Ideal Dietary Intakes of Vitamin B12 and Vitamin E Prevent Anemia During Pregnancy

Anemia in pregnancy is one of the priority nutritional problems to be tended to. WHO in 2019 reported Anemia in 40% of pregnant women worldwide; in Indonesia, based on the 2018 Riskesdas was 48.9%, and in West Sumatra and Padang City, 18.10% and 17.70%. One of the causes of Anemia was a low intake of vitamins B12 and E. This study aimed to determine if serum ferritin levels and vitamin B12 and E consumption were correlated with those of third-trimester pregnant women. This analytical cross-sectional study was done from April to July 2022 at Lubuk Kilangan Public Health Center and Andalas University's Biomedical Laboratory. The population was 64 third-trimester pregnant women, and 42 samples were used using proportional stratified random and simple random sampling. A SQ-FFQ (Semi-Quantitative Food Frequency Questionnaire) and Human ferritin kit DBC (Diagnostics Biochem Canada) examined by ELISA (Enzymed-Linked Immunosorbent Assays) were the instruments. The average of Vitamin B12 and vitamin E consumption daily was 7.71 µg and 5.87 mg, and serum ferritin was 10.53 µg/L. Serum ferritin levels were linked with vitamin B12 (r=0.879; p=0.001) and vitamin E (r=0.455; p=0.002) intake. Enough intake of vitamin B12 and vitamin E will lead to ideal serum ferritin levels.


INTRODUCTION
Anemia and micronutrient deficiency are nutritional problems during pregnancy that must be solved (Cortés-Albornoz et al., 2021).Anemia and iron deficiency affected 40% of pregnant women, 42% of children and 33% of non-pregnant women worldwide.Data published by the World Health Organization (WHO) in 2019 showed that 44.2% of Anemia cases were caused by iron deficiency in pregnant women in Indonesia (WHO, 2021).Basic Health Research Report in 2013 (Riskesdas) also showed a significant increase in the proportion of anaemic pregnant women, initially 37.1% to 48.9% in 2018 (Kemenkes RI, 2018).
The cases of anaemic pregnant women in 2018 in West Sumatra were 18.10%, and in Padang City, whose Anemia was 10.10% in 2020, it reached 2021 to 17.70% (Dinkes Kota Padang, 2022).At the Lubuk Kilangan Health Center, an increase in the proportion of anaemic pregnant women was also reported, namely 6.57% in 2018 and 25.7% in 2019.Lubuk Kilangan Health Center was one of Padang's health centres, covering the reduction of the incidence of anaemic pregnant women by less than 1% (Dinkes Kota Padang, 2021).The causes of nutritional problems in pregnancy include increased nutrient requirements, inadequate micronutrients, and inappropriate eating patterns (Gibore et al., 2021).Based on previous studies, macronutrients and micronutrients have been reported to be related to iron deficiency cases.
Micronutrient deficiencies that pregnant women often experience are deficiencies of iron, folic acid, and various types of vitamins.
A deficiency of vitamin B12 also has a role in the occurrence of Anemia; this is because vitamin B12 has a role as an enzyme and also a cofactor and mediates the formation of mitochondrial succinyl-CoA and cytosolic methionine synthesis and is very important for haemoglobin formation (Cortés-Albornoz et al., 2021).Vitamin B12 also has a role in folic acid activation and all cell's metabolic functions, especially bone marrow, digestive tract, and nervous tissue (Mayasari et al., 2023).Vitamin E is a vitamin that has some functions for maintaining the Insufficiency in the intake of vitamins also affects ferritin levels (Soppi, 2018).
Decreased ferritin levels are an early sign to predict low haemoglobin levels as a marker of Anemia in the future (Fitriani and Pamungkasari, 2020).Deficiency in vitamin B12 and E intake can contribute to morbidity and even mortality in mothers and children (Chen et al., 2018; Mayasari et al.,   2023).
The magnitude of the problem, the limited information about the results of the

E Data Collection and Analysis
An enumerator interviewed 42 pregnant women about their daily intake of vitamin B12 and vitamin E using the SQ-FFQ (Semi-Quantitative Food Frequency Questionnaire), and these data will be analysed by Nutrisurvey for Windows.
Insufficient daily intake of vitamin B12 was defined as daily intake <2.6 µg/day and vitamin E <15 mg/day for pregnant women.

Statistical Analysis
Data were analysed using SPSS 22, and the categorical variables were described in absolute numbers and simple percentages.

RESULTS AND DISCUSSION
Table 1 displays the characteristics of pregnant women, and it is clear that most are between the ages of 20 and 35 (76.20%).
Most pregnant women were multiparous (52.40%), the status of their occupation was not working (73.81%), and their education history was senior high school (59.50%).
The mean vitamin B12 intake throughout the third trimester of pregnancy, 2.60 µg/day, had reached a minimal standard (Table 2).
Still, none of the pregnant women had fulfilled the average daily vitamin E consumption, 15 mg/day, or the ferritin levels, 30µg/L.

Figure 1 Pregnant Women's Dietary Intake and Serum Ferritin Levels Distribution
Results in Figure 1 showed that most pregnant women had fulfilled their need for vitamin B12 (83.30.%), but none had normal ferritin levels and vitamin E intake.Table 3 shows a link between the daily intake of vitamins B12 and E and the serum ferritin level.
Pregnant women who had fulfilled their need for vitamin B12 and E would have better serum ferritin levels.Vitamin B12 is a water-soluble vitamin that ensures the body's metabolism goes well.
During the third trimester of pregnancy, nutritional needs will be increased to meet the needs of pregnant women and their fetuses.The need for Vitamin B12 intake for third-trimester pregnant women is 2.60 mg/day.Pregnant women are advised to be able to meet their vitamin B12 intake needs to prevent low birth weight, abnormalities of fetal brain growth and development, and also Anemia (Sukumar et al., 2016)   The kind of heme in the human body is found to be almost 95% functional iron (Li, Jiang and Huang, 2017).Vitamin B12 can help the process of forming haemoglobin.
The deficiency of these two substances could impact Anemia. in the blood will be seen after the iron storage or ferritin runs out.The result of our study was in line with research in Kebon Jeruk Health Center, which states that there is a significant correlation between vitamins B12 insufficiency and cases of Anemia (Meilinda Sembiring et al., 2020).

Pregnancy
Our study found a substantial correlation between normal vitamin E utilization and serum ferritin level (Table 3) (p-value = 0.002 and r = 0.455).This value indicated that the correlation between vitamin E intake and serum ferritin was positive, which means that enough vitamin E intake will lead to a normal serum ferritin level.This was not in line with other studies stating that vitamin E intake does not correlate positively with haemoglobin levels (Agustina, Hidayat, and Bustamam, 2020).
Vitamin E is the general name for two families of chemicals, tocopherols and tocotrienols, and functions within cell membranes as a lipid-soluble antioxidant, where synthetic antioxidants may perform many of its activities (Restrepo-Gallego et   al., 2021).According to certain research, using vitamin E in pregnant mothers with preterm birth and premature rupture of the membranes is connected with a prolonged latency time before birth (Chen et al., 2018).
Vitamin E insufficiency is common in impoverished countries, and levels are deficient during pregnancy.Due to the higher metabolic requirements brought on by pregnancy, pregnant women are susceptible to micronutrient deficiencies, including Vitamin E. Vitamin E is the primary antioxidant for the cell's antioxidant system.The mechanism of action of vitamin E is to convert peroxyl radicals into hydroperoxyl lipids in cell membranes (Rodwell et al., 2020).This process occurs in most cell membranes in the body, including erythrocytes, thereby preventing cell damage, and when vitamin E deficiency occurs in erythrocytes, it results in Anemia (Rodwell et al., 2018).
The Nutrition Adequacy Rate (RDA) of vitamin E in pregnancy is 15 mg/day.
Considering the outcomes of our study, the average intake of vitamin E for pregnant women was 5.87 mg/day.
body's metabolic function, antioxidant activity, and free radical scavengers (Chen et al., 2018).Erythrocytes are protected from harm and free radicals by vitamin E, and they also function in maintaining erythrocyte membrane stability (Antosik et al., 2018).One of the indicators used to diagnose Anemia and iron deficiency during pregnancy is serum ferritin levels.The normal serum ferritin level in healthy pregnant women is >30µg/L.Low ferritin concentrations indicate iron depletion.
that most third-trimester pregnant women had met their vitamin B12 intake needs.Vitamin B12 intake was significantly related to ferritin levels (pvalue = 0.001).The direction of positive relationship with muscular correlation strength (r = 0.879).Protein intake contributes 77.3% to ferritin levels, which means that vitamin B12 intake is directly proportional to normal ferritin levels.

Table 1 .
The Characteristics of Pregnant Women's Distribution and Frequency

Table 2 .
The Average Intake of vitamins B12 and E, as well as Serum Ferritin Levels

Table 3 .
The Correlation of Daily Intake of Vitamin B12 and Vitamin E with the Level of Serum Ferritin