Effect of a Dietary Iron Program on Iron Status and IQ in Children in Phatthalung Province, Thailand
Condition: Iron Deficiency, Anaemia in Children
MeSH terms: Anemia, Iron-Deficiency; Iron Deficiencies
Study type: Interventional

Summary: 
      Iron deficiency (ID) continues to be one of the most prevalent disorders, which can adversely
      affect cognitive ability in childhood. Our aim was to determine the effect of a dietary iron
      education program (DIP) on children's iron status and intelligence quotient (IQ) score. This
      pre-test (week 1) post-test (week 16) quasi-experimental study with follow-up (week 18)
      utilized constructs from the Health Belief Model. Children and caregivers participated in the
      DIP which incorporated group talks, presentations, brainstorming, game-based learning and
      cooking sessions from weeks 2-15. Knowledge of ID and dietary iron, perceived susceptibility
      and severity, benefits and barriers for changing behavior, dietary intake, iron status and IQ
      score were determined at all timepoints (weeks 1, 16, and 18).
    

Detailed description: 
      1. Objective The objective of this study was to determine whether an education-based
           dietary iron program that involved school teachers, parents and children could increase
           iron status and intelligence quotient (IQ) score in a group of schoolchildren.

        2. Methods

      2.1 Study design A quasi-experimental study (pre-test post-test design with follow-up) was
      used in this study that was based on the Health Belief Model as its theoretical framework.

      2.2 Study Setting and Participants Child-parent/caregiver dyads were recruited from one
      purposively selected government-administered primary school in Phatthalung province. Schools
      were not involved in any other programs, located in a rural area, and had at least 200
      children studying in grades 4-5. Hookworm screening was done 6 weeks before program
      implementation by the local government screening program. All children who were studying in
      grades 4-5 in the selected school were invited to participate. Out of 190 children, 34
      children who were mildly anemic were enrolled in the study, together with their
      parents/caregivers. Sample size was calculated based on serum ferritin concentrations among
      school-aged children from a study by Rahman et al. [17]. Informed written consent was
      obtained from child-parent/caregiver dyads prior to program implementation.

      2.3 Procedure for the intervention The Health Belief Model underpinned the development of the
      dietary iron program, which focused on the importance of adequate dietary iron consumption
      and emphasized prevention of iron deficiency (ID) and iron deficiency anemia (IDA). It was
      implemented from weeks 2 to 15 of the study. Child-parent/caregiver dyads and teachers
      received an ID/IDA booklet that included information about anemia, causes of ID, iron-rich
      food, iron concentration in traditional foods, dietary enhancers and inhibitors of iron
      absorption, and recipes for iron-rich local and culturally appropriate meals for teachers,
      parents/caregivers and children, as part of the dietary iron program.

      Teachers who were involved in school lunch design participated for discussing and planning
      iron-rich school lunch menus, and observed teaching and learning process with the use of
      media and games during the iron lessons for children. Four lessons were conducted for
      parents/caregivers. The first lesson was discussion that addressed parental perceptions about
      children's susceptibility to ID and IDA and the severity of ID and IDA concerning cognitive
      function. In the second lesson, parents/caregivers were asked to list the benefits and
      barriers for changing behavior with regards to preparing more iron-rich foods in the home.
      Then, the principal researcher invited parents/caregivers to brainstorm and share ways to
      overcome these barriers. Cooking classes for preparing iron-rich meals at home were
      conducted. Parents/caregivers voted for two iron-rich meals that they wanted to cook and then
      they prepared and cooked them in the classes. For the final lesson, the principal researcher
      visited each parent/caregiver to discuss the barriers they faced when trying to incorporate
      more iron-rich meals into their child's diet at home. Three lessons were conducted for the
      children, one per month. In the first lesson, group talks and games were used to engage the
      children about the causes and effects of ID and IDA. The second lesson focused on iron-rich
      food. After that, the children partook in games that entailed writing names of food
      ingredients that contained iron and circling pictures of iron-rich foods, and describing the
      sensations associated with consuming these foods. Both positive and negative answers from
      children were selected for discussion, and approaches for consuming more iron-rich food were
      brainstormed. A market assignment was set to help the children remember the names of
      iron-rich food and recognize the foods when they visited a market with their parents. The
      last lesson was a cooking class. After each cooking class finished, the researcher and a
      teacher encouraged them to eat this meal together.

      2.4 Measurement outcomes The main outcome for this study was the effect of an education-based
      dietary iron program on iron status and intelligence quotient (IQ) score among children
      before program implementation (week 1) and at week 16 (immediately after program
      implementation) and at 18 weeks (follow-up appointment to determine the sustainability of the
      intervention). All of the outcome variables were measured at different time points.
      Children's knowledge towards ID and IDA was determined using a questionnaire, while
      children's iron intake was estimated by using three days of 24-hour recalls (2 school days
      and 1 weekend day). Portion sizes were estimated by using household portion sizes
      (rice-serving spoon, tablespoon, teaspoon and glass). IQ score was measured by a trained
      child psychologist by using the Standard Progressive Matrices (SPM) parallel version. Iron
      status was determined from blood samples drawn by medical technologists in the first-aid
      rooms. Concentration of hemoglobin, serum ferritin and serum C-reactive protein were measured
      by laboratory staff at hematology laboratory at N-health laboratory, Bangkok Dusit Medical
      Service Hospital (BDMS), Songkla province, using the hemoglobin assay kit (Colorimetric),
      chemiluminescent immunoassay (CMIA) and high-sensitivity C-reactive protein methods,
      respectively. Iron status was defined iron-replete: hemoglobin >115 g/l and serum ferritin
      level > 30 µg/l; anemia: hemoglobin <115 g/l and serum ferritin level >30 µg/l; mild-moderate
      iron depletion with anemia: hemoglobin 80-114 g/l and serum ferritin level <30 µg/l.; mild
      iron depletion without anemia: serum ferritin level < 30 µg/l and hemoglobin>115 g/l. In
      addition, parents/caregivers were assessed by using a questionnaire toward knowledge and
      perceptions consisted of perceived susceptibility, severity, benefits and barriers in
      relation to ID and IDA.

      2.5 Data Analysis Data from questionnaires were recorded using EpiData version 3.1, while
      24-hour dietary recall data were entered into INMUCAL V3, which is a nutrient composition
      database of dietary items commonly consumed in Thailand. Portion sizes were converted into
      grams before entering data, and energy and nutrient intakes were calculated. Statistical
      analysis was carried out by using SPSS version 18. Frequencies, percentage, mean (SD) and
      median (25th-75th percentile) were calculated for demographic characteristics of participant
      knowledge, perceptions, iron intake, iron status, and IQ score. The One-Way Repeated Measures
      ANOVA and Friedman's Two-Way Analysis of Variance by Ranks were used to compare mean
      differences in knowledge score and perception score of IDA and ID prevention among
      parents/caregivers, total iron intake, heme iron intake, non-heme iron intake, iron status
      and IQ score among children at different time points. The Monte Carlo exact test was used to
      compare the number of children in grades 4-5 who met/did not meet the Thai DRI for iron at
      pre-test, post-test and follow-up. Differences were considered to be significantly different
      when p<0.05.

      2.6 Ethical approval The study was granted ethical approval by the Committee of the Ethical
      Review for Human Research, Faculty of Public Health, Mahidol University Thailand 9 March 2018
      (COA. No. MUPH 2018-048).
    

Intervention name(s): Dietary Iron Program
Intervention type(s): Behavioral
Intervention description(s): Teachers Lesson 1: Discuss about causes, prevention and effects of anemia and ID, dietary iron, dietary enhancers and inhibitors of iron absorption, and school lunch menu Lesson 2: Participate in and observe how to teach children in an iron curriculum
Caregivers Lesson 1: Presentation and group talk about causes, prevention, and effects of anemia and ID, dietary iron, and dietary enhancers and inhibitors of iron absorption Lesson 2: Discuss benefits and barriers of changing to an iron-rich meal at home Lesson 3: Cooking class for preparing an iron-rich meal at home (2 times) Lesson 4: Home visit
Children Lesson 1: Group talk about causes and effects of anemia and ID Games: "Where are you from?" Lesson 2: Presentation and group talk about dietary iron, and dietary enhancers and inhibitors of iron absorption, and iron-rich food Games: "What is the winner?" Assignment: Market assignment Lesson 3: Cooking class (2 times)
Intervention MeSH terms: Iron
Intervention model: Single Group Assignment
Intervention model description: Quasi-experimental (pre-test post-test) design with follow-up / Behavioral intervention, based on the Health Belief Model
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Iron deficiency; Iron status; Cognitive function; education