Multimicronutrient Biomarkers Are Related to Anemia during Infancy in Indonesia: A Repeated Cross-Sectional Study

BACKGROUND: Anemia during infancy in Indonesia is common, with iron deficiency (ID) assumed to be the major cause. Other micronutrients besides iron may have a role in determining hemoglobin (Hb) but have not yet been explored in Indonesia. OBJECTIVE: We investigated 7 micronutrient biomarkers and selected nonnutritional factors as potential predictors of Hb and anemia at ages 6, 9, and 12 mo in a cohort of Indonesian infants at risk of coexisting micronutrient deficiencies. METHODS: Apparently healthy breastfed infants were randomly selected from birth registries at 6 mo (n = 230) and followed-up at 9 mo (n = 202) and 12 mo (n = 190). Hb, serum micronutrient biomarkers—iron [as ferritin and serum soluble transferrin receptor (sTfR)], zinc, selenium, folate, vitamin A [as retinol-binding protein (RBP)], vitamin B-12, and vitamin D (as 25-hydroxyvitamin D) (adjusted for inflammation, where appropriate)—and maternal sociodemographic status, health, BMI, heminthiasis, and selected Hb genetic disorders were measured. Multivariate analysis examined relations between micronutrient biomarkers and nonnutritional factors (except helminthiasis and genetic Hb disorders) with Hb and anemia at 6 and 12 mo. RESULTS: ID (based on ferritin) was a predictor of lower Hb and anemia at both 6 and 12 mo of age (P < 0.02). Additional predictors at 6 mo were tertiary education and higher maternal Hb for higher Hb, sex (being male) and inflammation (P < 0.05) for both lower Hb and anemia, and greater maternal height (P = 0.036) for anemia only. At 12 mo, a significant biomarker predictor besides ID was RBP (P = 0.035) for Hb. CONCLUSION: ID was a major contributor to lower Hb and anemia, although RBP was also associated.