum ferritin concentration at level < 0.01 and < 0.05 respectively.

28

Table ( 11): Correlation coefficient between the participants

Hb concentration and some risk factors related to Iron
Status
Factor
Serum Ferritin
Age
Occupation
Marital status
Education
Family Income
Parity

Iron Deficient

Anemic

Non-Anemic

0.251*
0.019
0.048
0.002
0.196
0.18
- 0.114

- 0.432**
0.129
- 0.182*
0.107
0.058
0.032
- 0.041

0.178*
0.002
- 0.002
0.063
0.019
0.005
0.09

* Correlation is significant at the 0.05 level (2-tailed).

** Correlation is significant at the 0.01 level (2-tailed).

Table ( 12): Correlation coefficient between the participants

SF concentration and some risk factors related to Iron
Status
Factor
Age
Occupation
Marital status
Education
Family Income
Parity

Iron Deficient

Anemic

Non-Anemic

0.169
- 0.072
0.282*
0.195
0.011
0.142

0.014
0.199*
0.014
- 0.158
- 0.032
0.166**

0.154
- 0.015
0.074
- 0.295*
- 0.081
0.085

* Correlation is significant at the 0.01 level (2-tailed).

** Correlation is significant at the 0.05 level (2-tailed).

In order to explore the relationship between different blood indices and their effect on
the iron status, blood indices of the participants were correlated using 2-tailed
correlation coefficient analysis (Table 13). Serum ferritin was significantly correlated
with hemoglobin concentration at level 0.01, but was not correlated with folic acid
and vitamin B12. Furthermore, hemoglobin concentration was positively correlated
with vitamin B12 at the 0.05 level.

29

Table (13): Correlation coefficient between the participants

various blood indices
Variable

Serum Ferritin

Hemoglobin

Folic Acid

Vitamin B12

1
0.206*
- 0.053
0.041

0.206*
1
0.15
0.113**

- 0.053
0.015
1
0.138*

0.041
0.133**
0.138*
1

Serum Ferritin
Hemoglobin
Folic Acid
Vitamin B12

*Correlation is significant at the 0.01 level (2-tailed).

** Correlation is significant at the 0.05 level (2-tailed).

4- Current Study vs. National Nutrition Survey (NNS)

The data related to the hemoglobin concentration collected in this monitoring study
was compared with the data from the NNS (Moosa, 2002). Table (14) summarize the
comparison between both studies according to hemoglobin concentration among
different age groups. It was found that the data from both studies were almost similar,
however, there was no significant difference in hemoglobin concentration between
them.

Table (14): Comparison of Hb level by age group between

the current study and the NNS*
Age group
No.

Current Study**
%
Mean SD

No.

NNS*
Mean SD

19 29 yrs
30 39 yrs
40 49 yrs

122
102
105

37.1
31.0
31.9

11.9 1.1
11.9 1.1
12.0 1.3

195
205
184

33.4
35.1
31.5

11.7 1.3
12.0 1.6
11.9 1.5

Total

329

100

11.9 1.2

584

100

11.8 1.5

* NNS: National Nutrition Survey (Moosa, 2002).

** Participants aged less than 19 years were excluded.

Furthermore, low hemoglobin concentration in both studies were compared, although

the prevalence of low hemoglobin in the current study was higher than in NNS, but
the mean of low hemoglobin in the current study was statistically different than mean
hemoglobin in NNS at P value < 0.05 (Table 15).

30

Table (15): Comparison of low Hb level (< 12 g/dl) between

the current study and the NNS
Study
Current study
NNS

No.
202
262

Mean SD*

Minimum

Maximum

51.4
34.6

11.0 0.8
10.7 0.9

7.8
7.0

11.9
11.9

* The mean difference is significant at P < 0.05 between both studies.

5- Awareness Regarding Flour Fortification Program

The participants were asked if they know the meaning of fortification or if they have
any information about the flour fortification program or had heard about it.
Unfortunately, the majority of the participants (85.5%) stated that they do not know
the meaning of fortification is and had never heard about the fortification program
(table 16). On the other hand, with reference to the most consumed type of flour at
home, 68.4 % of the participants stated that the multipurpose flour (extraction rate
75%) is the most consumed type of flour, while 17.8% reported that they do not know
the type of flour they use.
About 62% of the participants knew the country of origin of the flour purchased or
consumed at home, as the majority reported that Bahrain is the country of origin
(88.4%). When participants were asked about the most type of dishes prepared at
home by the flour, they reported that the most dishes were sweets, cakes, and pastries
(57.5%, 22.1%, and 17.1% respectively).
Table (17) demonstrates the most frequent types of bread and derivatives consumed
by the participants. The majority of the participants (62.6%) consume the Tanoor
bread (the traditional bread) on daily basis (this type of bread is mostly prepared by
flour No. 1 which is extracted by 78% and fortified by iron and folic acid). On the
other hand, 47.3% of the participants consume the Western bread type (mainly sliced
bread) on daily basis. Moreover, 30.8 % consume pizza once a week, 17.8% for both
Arabic bread and rusks, while 14% and 10.9% consume Chappatti (Indian bread) and
Turkish bread once a week.

31

Table (16): Participants Knowledge about the Flour

Fortification Program
Variable

No.

Know
Do not Know

57
336

14.5
85.5

Total

393

100.0

Multipurpose
Flour No. 2*
Flour No. 1**
Others***

269
26
9
19

83.3
8.0
2.8
5.9

Total

323

100.0

Yes
No

242
151

61.6
38.4

Total

393

100.0

Bahrain
Saudi (KSA)
Kuwait
USA

214
12
10
6

88.4
5.0
4.1
2.5

Total

242

100.0

Sweets
Cakes
Pastries
Others

172
66
51
10

57.5
22.1
17.1
3.3

Total

299

100.0

Knowledge about the Program:

Type of most used Flour:

Country of Origin:

Name of the Country:

Dishes Made by Flour:

* Flour No. 2 with extraction rate of 86%

** Flour No. 1 with extraction rate of 78%
*** Others includes: American flour, Kuwaiti flour, Saudi flour, and flour 1&2 together.

32

Table (17): Types and Frequency of Consumed Bread by the

participants
Type of Bread
Tanoor Bread*
Western Bread
Pizza
Arabic Bread
Rusks
Chappatti**
Turkish Bread

Frequency

No.

Daily
Daily
Once a week
Once a week
Once a week
Once a week
Once a week

246
186
121
70
70
55
43

62.6
47.3
30.8
17.8
17.8
14.0
10.9

*Tanoor Bread is the traditional bread consumed in Bahrain.

** Chapptti is the Indian type of bread.

33

Discussion

34

Discussion
Introduction
Iron deficiency with or without anemia is the most common nutrient deficiency in the
developing world, whereas women of childbearing age are at greatest risk because of
the effects of menstruation and pregnancy (Patterson et al., 2001)
Furthermore, micronutrient deficiencies especially iron; still represent significant
problems in the Kingdom of Bahrain among women of reproductive age. An
estimated 40% of the pregnant mothers attending MCH suffer from iron deficiency
anemia and/or iron deficient (Moosa and Zein, 1996).
Important risk factors for iron deficiency and anemia among Bahraini women of
childbearing age are mainly dietary habits, noncompliance of women in taking the
iron supplements, infections, and hereditary diseases.
Overall, the prevalence of iron deficiency anemia in the Kingdom of Bahrain is
relatively high compared to the international rates and standards, especially among
women of reproductive age. Among adult women, iron deficiency was found to be
responsible for lost productivity and premature death (Wu et al., 2002). It is also
implicated as a cause of perinatal complications such as low birth weight and
premature delivery in affected mothers (CDC, 2002).
Therefore, in order to prevent, control and compact this health problem and its series
consequences, Nutrition Section (Ministry of Health) initiated a National Program
to reduce the prevalence rate of anemia and iron deficiency anemia by flour
fortification with iron and folic acid (according to the WHO recommendations).
Along with this study, we are attempting to set up a surveillance system by
implementing a national survey (system) to monitor the flour fortification program
and track the micronutrients status of targeted population. Our participants; females at
childbearing age, represents the most vulnerable group in the community to develop
anemia and /or iron deficiency anemia.
The flour fortification program was implemented in the Kingdom of Bahrain in
November 2001, while this study was carried out almost six months later. However, it
35

could be considered as the first monitoring study for the planned surveillance system.
In general, six months period could be an adequate period to improve the iron status
in the body of a person with iron deficiency if the intake of supplements and fortified
foods was on a regular basis (Stolzfus and Dreyfuss, 1998; WHO, 1989). However, in
very severe cases of iron storage depletion, recovery may take longer period and it
may need further intervention with certain iron supplementation. Conversely, in
Venezuela, Garcia-Casal and Layrisse (2002) found a striking reduction in the
prevalence of iron deficiency and anemia after 2 years of fortification.
One of the most common and important strategies for the control of iron deficiency
anemia worldwide is fortification. Fortification of an appropriate food vehicle with
specific nutrients has been practiced in numerous industrialized countries for many
years with considerable success (Darnton-Hill et al., 1999). Fortification efforts have
in the past been less effective, in term both of start-up and of sustainability, in
developing countries compared with the more industrialized world ( Hurrell, 1997).
Fortification of staples (e.g., wheat flour) is a cost-effective and feasible strategy, but
regular monitoring is required to demonstrate effectiveness and ensure quality (Yip
and Ramakrishnan, 2002).
Darnton-Hill et al. (1999) demonstrated that fortification has also been identified as
one of the most cost-effective and sustainable approaches to controlling iron
deficiency anemia. With improved iron status, gain in productivity have been shown
to increase by 10% to 30% (Darnton-Hill et al., 1999).
It was well known, since the late 40s of the last century, that fortification of cereal
flour is one of the most useful public health strategies to control certain deficiencies.
In addition, flour fortification with iron and other vitamins was also reported to be of
great impact on reducing the incidence of iron deficiency (Beinner and Lamounier,
2003).
Moreover, Yip and Ramakrishnan (2002) reported that fortification is probably the
most efficient method to improve the iron status even though it is not specific for
women; men and children will also benefit.

36

The elemental iron powders have been used for cereal fortification for more than 50
years and continue to be the most widely used iron compound for this purpose
(Hurrell, 2002). On the other hand, Uauy et al. (2002) argued that elemental iron
despite being very compatible with most food matrixes is very poorly absorbed and,
thus, is not useful even at high levels of fortifications
Nevertheless, for successful iron fortification, it is important to select food vehicles
that are consumed daily, to choose an iron compound that is well absorbed, and to
maintain control of the enrichment (INACG, 1993; INACG, 1982).
In the Kingdom of Bahrain, all the above premises have been fulfilled for the
fortification program. The flour was fortified with 60 ppm of elemental iron and
15 ppm of folic acid based on the WHO recommendation. Therefore, we selected the
elemental iron because it is most stable form at a very high temperature and humidity.
Consequently, the entire population (except infants) consumes the bread made by the
fortified flour. On the other hand, many authors have demonstrated the iron
bioavailability restrictions of the elemental iron (Hurrell, 2002; Uauy et al. 2002).
Conversely, the industrialized process of fortifying flour allows full control of the
ingredients.
Furthermore, there are some major technical constrains when cereals are selected as
vehicles for fortification: high levels of phytic acid was considered as a main
constrain. However, to overcome this obstacle in Bahrain, it was recommended to
fortify the flour with extraction rate less than 80% (i.e. less phytate).
Although, Martorell (2002) argued that in the Middle East, it is well-established that
most of the anemia is due to iron deficiency. Yip and Ramakrishnan (2002) showed
that in most industrialized areas, iron deficiency among women of reproductive age is
more likely to be due to increased blood loss than to poor diet.

Iron Status
Based on our results, table (8) shows the results of the survey carried out on the
prevalence of iron deficiency measured by serum ferritin concentration and the
prevalence of anemia measured by hemoglobin concentration. Accordingly, the
prevalence of IDA among our population group did not show any changes when it is
37

compared with previous studies (Moosa, 2002). However, the prevalence of IDA
raised by 16.8%. Conversely, the iron status reflected by mean serum ferritin showed
slight progress.
As indicated by Fleming et al. (2001), hemoglobin concentration is the last iron index
to change in uncomplicated iron deficiency, and thus it may not provide information
about early stage of iron storage depletion, which is reflected by decreased serum
ferritin concentration.
In Venezuela, according to Garcia-Casal and Layrisse (2002), they found that there
was a striking reduction in the prevalence of iron deficiency and anemia after two
years of fortification program implementation. Therefore, we believe it is still early
and very unlikely to drop out a conclusion about the effect and feasibility of the
fortification program in Bahrain.
In Sweden, at least 25% of the decline in prevalent of iron deficiency was attributed to
iron fortification (Martorell, 2002), while the reminder was attributed to greater
prescription of iron tablets, and use of ascorbic acid supplements, highlighting the
need for multiple strategies to prevent iron deficiency. Therefore, we should not
depend entirely on the fortification program to eradicate or reduce the incidence of
anemia or iron deficiency. Moreover, where other strategies must be implemented in
line with fortification like routine screening, supplementation programs, and dietary
diversification program.
Nevertheless, anemia of this type in this population group (females of childbearing
age) was diagnosed to be due to iron deficiency. It is therefore possible to conclude
that the amount of iron is not the limiting factor causing IDA; rather its absorption is
the problem.
An analysis of the diet of Bahraini population (Moosa, 2002), revealed that indeed the
main sources of iron were meat and fish, with negligible participation of fruits and
vegetables and other foods of animal source. In fact, these foods are considered as
good sources of quality iron and iron absorption enhancers. However, it was found
that the consumption rate of these foods were not high enough in our community.
Furthermore, Bahrainis dietary behavior consists of a lot of bad habits, as it contains
many iron absorption inhibitors such as phytic acid and polyphenols. The influence of
the diet composition on enhancing or inhibiting iron absorption has been well
38

documented and summarized by Hernnandez et al., (2003) and Layrisse and GarciaCasal (1997).
Hallberg and his colleagues (1998) have analyzed the influence of diet composition in
iron absorption and storage in the liver. They estimated that vegetarian diet with large
amounts of cereals and legumes limit iron bioavailability to 25 g/kg of food per day.
Comparatively, they also estimated that in the primitive diet of early humans, which
was mainly based on meat and fish, iron absorption was 15%, which caused liver
storage of 500 mg (Hallberg et al., 1998).
Other important conclusions included that the steady-state level or iron storage is
determined by iron bioavailability, and that any change in the quality of the diet
affects this parameter within the first year. Therefore, any effectiveness evaluation of
a food fortification program should be monitored mainly during its first year (Dary,
2002b).
The diagnosis of iron deficiency is often prompted by historical features and aided by
specific clinical and laboratory data. Thorough history taking is an essential part of
discovery and management. Dietary history may provide evidence supporting iron
deficiency. Specific dietary practices such as consume less rich iron sources, consume
more iron absorption inhibitors, and lack of iron supplementation. On the other hand,
Wu et al. (2002), suggest that history alone neither confirms nor rules out the
presence of iron deficiency but may help to identify those at low risk, thus avoiding
unnecessary screening.

Impact of Fortification Program on the Prevalence of Iron

Deficiency and Anemia
The amount of fortified flour consumed by target individuals at the household level is
an important issue. Do women at reproductive age, the group at highest risk of iron
deficiency anemia, eat enough processed wheat products at regular intervals to justify
a fortification intervention? In general, low socioeconomic status remains a predictor
of community rates for iron deficiency, even in countries where iron fortification is
widespread and has been successful in reducing iron deficiency. Members of the
poorer socioeconomic strata generally consume fewer meat products.
39

The second issue is the consumption of iron absorption enhancers. Among this
population the consumption of meat and fruits found to be very low as found in the
NNS findings (Moosa, 2002), especially among those who belong to low
socioeconomic group and to large families usually do not get their iron requirements.
It was well documented by many investigators, that in lower-income groups,
reduction in the quality and quantity of food consumption, characterized by a lower
intake of meat, vegetables, fruits, as well as cereals, grains, and tubers may lead to
decrease in dietary iron intake.
Wheat flour and its products are the most frequent fortified foods, mainly with
reduced iron, which has low bioavailability (Fritz et al., 1970; Forbes et al., 1989).
Whereas, studies in Venezuela (Layrisse and Garcia-Casal, 1997; Layrisse et al.,
1996) have reported that fortification of wheat and corn flour with ferrous fumarate is
more successful than with other iron sources.
Our results confirmed the findings reported by others that ferrous sulfate is well
utilized when added to wheat flour (Fritz et al., 1975). However, it is not a suitable
sources of iron fortification because it easily oxidizes the food matrix, affecting its
shelf-life and acceptability in storage (Hurrell et al., 1989).
This finding is contradictory to those reported by others who found a better iron
availability from diets with high iron content.
In Bahrain, the fortified flour (with iron and folic acid) supplies the body with only
25% of its daily iron requirements. However, this means that the other 75% of the
body iron requirements should be supplied by other sources, especially animal
sources. Consequently, the intention of fortification was not to overcome the problem
of anemia and iron deficiency, but as a part of a multi-national program to reduce the
magnitude of the problem. On the other hand, the diet in Bahrain based on rice, meat,
fish, and bread, with a very small proportion of foods from vegetable origin. Based on
the composition of this diet, it is possible to estimate that the amount of iron supplied
is sufficient to cover the recommended nutrient intake (RNI).
For example, by analyzing the consumption and nutritional composition of the daily
micronutrient intakes of the Bahraini adult females' diet, it is calculated that on
average their diet provides between 83.8% to 117.2% of the RNI for iron (Moosa,
40

2002). It is therefore difficult to explain through a dietary analysis why iron

deficiency anemia is so prevalent and extended in Bahrain. Consequently, there is
only one explanation for this, it could be attributed to the low iron bioavialability.
However, Dary (2002b) showed that in this case the improvement of iron status owing
to the consumption of iron-fortified flours was not determined either.
In spite of all efforts done before, during, and after the flour fortification with iron and
folic acid program including education and marketing, the Bahraini population is still
suffering from iron deficiency anemia. There are many reasons to explain this
situation, including of course that the implemented fortification program is still in
progress as the results are considered as provisional outcome, and because of the short
period between the implementation and conducting this study. Moreover, it is obvious
that large sectors of the population are not consuming sufficient amount of the
fortified foods as well as iron absorption enhancers, and other iron rich sources. In
addition, it might also be that the bioavailability of iron in the food they most
consume is low.
Darnton-Hill (1998) explained this as there are two main issues regarding
consumption of wheat flour. One is the larger question of whether wheat flour
products are consumed, and to what extent, by a target population. In our study, it was
shown that most of the participants (62.6%) consume the traditional bread (Tanoor)
which is made by fortified flour on daily basis, even though the prevalence of IDA
still high. Consequently, this finding confirm the fact that consuming fortified
products by itself without giving little concern to consume other rich iron sources
and/or enhancers, will never correct the iron status among all age groups in the
community.
A very important point, since the fortification program was not intended for a specific
group of population; in fact small children do not eat staple foods (bread) in sufficient
amount. Hence, they will continue to be at risk of suffering IDA, despite the existence
of food fortification programs with good coverage and good iron quality. This
problem, however, could be overcome easily by introducing a good screening
program for this age group along with iron supplementation (Nutrition Section future
plans).

41

In addition, it is worth mentioning that the bioavailability of elemental iron in its best
form (electronic iron) is usually half that of ferrous sulfate (Dary, 2002b). Therefore,
in the Kingdom of Bahrain it is used in double the amount, which was recommended
by the WHO for ferrous sulphate (ferrous sulphate 30 ppm while ferric sulphate 60
ppm).
Furthermore, it is well known that iron fortification of staple foods would benefit
large segments of the population, but it would be very difficult to solve iron
deficiency entirely, mainly owing to levels of iron that these foods allow (Dary,
2002b).
The flour fortification program implementation with elemental iron and folic acid in
Bahrain did not cause any kind of adverse complications, such as taste, texture, color,
smell, and even the price of the bread did not affected as the flour is subsidized by the
government.
Although in our study we concluded that the prevalence of IDA was higher than in the
NNS (Moosa, 2002), it was clear that, the implementation and consumption of the
fortified flour gave a small but statistically significant increase in the hemoglobin
concentration (0.3 g/dl) after only six months of implementation. Elwood and
colleagues (1971) support our finding. In their study, Elwood et al. (1971) found that
neither trial provided conclusive evidence of any beneficial effect of wheat
fortification on iron status, even though the reduced iron-fortified bread gave a small
but statistically significant increase in hemoglobin (0.24 g/dl) after nine months of
intervention.
Unfortunately, there is only one published study reporting improved iron status in a
population fed regularly with an elemental iron-fortified cereal, this study was
conducted among infants in Chile (Walter et al., 1993). Walter and his colleagues
(1993) concluded that cereal fortified with electrolytic iron could contribute
substantially to preventing IDA. Whereas this is true, it should be emphasized that
IDA was not eradicated completely in Chile according to Walter and colleagues' study
even though the cereal provided an extra 14 to 17 mg iron per day.
Moreover, the Central American population is still suffering from IDA in spite of all
efforts in food fortification with iron (Dary, 2002a). He argued that, there are many
reasons to explain this situation, including of course that the implemented fortification
42

programs have been unsuccessful. Dary (2002a) also reported that, it is obvious that
large sectors of the Central American population are not consuming sufficient amount
of the fortified food, but it might also be that the bioavailability of iron in those foods
is low.
Ultimately, the usefulness of elemental iron for food fortification depends on the
ability of the fortified food, when consumed as part of the normal diet, to prevent iron
deficiency in at-risk population group (Hurrell et al., 2002).
The bioavailability or efficacy of this product, however, has not been tested in
Bahrain. Bioavailability and/or efficacy tests of the fortified products will be
important in guiding policy on these products.
Strengthening of both program monitoring and evaluation is required to generate
proper data for decision makers, in terms of both policy and program improvement,
and to assess the effectiveness of intervention strategies (Winichagoon, 2002).
The result of this study suggests that dietary treatment of iron deficiency is feasible
for women of childbearing age. It also emphasizes on the fact that flour fortification
program somehow improved the iron status for a certain limit of the population of this
study after six months only of the implementation of flour fortification program.
Therefore, this may lead us to conclude that continuity of the fortification program
with continuous monitoring may help to reduce the prevalence of IDA among this age
group. In fact, the findings of this study are supported by Darys (2002a) assumption
that iron deficiency in many developing countries is usually a problem of iron quality
rather than iron quantity.
Hurrell et al. (2002) argued that the elemental iron powders are less well absorbed
than soluble iron compounds and they vary in their absorption depending on
manufacturing method and physiochemical characteristics. This argument emphasizes
on the importance of educating the people not to depend merely on the fortified flour
to correct their iron status. Therefore, encouraging them to consume more iron
absorption enhancers and to give up the bad dietary habits which are considered as a
crucial technique.

43

Fortification and Public Awareness

Although a condensed national educational and marketing campaign was conducted
for the public prior to and after the implementation of the fortification program, it
seems from this study that this campaign did not achieve its goals and objectives.
Based on our results, awareness of fortification and the importance of avoiding iron
absorption inhibitors were very low among our population. Whereas, the results
acquired from this study show that only 15% of the study population are aware of the
fortification program, or the meaning of the word "fortification" itself.
Moreover, the majority of them knew very little about the consequences of anemia or
even IDA. In the United States (CDC, 1998), the public health approaches of
education and iron fortification had a great success in reducing the prevalence of
anemia in women at reproductive age. Consequently, this could put on our burden
more obligations to condense and spread the education for the whole population
groups.
Iron deficiency and anemia occur in this population group within a dietary context
that is much constrained by dietary habits, economic and environmental conditions
that limit proper iron intake and absorption.
Another issue relating to fortification, as described by Yip and Ramakrishnan (2002),
is the concern that people in the target population may not consume enough of the
fortified food, such as iron-fortified wheat flour. However, even a low consumption of
fortified wheat flour is likely to provide a significant increase in iron intake. Whereas,
in such small population like Bahraini population, the iron fortified flour is consumed
by almost all the population sectors for a very simple reason. This is because in
Bahrain there is only one Mill Company, this company is responsible for supplying
almost 80% of the bakeries in the country with the fortified flour for different uses
and purposes. Recently, HE Minister of Trade issued a resolution stated that All
imported flour should be fortified with iron, otherwise, it well be rejected.
Therefore, this means that we are quite confident that all the flour used in Bahrain for
preparing the bread and its derivates (products) is fortified. Therefore, this fact
confounds the above assumption.
Overall, in the Kingdom of Bahrain, the apparent lack of effect of the fortification
program on anemia prevalence has several reasons: first is the short period between
44

the monitoring study and the implementation of the fortification program, and second
is the lack of awareness, high intake of iron absorption inhibitors, and continuity of
certain dietary habits.

45

Conclusion

46

Conclusion
The fortification of flour with iron and folic acid in the Kingdom of Bahrain is
considered as a big challenge for many reasons. Actually, it went through various
stages and faced several difficulties and barriers. These barriers were within the
Ministry of Health and other related governmental organizations; mainly convincing
policy makers as well as convincing the millers about the importance and urgent
needs for the fortification program. Therefore, the implementation of the program by
itself could be considered as a huge victory for the Nutrition Section. In fact, the
process of iron fortification was introduced with a multiphase system in order to
check for its efficacy and effectiveness by the time. Fortification is the beginning
phase of this system, which will be an ongoing system.
However, the results of this monitoring study showed for a certain extent a slight
improvement in the hemoglobin concentration and iron status of the population
investigated. Although, there were some unexpected or frustrating findings, these
could be translated as positive results to be used in future for planning of more
effective and accurate programs and studies.
On the other hand, to really overcome iron deficiency, any fortification program
should be complemented with the implementation of other interventions. In this
context, most of the reviewed articles, emphasized on the importance of the
monitoring program during the first year of fortification. In addition, it is very
difficult to come up with a conclusion from this first stage, which is actually six
months period of post fortification implementation as it is too short to draw up a
conclusion.
In general, the monitoring program will be continued and the data of this study will be
used as a reference to evaluate the entire program.

47

Recommendations

48

Recommendations
In order to overcome the barriers facing the fortification program to achieve its
intended purpose of reducing the prevalence of IDA and improve the iron status of the
Bahraini population, and according to the outcomes of this study, we recommend the
following:
1- The composition of the natural diet must improve because the presence of iron
inhibitors is the main constraint to enhancement of iron absorption. Inclusion
of meat is very important in the diets of developing countries.
2- Nutritional education is essential to achieve a good impact of food fortification
programs, promoting simultaneously the composition of iron absorption
enhancers (such as ascorbic acid and red meat) and avoiding iron inhibitors
(tea and coffee, for example).
3- Strengthening other strategies to complement the fortification program; such
as supplementation program for vulnerable groups as well as screening
program and dietary diversification.
4- Further studies and investigations should be carried out in the future.
5- One of the most important issues, regulatory monitoring is required to
demonstrate effectiveness and ensure quality.

49

Appendices

50

APPENDIX (1): Study Questionnaire

-

49 15 ) (
:
........................................................ :
..................................................... :

:
-1 :
-......................................................................................................................... :
-....................................................................................................................... :
- 19......../....../...... :.
-2:

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

-3 :

-4:

-5 :

-6 ......................... :.
-7 ) (:

:
-8 ............................. :.
-9 .................................... :.
-11 :

-10 .............................. :

51

 :
-12 .......................... :.

-13 1 :

-14 " " " " .............................................................. :

-15 :
-16 :

-17 "" :

:
-18 :

- 19 :
-20 :
-21 :

-22 "" :
-23 :

-24 1 :

:
-25 6 :

-26 " " ......................................................................... :

52

-27 6 :

-28 " " .............................................................................. :

-29 1 :
-30 "" :

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

-31 1 :

-32 " " ..................................................................................... :

1

-33 :

-34 "" ....................................................................................... :

1

-35 :

-36 " " ....................................................................................... :

-37 1 :

-38 " " ....................................................................................... :

-39 ................................................................................................ :

53

 :
1

40 :

-41 "" ................................................................... :

-42 :

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

-44 ............................................................................... :
1

-45 :

-46 "" .............................................................................................. :

-47 :

)(



/

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

54

References

55

References
- Beinner, M.A. and Lamounier, J.A. (2003). Recent experience with
fortification of foods and beverages with iron for the control of iron-deficiency
anemia in Brazilian children. Food and Nutrition Bulletin 24 (3), 268 274.
- Center for Disease Control and Prevention (1998). Recommendations to
Prevent and Control Iron Deficiency in the United States. Department of
Health and Human Services. U.S. CDC. Vol. 47/No. RR-3, April 3, 1998.
- Center for Disease Control and Prevention (2002). Iron Deficiency United
States, 1999 2000. Morbidity and Mortality Weekly Report 51 (40), 897
899.
- Darnton-Hill, I. (1998). Overview: rationale and elements of a successful
food fortification program. Food and Nutrition Bulletin 19, 92 -200.
- Darnton-Hill, I., Mora, J.O., Weinstein, H., Wibur, S. and Nalubola, P.R.
(1999). Iron and folate fortification in the Americas to prevent and control
micronutrient malnutrition: An analysis. Nutrition Reviews 57 (1), 25 31.
- Dary, O. (2002a). Lessons learned with iron fortification in Central America
Discussion. Nutrition Reviews 60 (7), S30 S31.
- Dary, O. (2002b), Staple food fortification with iron: A multifactorial
decision Discussion. Nutrition Reviews 60 (7), S34 S41.
- Elwood. P. C., Waters, W. E. and Sweetran, P. (1971). The haematinic effect
of iron in flour. Clinical Sciences 40, 31 37.
- Fleming, D. J., Jacques, P.F., Massaro, J.M., D'Agostino, R. B., Wilson,
P.W.F. and Wood, R.J. (2001). Aspirin intake and the use of serum ferritin as
a measure of iron status. American Journal of Clinical Nutrition 74 (2), 219
226.
56

- Forbes, A.L., Adams, C.E., Arnaud, M.J., Chichester, C.O., Cook, J.D. and
Harrison, B.N. (1989). Comparison of in vitro, animal determinations of iron
bioavailability: International National Anemia Consultant Group Task Force report on
iron bioavailability. American Journal of Clinical Nutrition 94, 225 238.
- Fritz, J.C., Pla, G.W., Roberts, T., Bohene, J.W., and Hove, E. (1970). Biological
availability in animals of iron from common dietary sources. Journal of Agriculture
and Food Chemistry 18, 647 - 651.
- Hallberg, L., Hulthen, L. and Garby, L. (1998). Iron stores in man in relation
to diet and iron requirement. European Journal of Clinical Nutrition 52, 623
631.
- Hernandez, M., Sousa, V., Moreno, A., Villapando, S. and Lopez-Alarcon,
M. (2003). Iron bioavailability and utilization in rats are lower from limetreated corn flour than from wheat when they are fortified with different
sources of iron. The Journal of Nutrition 133 (1), 154 159.
- Hurrell, R. F. (2002). Fortification: Overcoming technical and practical
barriers. The Journal of Nutrition 132, 806S 812S.
- Hurrell, R. F. (1997). Preventing iron deficiency through food fortification.
Nutrition Reviews 55, 210 - 222.
- Hurrell, R., Bothwell, T., Cook, J.D., Dary, O., Davidsson, L., FairweatherTait, S., Hallberg, L., Lynch, S., Rosado, J., Walter, T. and Whittaker, P.
(2002). The usefulness of elemental iron for cereal flour fortification:
SUSTAIN Task Force report. Sharing United States Technology to Aid in the
Improvement of Nutrition. Nutrition Reviews 60 (12), 391 406.

- Hurrell, R. F., Furniss, D.E., Burri, J., Whittaker, P., Lynch, S.R. and Cook,
J.D. (1989). Iron fortification of infant cereals: a proposal for the use of
57

ferrous fumarate or ferrous succinate. American Journal of Clinical Nutrition

49, 1274 1282.
- International Nutritional Anemia Consultation Group (INACG) (1993). Iron
EDTA for Food Fortification. INACG, Washington, DC.
- International Nutritional Anemia Consultation Group (INACG) (1982). The
effect of cereals and legumes on iron availability. INACG, Washington, DC:
Nutrition Foundation, 16 22.
- Garcia-Casal, M.N. and Layrisse, M. (2002). Iron fortification of flour in
Venezuela Discussion. Nutrition Reviews 60 (7), S26 - S29.
- Layrisse, M., Chavez, F., Mendez-Castellano, H., Bosch, V., Tropper, E.,
Bastardo, B. and Gonzalez, E. (1996). Early response to the effect of iron
fortification in the Venezuelan population. American Journal of Clinical
Nutrition 64, 903 907.
- Layrisse, M. and Garcia-Casal, M.N. (1997). Strategies for the prevention of iron
deficiency through foods in the household. Nutrition Reviews (55), 233 239.
- Martorell, R. (2002). Panel Discussion: Regional Action Priorities. The
Journal of Nutrition 132, 817S 874S.
- Moosa, K (2002). National Nutrition Survey for Adult Bahrainis Aged 19
years and Above. Nutrition Section, Ministry of Health, Kingdom of Bahrain.
- Moosa, K. and Zein, Z.A. (1996). Assessment of the iron status and dietary
intakes of pregnant women in Bahrain. Nutrition Section, Ministry of Health,
Bahrain.
- Patterson , A. J., Brown, W.J., Roberts, D.C.K. and Seldon, M.R. (2001).
Dietary treatment of iron deficiency in women of childbearing age. American
Journal of Clinical Nutrition 74 (5), 650 656.

58

- Stolzfuss, R.J. and Dreyfuss, M.L. (1998). Guidelines for the use of iron
supplements to prevent and treat iron deficiency anemia. International
Nutritional Anemia Consultation Group (INACG), Washington, DC.
- Uauy, R, Hertrampf, E. and Reddy, M. (2002). Iron fortification of foods:
Overcoming Technical and Practical barriers. The Journal of Nutrition 132,
849S 852S.
- Walter T., Dallman, P.R., Pizarro, F., Velozo, L., Pena, G., Bartholmey, S.J.,
Hertrampf, E., Olivares, M., Letelier, A. and Arredondo, M. (1993).
Effectiveness of iron-fortified cereal in prevention of iron deficiency anaemia.
Pediatrics 91, 976 982.
- Whittaker P., Tufaro, P.R. and Rader, J.I. (2001). Iron and Folate in Fortified
Cereals. Journal of American College of Nutrition 20 (3), 247 54.
- Winichagoon, P. (2002). Prevention and control of anemia: Thailand
experiences. Nutrition Reviews 132, 862S 866S.
- World Health Organization (1999). Fortification of Flour To Control
Micronutrient Deficiencies in Countries of The Eastern Mediterranean,
Middle East and North Africa. WHO-Em/NUT/203/E/G/1999.
- World Health Organization (1998). Fortification of Flour with Iron In
Countries of The Eastern Mediterranean, Middle East and North Africa.
WHO-EM/NUT/202/E/G/1998. Geneva.
- World Health Organization (1993). Micronutrient Deficiency Information
System (Overview). WHO Nutrition Unit, Geneva.
- World Health Organization (1989). Preventing and Controlling Iron
Deficiency Anemia Through Primary Health Care. WHO, Geneva.

59

- Wu, A.C., Arthur, P., Antwi, K.Y. and Yeung, G. (2002). Randomized,
controlled trial of single versus 3-times-daily ferrous sulfate drops for
treatment of anemia. Pediatrics 108 (3), 613 -616.
- Yip, R., Ramakrishnan, U. (2002). Experience and Challenges in Developing
Countries. Supplement: Forging Effective Strategies to Combat Iron
Deficiency. The Journal of Nutrition 132, 827S 830S.

60

First Published 2003 by

Ministry of Health Kingdom of Bahrain
Impact of the National Flour Fortification Program on the Prevalence of Iron Deficiency and
Anemia among Women at Reproductive Age in the Kingdom of Bahrain (First Monitoring
Study).
1. Flour Fortification
I. Title

2. Iron Deficiency Anemia

II. Al-Dallal, Z. S.

3. Monitoring Study
III. Moosa, K. H.

Bahrain Public Library, 3752 / Dal Ain / 2003

(2003 / 3752 . . )
ISBN 99901 18 - 09 - 4

61