International Journal of Community Medicine and Public Health

Sudargo T et al. Int J Community Med Public Health. 2016 Jul;3(7):1949-1956

http://www.ijcmph.com pISSN 2394-6032 | eISSN 2394-6040

DOI: http://dx.doi.org/10.18203/2394-6040.ijcmph20162071
Research Article

Egg supplementation to improve cognitive ability in elementary

school children with iodine deficiency
Toto Sudargo1*, Hamam Hadi1, Wiryatun Lestariana1, Amitya Kumara2

1
Faculty of Medicine, Gadjah Mada University, Yogyakarta, 55281, Indonesia
2
Faculty of Psychology, Gadjah Mada University, Yogyakarta, 55281, Indonesia

Received: 28 May 2016

Accepted: 15 June 2016

*Correspondence:
Dr. Toto Sudargo ,
E-mail: toto_sudargo@yahoo.co.id

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Elementary school children who live in iodine deficient areas have lower cognitive abilities than
children from iodine sufficient area. This study aimed to investigate the effect of supplementation of egg with iodine
and iron on cognitive ability (IQ score) in elementary school children with iodine deficiency.
Methods: This was a randomized double-blind controlled trial involving 109 elementary school children aged 8-13
years in endemic iodine deficient District, Kismantoro, Wonogiri. Subjects were divided into 4 groups which are
group A (iodine + iron + eggs); B (iron + eggs); C (iodine + eggs); and D (eggs) and supplementation were given for
16 weeks. Cognitive abilities (IQ score) was measured by CFIT (culture fair intelligence test) measured pre and post
intervention.
Results: There was a significant difference on cognitive abilities (IQ) within group of intervention after 16 weeks of
intervention (p<0.05). In cognitive abilities the difference not found among the group of intervention (p>0.05).
Conclusions: There was found that children who received egg alone or in combination with iodine and iron have the
highest cognitive abilities compared with supplementation of egg with iron. In addition, children who received egg
alone or combination with iron and iodine can increase the IQ score by 4 point. Supplementation with egg alone or in
combination with iodine and iron improve the cognitive abilities (IQ score) of primary school children who suffer
from iodine deficiency disorders.

Keywords: Egg, Iodine, Iron, Cognitive ability, Children, Iodine deficiency disorders

INTRODUCTION the iodine deficiency generally has low average mental

capacity, cognitive abilities, and academic
The program to overcome iodine dificiency disorder has performance.5,6 One of the nutrition insecure groups in
been started since 1970, however the prevalence of Indonesia is elementary school students. Those who are
people suffering iodine deficiency is still relatively high, nutrition deficit have low cognitive abilities.1,2 A study in
especially in Central Java, in example the Wonosobo Thailand stated that the cognitive abilities of elementary
district (42.3%) and Wonogiri district (24.1%), while the school students who were micro-nutrient deficit could be
total goitre rate (TGR) in Indonesia is 11.1%. 1 According enhanced.7 Cognitive abilities are an identifying and
to WHO report approximately 2.2 billion citizens of the organizing process, and to process information into an
world are at risk to suffer the disorders from iodine accurate, valid and beneficial knowledge to solve a
deficiency because they are living in the area that lacks of problem or make a decision.
iodine.2-4 An individual who suffers the disorders from

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 Sudargo T et al. Int J Community Med Public Health. 2016 Jul;3(7):1949-1956

Based on advanced testing study on three elementary test (CFIT) used borderline mark with 70-109 IQ point.
school (ES) in Kismantoro, Wonogiri District on early Subject excluded if suffering goitre.
September i.e ES Miri, Pucung I, and Pucung II, here
were 71 students (9-12 years old), there found 22 students Subject fullfilled the inclusion and exclusion criteria were
(30.99%) suffered enlargement thyroid gland, 24 students given inform consent. Enumerator gave the inform
(16.90%) stunted based on height per age parameter.6 consent obtained from the subject’s parent/guardian
Results of cognitive abilities assessment using wechsler before the randomization. Random allocation was done
Intelligence Scale for Children-Revised (WISC-R) test, by using block random method.11 This study protocol was
there found 29 (40.84%) mentally defective, 18 (25.35%) agreed by Medical and Health Research Ethics
borderline, 12 (16.90%) quite low, 12 (16.90%) average, Committee Faculty of Medicine Gadjah Mada University,
and clever student was not found. Results of food Yogyakarta.
consumption recall showed that the energy intake is
52.60%, protein intake is 58.75% and iron intake is Intervention
22.20%.6
Subject fullfiled inclusion and exclusion criteria were
It is explained theoretically that inadequate intake of randomized into 4 group’s treatment: group which
iodine is one of the factors that cause iodine deficiency received iodine, iron and egg (group A), group which
disorder. Besides iodine, iron and protein are needed in received iron and egg (group B), group which received
thyroid hormones synthesis. During the thyroid hormone iodine and egg (group C), group which received egg only
synthesis process, thyroperoxide enzyme is needed as a (group D). Iron supplementation was given using ferro
biocatalisator where about is depending on the sulfate tablet with the same form, size and package as
availability of iron. Thyroid hormones affect many placebo. Subtitute tablet in placebo contains amylum,
enzyme mechanisms on the development of brain talk, saccarum lactic and dye. Iodine was given in yodiol
function such as controlling ribonucleic acid (RNA) form (Kimia Farma, Watukadon, Indonesia) which is an
transcription. Iodine deficiency would decrease the RNA iodine supplement in the form of vegetable oil.
transcription, then influence inter neuron transmission
and affect the development of brain function.8 Iodine capsule were given only once within research
Development process is a result of an interaction of many period and Iron tablet were given 1 times a week matched
factors which initiated from inside the womb and then with the treatment group. Egg was given 3 times a week
continued until the child is able to interact with its matched with the treatment group. Subject received
environment. This process would determine the child’s treatment during 16 weeks. Subject’s cognitive ability
brain growth to the next development period.9 was measured before and after treatment used
Cattellculture Fair Intelligence Test (CFIT) method
Food ingredient which contains high protein and is according to Gregory’s submitted method.12 Culture fair
common in the community is egg. Besides obtainable, intelligence test method contains 4 sub-components : a)
egg is also more affordable than the other animal sources series, b) classification, c) matrix, d) typology, where in
of protein. Egg is one of the animal-sourced proteins each sub-component is consisted of multiple choices
which has a good taste, easy to digest, and has a high questions to observe visuospatial reason aspect. Total
nutritional value. Nutrition composition in egg contains value from fourth component were calculated and
13% protein, 12% fat, vitamin and mineral. The highest converted into IQ value.12,13 IQ value was measured 2
value of nutrient is contained in the yolk. Amino acid times before and after treatment used CFIT and was done
essential in yolk is needed in human body.10 by psychologist.

This study aimed to investigate the effect of Household and family information
supplementation of egg with iodine and iron on cognitive
ability (IQ score) of elementary school children with Demography characteristics of the household and family
iodine deficiency. condition of subject are education level of father,
education level of mother and total family load were
METHODS obtained by questionnaires. Social-economy conditions
such as level of family income were also obtained by
Subject questionnaires. Household and family condition data
were taken by enumerator.
This study was implemented in endemic iodine
deficiency sub district Kismantoro, Wonogiri district, Nutritional assessment in children
Central Java. This was an experimental study with
randomized double blind controlled trial design. Subject Nutritional assessment was done by weight and height
included in this study have to fullfil the inclusion criteria measurement of children according to WHO chart 2005.
such as age 8-13 years old, not suffering chronic disease, Weight and height measurement based on WHO/CDC
suffering iodine deficiency with enlargement of thyroid method, which then plotted into WHO growth chart
gland grade 1, having mark from culture fair intelligence 2005.14

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 Sudargo T et al. Int J Community Med Public Health. 2016 Jul;3(7):1949-1956

Measurement of haemoglobin level in children (25.92%) were eligible and a number of 109 children
fullfilled inclusion and exclusion criteria in this study.
Blood haemoglobin level was analyzed used beckman Two children were suffering from chronic disease, CFIT
counter tools with cyanmethaemoglobin method. value on 12 children more than 109 IQ point and CFIT
Generally, 0.02 mL blood mixed with drabkins reagent value on 52 children less than 70 IQ point. After
and incubated for 5 minutes. After incubated, the colour randomization, 3 children in the group B were dropped
would change which later will be read on the 540 nm of out from the study because of sickness, 1 child from the
wavelength. group C transferred to other school, and 1 child from
group D was dropped out because of circumcision
Dietary intake measurement of subject (Figure 1).

Dietary intake of subject such as energy, protein, iron, Based on demography characteristics, most of the father
iodine, zinc and vitamin C intake were measured using and mother’s education background were low, a number
multiple recall. Recall was done 6 times consecutively in of 90 people (86.5%) and 91 people (87.5%) are low
different days according to Willet’s calculation.15 educated (only went through from elementary school to
junior high). Analysis result shows there were not any
Sample significant difference of father and mother’s education
between the study groups (p>0.05). The family income
To fullfill the aim of this study, sample was calculated between the study groups were almost the same, 57%
using 95% confidence inteval, 90% power, 2.2 deviation families’ income was ≤ Rp 400.000/month, and the result
standard and mean difference abilities after and before of statistic analysis showed there was not any significant
the treatment was assigned 2.16 Based on this differences between the study groups (Table 1).
assumption, then the result of calculation obtained 26
children of each group with asssumption 10% probability As much as 67 (58.6%) male subjects and 37 (35.6%)
of subject’s loss in observation, then 28 children were female subjects were 125 months old of age in average.
needed for each group or about 112 children over all. 17 Based on the initial anthropometry measurement on the
subject, as much as 49 (47.1%) subjects were
Statistical Analysis underweight, 34 (32.7%) subjects were stunted and 19
(18.3%) subjects were wasting. Besides that, motivation
All data was analyzed using SPSS program. Continuous for achievement and cognitive stimulation of the subjects
variable data was presented in mean ± deviation standard had the average value of 18.6 dan 74.6. Statistic results
while chategorical data was presented in total and showed that age, gender, nutritional status and cognitive
percent. Chategorical data was analyzed with chi square. stimulation not showed a significant difference (p>0.05)
While, continous variable data inter group treatment was but showed a significant difference on motivation for
analyzed with one way ANOVA. achievement (p<0.05) between treatment groups. Besides
that, the subjects hemoglobin level was 13.1 g/dL in
RESULTS average but not different in each of the treatment groups
(Table 1).
A number of 675 children in ES were examined on
thyroid gland with palpation method, there found 175

Table 1: Subject characteristic in sub-district kismantoro elementary school.

Groups
Total A.Iodine+iron+ B. C. D. Sig.(p)
Variable egg (n=28) iron+egg iodine+egg egg
(n= 25) (n=26) (n=25)
N % n % N % N % N %
Sex
Female 37 35.6% 8 28.6 6 24.0 13 50.0 10 40.0 0.20 *
Male 67 64.4% 20 71.4 19 76.0 13 50.0 15 60.0
Father’s education
High 14 13.5% 5 17.9% 2 8.0% 5 19.2% 2 8.0% 0.46 *
Low 90 86.5% 23 82.1% 23 92.0% 21 80.8% 23 92.0%
Mother’s education
High 13 12.5% 7 25.0% 0 0% 4 15.4% 2 8.0% 0.04 *
Low 91 87.5% 21 75.0% 25 100% 22 84.6% 23 92.0%
Family Income

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>Rp 400.000.- 57 54.8% 17 60.7% 15 60.0% 14 53.9% 11 44.0% 0.60 *

≤Rp 400.000.- 47 45.2% 11 39.3% 10 40.0% 12 46.1% 14 56.0%
Family Load
>4 43 41.4% 9 32.1% 10 40.00% 15 57.7% 9 36.0% 0.25 *
≤4 61 58.6% 19 67.9% 15 60.0% 11 42.3% 16 64.0%
Weight /Age (z-score)
≤-2 (underweight) 49 47.1 11 39.3 12 48.0 13 50.0 13 52.0 0.80 *
>-2 (normal) 55 52.9 17 60.7 13 52.0 13 50.0 12 48.0
Height/Age (z-score)
≤-2 (stunted) 34 32.7 11 39.3 8 32.0 7 26.9 8 32.0 0.81 *
>-2 (normal) 70 67.3 17 60.7 17 68.0 19 73.1 13 68.0
Weight/Height(z-score)
≤-2 (wasted) 19 18.3 4 14.3 2 8.0 9 34.6 4 16.0 0.45 *
>-2 (normal) 85 81.7 24 85.7 23 92.0 17 65.4 21 84.0
Age (month) 124.8±10.7 125.9±12.4 125.6±9.2 123.1±10.9 124.4±9.9 0.77 **
Motivation 18.6±17.6 18.53±2.6 19.20±1.64 19.19±1.69 17.28±3.2 0.01 **
Cognitive stimulation 74.6±17.6 71.4±16.2 75.2±16.7 79.9±19.6 72.3±17.3 0.26 **
Haemoglobin level - 13.10±0.79 13.01±0.78 13.14±0.71 13.00±0.72 13.24±0.9 0.69 **
pretest
Haemoglobin level - 13.47±0.97 13.45±0.91 13.64±0.94 13.21±0.96 13.59±1.06 0.38 **
posttest
*p-value (p<0.05) according to X statistic from2-test.**p-value (p<0.05) according to F from ANOVA.Value in table presented in n
form and % or mean±Deviation standart.

According to result of 24 hours recall, the average treatment groups for energy, protein, iodine, iron and
consumption of energy on subject was 1634.9 Kcal/day, vitamin C consumption. However the difference showed
average intake of protein was 44.5 gram/day. Iodine in zinc consumption between treatment groups. There
consumption was 110.9 mcg/day with average was a difference in zinc consumption in groups with
consumpton of iron, zic and vitamin C were 5 mg, 4.5 mg egg+iron supplementation and group with iodine and egg
dan 73.9 mg/day respectively. Statistical analysis result supplementation (Table 2).
did not show any significant differences between

Table 2: Means of nutritional intake on subject in sub-district kismantoro elementary school.

Groups
Variable Total A. B. C. D. p
Iodine+iron+egg iron+egg iodine+egg egg
(n=28) (n= 25) (n=26) (n=25)
Energy 1634.9±415.0 1544.7433.8 1528.4381.8 1756.8406.2 1715.9407.2 0.06
Protein 44.5±11.8 42.2 11.8 41.9 11.8 48.4 11.7 45.4 11.5 0.11
Iodine 110.9±21.1 111.922.6 104.917.1 114.924.3 111.919.5 0.38
Iron 5.0±2.0 4.71.6 4.92.5 5.82.4 4.71.6 0.19
Zinc 73.9±55.5 4.31.2a.c) 4.11.1a.b) 4.81.1c) 4.61.1a.c) 0.02**)
Vitamin C 4.5±1.1 72.644.6 79.652.8 79.170.2 64.553.6 0.75
* Data presented in means ± deviation standart. **Significance (p<0.05). (a.b.c) Different notation showed differences
(p<0.05).

showed cognitive ability’s homogenity on each treatment

Before treatment, a number of 65 subject (62.5%) had group.
low cognitive abilities, however there were no significant
difference between treatment groups (p>0.05). In early After 4 months of intervention, cognitive ability was
treatment, subject’s cognitive ability was 86.19±11.30 increased on each group treatment. Cognitive ability (IQ)
(Table 3). Statistical analysis result did not show any increased 4.17 point into 90.37±13.40 significantly.
significant differences between treatment groups before Cognitive abilitity value (IQ) significantly increased in
implementation of treatment on subject (p>0.05) which group with iodine+iron+egg supplementation, which

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 Sudargo T et al. Int J Community Med Public Health. 2016 Jul;3(7):1949-1956

increased 7 point and followed by egg treatment group groups (Tabel 3). This result showed that all treatment
with 6.88 point. Although the increasing point in group groups could increase cognitive ability (IQ) in elementary
with iodine+iron+egg is higher than other groups, school children with iodine deficiency.
however ANOVA analysis result for delta value showed
that there was no significant difference between treatment

Table 3: Cognitive abilities subject before and after treatment of egg with and without iodine and iron
supplementation during 4*.

Groups Treatment Cognitive Abilities (IQ)

Before treatment After treatment Delta p1)
Iodine+Iron+Egg 85.21±11.7 92.21±13.01 7.00 12.07 0.05
Iron+Egg 84.96±11.74 84.76±13.59 -0.2014.28 0.95
Iodine+Egg 87.96±10.56 90.88±14.09 2.9213.42 0.28
Egg 86.68±11.49 93.36±11.89 6.6813.00 0.02
Total 86.19±11.30 90.37±13.40 4.1713.32 0.02
p2) 0.76 0.10 0.17 -

in decreasing of human cognitive ability. Study results

According to Table 3 and Figure 2, the analysis between found that proportion of subject who has cognitve ability
treatment groups found that the group given egg, iron and <90 IQ (below average) is quite high as much as 62.55%.
iodine had IQ point 0.32 higher than the group that was This fact shows that endemic iodine deficiency area has a
given egg only, 4.08 higher than the group that was given significant cognitive problem. A study in endemic iodine
egg and iodine, and 7.20 higher than the group that was deficiency area in Malang district found that elementary
given egg with iron. school children who have cognitive ability < 80 IQ point
have troubles in speaking, writing and counting. Then,
children who have one of the disorders could be
identified as suffering with mild cretin.18

Supplementation and fortification of iodine have been

used as methods to decrease iodine deficiency rate in
Indonesia. Zimmermann, demonstrates that iodine
supplementation in elementary school children with
iodine deficiency could improve their cognitive abilities
during receiving iodine capsul in 24 weeks. The other
study conducted by Gordon, elementary school children
with moderate level of blood iodine, receiving iodine
Figure 1: Subject determination scheme.
supplementation significantly could improve cognitive
abilities.16,19 A study conducted by van den Briel in 10-12
years old elementary school children during 24 weeks in
Benin, showed that iodine supplementation treatment on
elementary school children could improve perceptual
logical ability and intelligence compared with elementary
school children without iodine supplementation.20

Based on the result of this study, it is known that the egg

Figure 2: The change of marginal average of cognitive supplementation combined with iodine and iron has the
abilites (IQ) before and after the treatment. Black line same effect on increasing the cognitive abilities in the
shows the average score of pre-test and grey line iodine deficit elementary students. However, even though
shows the average score of post-test in each treatment it has the same effect in increasing the cognitive the
group. Group A (egg+iodine+iron), group B administration of egg only supplement has a high impact
(egg+iron), group C (egg+iodine), group D (egg). on increasing the cognitive in the iodine deficit
elementary school students. This showed that egg only
DISCUSSION administration could be another alternative program to
enhance the cognitive abilities of iodine deficit
Iodine deficiency disorder is a health problem in elementary school students.
developed country such as Indonesia which could affect

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The result of this study support the result of Van Den suffer iron deficiency syndromes because of the mutual
Briel study, which found that iodine or iron interactions between protein, iron, and iodine.
supplementation could increase the cognitive abilities of
treatment groups.20 However in this study is also found Protein also plays the role as “ligand” (binder) and
that the group which was given egg supplementation with “clathrin” which is used in the absorption of iron,
iron was not as effective as the group which was given transferin, feriitin, hemoglobin, and myoglobin. 27 Besides
the complete supplementation (egg+iodine+iron) even that iron also takes effect on the first two steps of thyroid
though the increasing cognitive abilitites of both groups hormon synthesis which is catalyzed by
were not different. thyroperoxidasethat is contained in iron. Iron deficiency
anemia lowers thyroxine (T4) andtriiodothyronine (T3)
Even though there was no difference between the plasma and might also increase the tirotropin
treatment groups, however there was an escalation in concentration (Hess et al., 2002). Iron deficiency also
cognitive abilities in iron deficit children after the significantly lowers the activity of thyroid Peroxidase
treatment. The highest uplift of cognitive abilities was in (TPO).28
the group given egg supplementation with iron and iodine
compared with the other treatment groups even though Results of the study groups showed that egg
there was not any significant differences between the supplementation with or without iodine and iron
treatment groups. This result showed that egg is a right combination could give a higher effect in increasing the
comestible to enhance the cognitive abilities of the iron cognitive abilities. However, cognitive abilities in the
deficit children. iodine deficit elementary school students didn’t show any
significant difference among the treatment groups.
Egg contains aromatic amino acids which are important
in synthesizing DNA and RNA, producing The result of this study could be used as a basis of
neurotransmitter, synthesizing growth factor and neurit cognitive abilities enhancing program in elementary
prolongation. The change of amino acid profile in plasma school students who are iodine deficit using egg
could alter the neurotransmitter synthesis pattern in the supplementation or complete supplementation (iodine,
brain which could impact in the absence of iron, and egg combined) adjusted to the availability of
neurotransmitter synthesis and manifests towards the founds in the area. The results of this study may be one of
digression of cognitive function.21 Rosier proved that the basic education to parents in preparing family meals
post-depression patient who received low aromatic amino menu, because parents were still lack of learning on how
acid diet would sustain a digression of cognitive abilities to prepare a healthy menu, to give awards to maintain
significantly which was measured with comprehensive good eating behavior of children.29 Erikson's stages of
battery of well-validated computerized cognitive test.21 development according to school-age children need to
develop a sense of the industry, so parents need to
Egg contains 21% of branched-chain amino acid that are provide an appreciation of the ability of children who
leusin, isoleusin, and valin. Some studies showed that have healthy eating behaviors.29,30
branch chain amino acid could repair cognitive disorders
caused by trauma.22,23 Branched-chain amino acids CONCLUSION
(BCAA) supplementation is proved to increase the
cognitive abilities animal, which was shown by them The conclusion of the study groups showed that egg
doing less mistakes when given obstacles.24 Egg is supplementation with or without iodine and iron
consisted of amino acids, one of them is triptofan. combination could give a higher effect in increasing the
Triptofan is a precursor of serotonin. High carbohydrate cognitive abilities. However, cognitive abilities in the
food intake could increase the triptofan uptake of brain. 25 iodine deficit elementary school students didn’t show any
Serotonin is a monoamina neurotransmitter which located significant difference among the treatment groups.
in the central nervous system and synthesized in
serotonergic neuron in the central nervous system. ACKNOWLEDGEMENTS
Serotonin has several functions, including mood
regulation, muscle contraction, and some cognitive During this opportunity, the Authors would like to
functions such as memory and learning. This corresponds express gratitude towards the school headmaster, the
to the study conducted by Booji, which said that acute teachers, especially the students of SD Kismantoro I, SD
triptofan depletion could affect the mood through mood Kedawung and, SD Gambiranom, SD Ngroto and in
regulation, emotional information process, and normal Kismantoro sub-district, Wonogiri district, who had
information process.26 voluntarily helped and involved as a subject in this
study.1-3 The authors would also like to say thanks to all
The combination supplementation of egg, iodine, and parties who can’t be mentioned one by one and were also
iron is the group that has the highest cognitive abilities a great help in making it possible to finish this study.
compared to the other treatment groups. This shows that
egg, iodine, and iron supplementation is one effective Authors extended thier gratitude to the LPPM (Lembaga
strategy in enhancing the cognitive abilities of those who Penelitian dan Pengabdian kepada Masyarakat) UGM

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 Sudargo T et al. Int J Community Med Public Health. 2016 Jul;3(7):1949-1956

Yogyakarta, Ministry of Culture and Education for 9. Maggi S, Irwin LG, Siddiqi A, Poureslami I,
funding assistance during this research. Authors would Hertzman E, Hertzman C. Knowledge Network For
also like to thank Dr. Abdul Rohman and Harry Freitag, Early Child Development. The University of British
MSc for his suggestion during preparation of this Columbia. 2005.
manuscript. Authors would also like thank officers and 10. Indratiningsih S, Rihastuti TS. Dasar Teknologi
assistants making this research success. Hasil Ternak. Yogyakarta: Animal Husbandry
Faculty, Universitas Gadjah Mada. 2001.
Funding: No funding sources 11. Sastroasmoro S, Ismael S. Dasar-Dasar Metodologi
Conflict of interest: None declared Penelitian Klinis. Jakarta: Binarupa Aksara. 1995.
Ethical approval: The study was approved by the the 12. Gregory RJ. Psychological testing: history,
ethics committee of the Faculty of Medicine, Universitas principles and applications. USA: Allyn and Bacon,
Gadjah Mada Inc.1992.
13. Abdullah NH. Intelligence As A Predictor Of
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