Intersectoral and eco-nutritional approaches to resolve persistent anemia in Indonesia

Anemia in Indonesia has been of concerning persistence in all age groups for some 75 years since independence. The relationships between anemia and nutrition are complex being evident with compromised general health and nutrition. Increased micronutrient intakes, especially iron and folic acid, has alleviated the problem, but encouraged nutrient-specific micronutrient interventions as attractive policy directions as if anemia were a stand-alone disease irrespective of associated disorder. Concerted action to deal with the fundamental causality has been missing. Much of the pathogenetic pathway may be nutritional, but its multifactoriality is ultimately socioecological. Given the intransigence and progression of societal and ecosystem dysfunction, it can be expected that failure to recognize their causal importance will further entrench endemic anemia. This review deliberates the practical measures taken to recognize anemia by symptomatology, food and nutrition surveys, screening (fingerpick blood), nutrition assessment, and blood loss (menstrual and faecal). It identifies vulnerable groups including premenopausal and pregnant women, children and adolescents, unwell adults, and the dependent aged. Risk settings include food insecurity, infectious disease, non-communicable disease, inheritance and epigenetics, and socioeconomic disadvantage. Underlying socio-ecological problems are livelihood, food systems, cultural habits, belief systems, and social networks and activities. With this framework, policy directions could deal more comprehensively and effectively with the socioecological complexity which underpins and limits progress towards anemia eradication at a time of intense global food and health insecurity. It will require co-operative intersectoral and eco-nutritional approaches which take into account the need for universal, sustainable livelihoods. Recommendations have been made accordingly.