Efficacy of iron-fortified whole maize flour on iron status of schoolchildren in Kenya: a randomised controlled trial

Consumption of Iron-Fortified Lentils Is Protective against Declining Iron Status among Adolescent Girls in Bangladesh: Evidence from a Community-Based Double-Blind, Cluster-Randomized Controlled Trial

BACKGROUND

In many low-income countries, iron deficiency (ID) and its anemia (IDA) pose significant health challenges, particularly among females and girls. Finding sustainable and effective solutions to address this issue is critical.

OBJECTIVES

This study aimed to evaluate the efficacy of incorporating iron-fortified lentils (IFLs) into the diets of rural Bangladeshi adolescent girls on their body iron (Fe) status.

METHODS

A community-based, double-blind, cluster-randomized controlled trial involved n = 1195 girls aged 10-17 y. A total of 48 adolescent clubs (n = ∼27 girls each) were randomized into 3 groups: 1) 200 g cooked IFLs, 2) 200 g cooked noniron-fortified lentils (NIFLs), and 3) a control group with no lentils (usual dietary intake). The intervention, administered 5 days a week for 85 feeding days, provided ∼8.625 mg Fe from each serving of IFLs and 2.625 mg from NIFLs. Blood samples collected at baseline, midpoint (42 feeding days), and endpoint (85 feeding days) assessed key Fe and inflammation biomarkers. Statistical analyses were filtered for inflammation.

RESULTS

Although all groups experienced a decline in Fe status over time, the IFL group exhibited a significantly reduced decline in serum ferritin (sFer -7.2 μg/L), and total body iron (TBI -0.48 mg/kg) level compared with NIFL (sFer -14.3 μg/L and TBI -1.36 mg/kg) and usual intake group (sFer -12.8 μg/L and TBI -1.33 mg/kg). Additionally, those in the IFL group had a 57% reduced risk of developing clinical ID (sFer <15 μg/L) compared with the usual intake group.

CONCLUSIONS

Our findings suggest that incorporating IFLs into the diet can help mitigate a decline in sFer, indicating a positive impact on the body Fe status of adolescent girls. This research underscores the potential role of fortified foods in addressing ID and IDA in vulnerable populations, emphasizing the significance of food-based interventions in public health.

TRIAL REGISTRATION NUMBER

This trial was registered at the clinicaltrials.gov on May 24, 2018 (https://clinicaltrials.gov/study/NCT03516734?locStr=Bangladesh&country=Bangladesh&distance=50&cond=Anemia&intr=Iron%20fortified%20lentils&rank=1) as NCT03516734.

National Mandatory Grain Fortification Legislation Decreases Anemia Prevalence among Nonpregnant Women of Reproductive Age: Findings from Multiple Demographic and Health Surveys

BACKGROUND

Two billion people are affected by anemia globally, mostly including women of reproductive age (WRA) and those residing in low- and middle-income countries (LMICs). Large national population-representative studies examining the impact of national grain fortification policies on the prevalence of anemia among WRA are lacking from recent years.

OBJECTIVES

We aimed to determine whether mandatory national grain fortification policies reduce the prevalence of anemia among nonpregnant WRA.

METHODS

We examined national food fortification policy characteristics from the Global Fortification Data Exchange (GFDx) database and anemia prevalence data from the Demographic and Health Surveys (DHSs). In total, 21 LMICs, with and without national grain fortification policies, completing ≥2 DHSs between 2000 and 2018, met study eligibility. We applied the difference-in-differences approach to compare changes in the prevalence of anemia among WRA in 10 countries with and 11 countries without fortification between each DHS year. Odds ratios (ORs) and average marginal effects, along with 95% confidence intervals (CIs) were calculated, adjusting for individual-, household-, and country-level factors.

RESULTS

Our analytic study sample included 96,334 and 874,984 WRA in countries with and without fortification, respectively. Overall, countries with fortification showed 27% decreased odds of anemia (adjusted OR: 0.73; 95% CI: 0.63, 0.85) and a 7.47-percentage-point decrease in the mean anemia prevalence (average marginal effect: -7.47; 95% CI: -11.03, -3.92) from the pre- to the postfortification period, compared with countries without fortification, after controlling for selected individual-, household-, and country-level factors.

CONCLUSIONS

Our findings, using nationally representative DHS data and applying a recommended analytic method to measure policy effectiveness, suggest significant reductions in anemia prevalence in WRA in countries with mandatory grain fortification compared with those without. Implementing national mandatory grain fortification in LMICs would effectively reduce anemia resulting from micronutrient deficiencies among WRA.

Rice: a potential vehicle for micronutrient fortification

The choices of consumer towards food have been changed. Consumer prefers to eat food which is not only safe but also nutritious. Now a day, they like to eat the food which promote their health and help in minimizing nutrition related health hazards. Rice is a staple food in many countries, but most emerging issue is that rice is deficit in minerals. Rice ranks second among cereals in dietary uses around the world. Rice is deficit in iron (Fe) zinc (Zn) and these are important micronutrients for infants, men and women. Fortification of rice with iron and zinc would help to minimize nutrient deficient disorders among humans. Present study is aimed to introduce nutrients rich rice for consumers and also to encourage food-fortification organizations for diverting their focus on rice fortification. In south Asian countries, micronutrient deficiency especially Fe and Zn deficiency is very common. The rice because of its use as a staple food can be utilized as a carrier medium for transporting micronutrients from plants sources to human beings. Hence, rice fortification with microminerals can prove as a miracle for the virtual eradication of nutrition related diseases in humans.

Ensuring the Efficacious Iron Fortification of Foods: A Tale of Two Barriers

Iron fortification of foods has always been a challenge. This is because iron fortification compounds vary widely in relative absorption; because many foods undergo unacceptable changes in color or flavor from the addition of iron; and because many of the iron-fortified foods contain potent inhibitors of iron absorption. These technical barriers have largely been overcome, and efficacious iron-fortified foods, that maintain or improve the iron status of women or children in long-term feeding studies, can be designed. Commercially fortified infant foods are efficacious, and other commercial iron-fortified foods targeted at women and children will provide a useful amount of iron provided the fortification level is adjusted according to the relative absorption of the iron compound. Technologies for the large-scale fortification of wheat and maize flour are also well established, and iron fortification of rice, using the recently developed extruded premix technique, is showing great promise. However, some important knowledge gaps still remain, and further research and development is needed in relation to iron (and iodine)-fortified salt and iron-fortified liquid milk. The usefulness of less-soluble iron compounds, such as ferrous fumarate, to fortify foods for infants and young children in low- and middle-income countries (LMICs) also needs further investigation. A more formidable barrier to efficacious iron-fortified food has been reported in recent years. This is the infection-initiated inflammation barrier, which inhibits iron absorption in response to infection. This barrier is particularly important in LMICs where infections such as malaria and HIV are widespread, and gastrointestinal infections are common due to poor quality water supplies and sanitation. Another source of inflammation in such countries is the high prevalence of obesity in women. Most countries in sub-Saharan Africa have high inflammation which not only decreases the efficacy of iron-fortified and iron-biofortified foods but complicates the monitoring of large-scale iron fortification programs. This is because iron deficiency anemia cannot be differentiated from the more prominent anemia of inflammation and because inflammation confounds the measurement of iron status. There is an urgent need to better quantify the impact of inflammation on the efficacy of iron-fortified foods. However, at present, in LMICs with high inflammation exposure, infection control, cleaner water, improved sanitation, and a decrease in obesity prevalence will undoubtedly have a greater impact on iron status and anemia than the iron fortification of foods.

Can the supplementary consumption of baobab (Adansonia digitata L.) fruit pulp improve the hemoglobin levels and iron status of schoolchildren in Kenya? Findings of a randomized controlled intervention trial

PURPOSE

In the rural Kenyan diet, the bioavailability of iron is low and predisposes the population to iron deficiency. Fruit pulp of the indigenous baobab tree contains significant amounts of vitamin C, which enhances non-heme iron bioavailability. We studied the impact of baobab fruit pulp (BFP) consumption on the hemoglobin (Hb) and iron status of Kenyan schoolchildren.

METHODS

The single-blind randomized controlled intervention trial was implemented daily among apparently healthy schoolchildren aged 6-12 years with hemoglobin level < 12.2 g/dl. For 12 weeks, children in the intervention group (n = 29) received a drink with BFP, while the control group (n = 29) received an isoenergy drink without BFP. At baseline and endline, blood samples were taken.

RESULTS

The development of hemoglobin, ferritin (FER) and soluble transferrin receptor (sTfR) did not differ significantly between the intervention and control groups. However, in the intervention group, Hb levels improved slightly (2.2%), while they decreased slightly (1.2%) in the control group. Levels of geometric means of sTfR remained almost unchanged (0.7%) in the intervention group and slightly worsened (2.7%) in the control group. In both the groups, geometric mean of FER levels decreased, yet to a smaller extent in the intervention (17.3%) than in the control (26.0%) group.

CONCLUSION

Even though no significant effects of BFP could be detected in this study, the identification of products such as BFP remains pertinent to help improve non-heme iron absorption in the most vulnerable populations.

Ultrastructural aberrations, histological disruption and upregulation of the VEGF, CD34 and ASMA immunoexpression in the myocardium of anemic albino rats

Iron deficiency anemia (IDA) is a global health problem affecting various body systems and tissues including the cardiovascular system. Several literatures described the associated physiological and clinical changes in the cardiovascular system and heart. However, the associated structural changes were poorly investigated. Therefore, the main aim of the present work was to elucidate whether IDA induces structural changes and alterations in the VEGF, CD34 and ASMA immunoexpression in the myocardium of albino rats. Thirty adult male albino rats were divided into two groups (fifteen rats each); control and anemic. Hematological data for all animals were assessed weekly and statistically analyzed. Three weeks later, animals were sacrificed, and heart specimens were obtained and processed for light and electron microscopy. All hematological parameters showed a statistically significant decrease in the anemic group. Structurally, the anemic group showed markedly degenerated, disrupted and disorganized cardiomyocytes in addition to markedly congested blood vessels, fibroblasts, collagen fibers deposition and perivascular cellular infiltration were noted. Also, positive immunostaining for VEGF, CD34 and ASMA was observed. Ultra-structurally, the myocardium of the anemic group showed disrupted and degenerated myofibrils with degenerated nuclei, perinuclear edema, widened interstitial spaces and marked collagen deposition. Mitochondria markedly increased with abnormal shapes. IDA induced myocardial injury that may propagate to regeneration through activated CD34 progenitor cells and increased VEGF or to degeneration and fibrosis through collagen fibers deposition and enhanced ASMA. So, early diagnosis and treatment of IDA is mandatory to avoid the associated myocardial structural changes.

Do cash transfers increase nutritional intakes? Experimental evidence from an unconditional cash transfer in Kenya

Malnutrition due to persistent food insecurity has been a serious public health issue in Kenya. An unconditional cash transfer programme, the Hunger Safety Net Programme (HSNP), was launched in 2009 in northern Kenya to reduce extreme poverty and to mitigate food insecurity. This study investigates the impact of the HSNP, on expenditure on food, types of food consumed and nutritional intake. Focusing on nutritional intake as well as spending and consumption is important because an unconditional cash transfer, which does not specify how the transferred money must be used, does not guarantee nutritional intake improvement. Converting food consumption data to caloric intake and nutrient content using food consumption databases, we calculate the intake of five macro-nutrients, seven vitamins and seven minerals and then estimate the impacts on nutritional intake 12 and 24 months after treatment exposure. This study finds the increased total expenditure on food items. Specifically, the beneficiary households increased their expenditure on milk and milk products and that on sugar after 12 months and expenditure on roots and tubers after 24 months. For consumption amounts, however, the HSNP did not show significant increases in all food categories except sugar. On the other hand, the HSNP improved the nutritional intakes of some macro- and micro-nutrients. The results show that beneficiary households substantially increased their intake of fat by 25.2% after 24 months and their intake of vitamin B12 by 36.6% and calcium by 34.9% after 12 months. The result does not yield sufficiently strong evidence that poorer households significantly enjoy greater improvements than other households.

The Potential of Iodine and Iron Double-Fortified Salt Compared with Iron-Fortified Staple Foods to Increase Population Iron Status

The potential of double-fortified salt (DFS) to improve population iron status is compared with the potential of iron-fortified wheat flour, maize flour, rice grains, and milk products. The potential for a positive impact on iron status is based on reported efficacy studies, consumption patterns, the extent of industrialization, and whether there are remaining technical issues with the fortification technologies. Efficacy studies with DFS, and with iron-fortified wheat flour, maize flour, and rice, have all reported good potential to improve population iron status. Iron-fortified milk powder has shown good impact in young children. When these foods are industrially fortified in modern, automated facilities, with high-level quality control and assurance practices, high-quality raw materials, and a wide population coverage, all vehicles have good potential to improve iron status. Relative to other fortification vehicles, fortification practices with wheat flour are the most advanced and iron-fortified wheat flour has the highest potential for impact in the short- to medium-term in countries where wheat flour is consumed as a staple. Liquid milk has the least potential, mainly because an acceptable iron fortification technology has not yet been developed. Maize is still predominantly milled in small-scale local mills and, although the extruded rice premix technology holds great promise, it is still under development. Salt has a proven record as an excellent vehicle for iodine fortification and has demonstrated good potential for iron fortification. However, technical issues remain with DFS and further studies are needed to better understand and avoid color formation and iron-catalyzed iodine losses in both high- and low-quality salts under different storage conditions. There is currently a risk that the introduction of DFS may jeopardize the success of existing salt iodization programs because the addition of iron may increase iodine losses and cause unacceptable color formation.

Iron supplementation and iron-fortified foods: a review

About one-third of the world population is suffering from iron deficiency. Delivery of iron through diet is a practical, economical, and sustainable approach. Clinical studies have shown that the consumption of iron-fortified foods is one of the most effective methods for the prevention of iron deficiency. However, supplementing iron through diet can cause undesirable side-effects. Thus, it is essential to develop new iron-rich ingredients, iron-fortified products with high bioavailability, better stability, and lower cost. It is also essential to develop newer processing technologies for more effective fortification. This review compared the iron supplementation strategies used to treat the highly iron-deficient population and the general public. We also reviewed the efficacy of functional (iron-rich) ingredients that can be incorporated into food materials to produce iron-fortified foods. The most commonly available foods, such as cereals, bakery products, dairy products, beverages, and condiments are still the best vehicles for iron fortification and delivery.Scope of reviewThe manuscript aims at providing a comprehensive review of the latest publications that cover three aspects: administration routes for iron supplementation, iron-rich ingredients used for iron supplementation, and iron-fortified foods.

Efficacy of an iron-fortified infant cereal to reduce the risk of iron deficiency anemia in young children in East Cameroon

Complementary foods in Africa are often poor sources of bioavailable iron. We assessed the efficacy of iron-fortified wheat-based infant cereal (IC) to reduce the risk of iron deficiency anemia in children aged 18-59 months in Cameroon. A 6-month double-blind, cluster-randomized controlled trial was conducted in 2017 among anemic (hemoglobin 7-11 g/dl) but otherwise healthy children. In conjunction with usual diet, children received two 50 g servings/day of a standard, micronutrient-fortified IC (providing 3.75 mg iron/serving; n = 106) or the same IC without iron fortification (n = 99). Anthropometric measurements, blood sampling, and systematic deworming were performed in all children at baseline (pre-intervention), 3, and 6 months. Mean hemoglobin, ferritin adjusted for C-reactive protein (CRP), serum iron, transferrin saturation, prevalence of anemia, iron deficiency, and iron deficiency anemia as well as anthropometrics were compared between the groups at baseline, 3, and 6 months. Compared to the control group, children consuming the iron-fortified IC had significantly higher baseline-adjusted mean hemoglobin (10.0 ± 1.8 vs. 9.7 ± 1.4 g/dl, respectively; p = .023), ferritin adjusted for CRP (16.1 ± 8.3 vs. 9.5 ± 7.5 μg/L, p < .001), serum iron (14.5 ± 3.9 vs. 11.2 ± 4.4 μg/dl; p < .001), and transferrin saturation (19.0 ± 17.4 vs. 10.7 ± 12.5%; p ˂ .001) at 6 months. The prevalence of anemia, iron deficiency, and iron deficiency anemia at 6 months decreased by a larger extent in the iron-fortified group versus controls (all p < .01). In addition, at 6 months, children in the iron-fortified group demonstrated higher weight-for-age z-scores (p = .016) compared to the control group. Wheat-based IC fortified with 7.5 mg ferrous fumarate administered daily for 6 months improved iron and nutritional status and decreased the prevalence of iron deficiency anemia in children aged 18-59 months in Salapoumbé, Cameroon.

Stakeholder's Perceptions of Mexico's Federal Corn Flour Fortification Program: A Qualitative Study

Background: In Mexico, the fortification of corn and wheat flours with iron, zinc, and folic acid and the restoration of B-vitamins is a mandatory program. However, the monitoring and evaluation (M&E) of this fortification process is not well understood. Thus, the purpose of the study was to understand the M&E of the food fortification program in Mexico, with an emphasis on technology research and development. Methods: Open-ended exploratory interviews were conducted with food technology representatives (n = 9), food science academic faculty (n = 1), president of a private tortilla-making federation (n = 1), and representatives of the federal monitoring agency (n = 2). Interviews were transcribed and themes were identified using the content analysis methodology. Inter-rater reliability was assessed by calculating an intraclass correlation coefficient (ICC) between the raters (n = 3). Results: A total of 49 codes were identified that resulted in three overarching themes, manufacturing/processing, monitoring logistics, and nutrition. Overall, there is a need for more robust internal and external M&E with Mexico’s fortification program to improve the manufacturing/processing of fortifying the tortillas, the monitoring of this fortification program, and the impact the fortified tortillas have on the nutritional status of the Mexican population. The overall ICC was 0.87. Conclusions: The present study can be used to gain insight into Mexico’s fortification program and to inform food fortification policymakers of best practices.

The Nutritional and Micronutrient Status of Urban Schoolchildren with Moderate Anemia is Better than in a Rural Area in Kenya

Low diet quality is a driver of general and micronutrient malnutrition in urban and rural areas. The objective was to compare malnutrition and micronutrient deficiencies linked to dietary intake among urban and rural schoolchildren from food insecure settings in Kenya. The cross-sectional study was conducted among urban and rural schoolchildren aged 7–9 years. Height and weight were measured, venous blood samples were assessed and data on dietary intake was collected. After screening out children with hemoglobin >12.2 g/dL and moderate or severe undernutrition, a total of 36 urban and 35 rural children participated. The prevalence of moderate underweight, wasting, and stunting were lower in urban than in rural children, with significant differences in median z-scores for underweight (p < 0.001) and wasting (p < 0.001). Significantly higher values for serum ferritin (p = 0.012) and zinc (p < 0.001) were found in urban children. Yet, the median adequacy ratios were higher for vitamin C (p = 0.045), iron (p = 0.003), and zinc (p = 0.003) in rural than in urban children. General nutritional, iron, and zinc status were significantly better in slightly anemic urban children than in rural ones. Improving the nutrition of schoolchildren in urban and rural settings requires different dietary approaches.

Systematic review and meta-analysis of the effect of iron-fortified flour on iron status of populations worldwide

Objective:

Assess the effectiveness of iron-fortified flour on iron status.

Design:

Systematic review and meta-analysis.

Setting:

Argentina, Australia, Azerbaijan, Bangladesh, Brazil, Cameroon, Chile, China, Costa Rica, Côte d’Ivoire, Denmark, India, Iran, Jordan, Kazakhstan, Kenya, Kuwait, Mongolia, Morocco, Norway, South Africa, Sri Lanka, Tajikistan, Thailand, UK, USA, Uzbekistan, Venezuela, Vietnam, and Zambia.

Participants:

Fifty-two articles (ninety-four trials) were examined. The main target groups were women, children, and infants/toddlers. The effects of different types of iron-fortified flour (wheat, maize, rice, soy, and beans) on iron status were examined.

Results:

A random effects analysis of before–after studies showed that iron-fortified flour led to significant increases of mean haemoglobin level (3·360 g/l; 95 % CI: 0·980, 5·730) and mean serum ferritin level (4·518 µg/l; 95 % CI: 2·367, 6·669); significant decreases of anaemia (−6·7 %; 95 % CI: −9·8 %, −3·6 %) and iron deficiency (ID) (−10·4 %; 95 % CI: −14·3 %, −6·5 %); but had no significant effect on iron deficiency anaemia (IDA). A random effects analysis of controlled trials indicated that iron-fortified flour led to significant increases of mean haemoglobin level (2·630 g/l; 95 % CI: 1·310, 3·950) and mean ferritin level (8·544 µg/l; 95 % CI: 6·767, 10·320); and significant decreases of anaemia (−8·1 %; 95 % CI: −11·7 %, −4·4 %), ID (−12·0 %; 95 % CI: −18·9 %, −5·1 %), and IDA (−20·9 %; 95 % CI: −38·4 %, −3·4 %).

Conclusions:

Flour fortification with iron is an effective public health strategy that improves iron status of populations worldwide.

Complementary Feeding of Sorghum-Based and Corn-Based Fortified Blended Foods Results in Similar Iron, Vitamin A, and Anthropometric Outcomes in the MFFAPP Tanzania Efficacy Study

BACKGROUND

Fortified blended foods (FBFs) are micronutrient-fortified food aid products containing cereals and pulses. It has been suggested to reformulate FBFs to include whey protein concentrate, use alternative commodities (e.g., sorghum and cowpea), and utilize processing methods such as extrusion to produce them. The Micronutrient Fortified Food Aid Pilot Project (MFFAPP) efficacy study was designed to test the efficacy of complementary feeding of newly formulated FBFs.

OBJECTIVES

The aim of this study was to test the effectiveness of 5 newly formulated FBFs in combating iron deficiency anemia and vitamin A deficiency compared with traditionally prepared corn-soy blend plus (CSB+) and no intervention. A secondary aim was to determine the impact on underweight, stunting, wasting, and middle-upper arm circumference.

METHODS

A 20-wk, partially randomized cluster study was completed. Two age groups (aged 6-23 and 24-53 mo) with hemoglobin status <10.3 g/dL, and weight-for-height z scores >-3 were enrolled and assigned to diet groups. Biochemical and anthropometric measurements were collected at 0, 10, and 20 wk.

RESULTS

Both hemoglobin concentrations and anemia ORs were significantly improved in all intervention groups except for CSB+ and the no-intervention groups at week 20. Only extruded corn-soy blend 14 and the no-intervention age groups failed to significantly decrease vitamin A deficiency risk (P < 0.04). There were no consistent significant differences among groups in anthropometric outcomes.

CONCLUSIONS

FBFs reformulated with sorghum, cowpea, corn, and soy significantly improved anemia and vitamin A deficiency ORs compared with week 0 and with no intervention. Although newly formulated FBFs did not significantly improve vitamin A deficiency or anemia compared with CSB+, CSB+ was the only FBF not to significantly improve these outcomes over the study duration. Our findings suggest that newly formulated sorghum- and cowpea-based FBFs are equally efficacious in improving these micronutrient outcomes. However, further FBF refinement is warranted. This trial was registered at clinicaltrials.gov as NCT02847962.

Health effects of micronutrient fortified dairy products and cereal food for children and adolescents: A systematic review

INTRODUCTION

Micronutrient (MN) deficiencies cause a considerable burden of disease for children in many countries. Dairy products or cereals are an important food component during adolescence. Fortification of dairy products or cereals with MN may be an effective strategy to overcome MN deficiencies, but their specific impact on health in this age group is poorly documented.

METHODS

We performed a systematic review and meta-analysis (registration number CRD42016039554) to assess the impact of MN fortified dairy products and cereal food on the health of children and adolescents (aged 5-15 years) compared with non-fortified food. We reviewed randomised controlled trials (RCT) using electronic databases (MEDLINE, EMBASE, Cochrane library; latest search: January 2018), reference list screening and citation searches. Three pairs of reviewers assessed 2048 studies for eligibility and extracted data. We assessed the risk of bias and applied GRADE to rate quality of evidence.

RESULTS

We included 24 RCT (often multi MN fortification) with 30 pair-wise comparisons mainly from low- and middle income countries. A very small and non-significant increase of haemoglobin values emerged (0.09 g/dl [95%-CI: -0.01 to 0.18]; 13 RCT with iron fortification; very low quality of evidence). No significant difference was found on anaemia risk (risk ratio 0.87 [95%-CI: 0.76 to 1.01]; 12 RCT; very low quality), but a significant difference in iron deficiency anaemia favouring fortified food was found (risk ratio 0.38 [95%-CI: 0.18 to 0.81]; 5 RCT; very low quality). Similar effects were seen for fortified dairy products and cereals and different fortification strategies (mono- vs. dual- vs. multi-MN). Follow-up periods were often short and the impact on anthropometric measures was weak (low quality of evidence) Very low quality of evidence emerged for the improvement of cognitive performance, functional measures and morbidity.

CONCLUSIONS

Fortification of dairy products and cereal food had only marginal health effects in our sample population from 5-15 years. Further evidence is needed to better understand the health impact of fortified dairy products and cereals in this age group.

SYSTEMATIC REVIEW REGISTRATION

The study protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 26 May 2016 (registration number CRD42016039554).

Fortification of maize flour with iron for controlling anaemia and iron deficiency in populations

BACKGROUND

Approximately 800 million women and children have anaemia, a condition thought to cause almost 9% of the global burden of years lived with disability. Around half this burden could be amenable to interventions that involve the provision of iron. Maize (corn) is one of the world's most important cereal grains and is cultivated across most of the globe. Several programmes around the world have fortified maize flour and other maize-derived foodstuffs with iron and other vitamins and minerals to combat anaemia and iron deficiency.

OBJECTIVES

To assess the effects of iron fortification of maize flour, corn meal and fortified maize flour products for anaemia and iron status in the general population.

SEARCH METHODS

We searched the following international and regional sources in December 2017 and January 2018: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; MEDLINE (R) In Process; Embase; Web of Science (both the Social Science Citation Index and the Science Citation Index); CINAHL Ebsco; POPLINE; AGRICOLA (agricola.nal.usda.gov); BIOSIS (ISI); Bibliomap and TRoPHI; IBECS; Scielo; Global Index Medicus - AFRO (includes African Index Medicus); EMRO (includes Index Medicus for the Eastern Mediterranean Region); LILACS; PAHO (Pan American Health Library); WHOLIS (WHO Library); WPRO (includes Western Pacific Region Index Medicus); IMSEAR, Index Medicus for the South-East Asian Region; IndMED, Indian medical journals; and the Native Health Research Database. We searched clinicaltrials.gov and the International Clinical Trials Registry Platform (ICTRP) for any ongoing or planned studies on 17 January 2018 and contacted authors of such studies to obtain further information or eligible data if available.For assistance in identifying ongoing or unpublished studies, we also contacted relevant international organisations and agencies working in food fortification on 9 August 2016.

SELECTION CRITERIA

We included cluster- or individually randomised controlled trials and observational studies. Interventions included (central/industrial) fortification of maize flour or corn meal with iron alone or with other vitamins and minerals and provided to individuals over 2 years of age (including pregnant and lactating women) from any country.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of studies for inclusion, extracted data from included studies and assessed the risk of bias of the included studies. Trial designs with a comparison group were included to assess the effects of interventions. Trial designs without a control or comparison group (uncontrolled before-and-after studies) were included for completeness but were not considered in assessments of the overall effectiveness of interventions or used to draw conclusions regarding the effects of interventions in the review.

MAIN RESULTS

Our search yielded 4529 records. After initial screening of titles and abstracts, we reviewed the full text of 75 studies (80 records). We included 5 studies and excluded 70. All the included studies assessed the effects of providing maize products fortified with iron plus other vitamins and minerals versus unfortified maize flour. No studies compared this intervention to no intervention or looked at the relative effect of flour and products fortified with iron alone (without other vitamins and minerals). Three were randomised trials involving 2610 participants, and two were uncontrolled before-and-after studies involving 849 participants.Only three studies contributed data for the meta-analysis and included children aged 2 to 11.9 years and women. Compared to unfortified maize flour, it is uncertain whether fortifying maize flour or corn meal with iron and other vitamins and minerals has any effect on anaemia (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.58 to 1.40; 2 studies; 1027 participants; very low-certainty evidence), or on the risk of iron deficiency (RR 0.75, 95% CI 0.49 to 1.15; 2 studies; 1102 participants; very low-certainty evidence), haemoglobin concentration (mean difference (MD) 1.25 g/L, 95% CI -2.36 to 4.86 g/L; 3 studies; 1144 participants; very low-certainty evidence) or ferritin concentrations (MD 0.48 µg/L, 95% CI -0.37 to 1.33 µg/L; 1 study; 584 participants; very low-certainty evidence).None of the studies reported on any adverse effects. We judged the certainty of the evidence to be very low based on GRADE, so we are uncertain whether the results reflect the true effect of the intervention. We downgraded evidence due to high risk of selection bias and unclear risk of performance bias in one of two included studies, high heterogeneity and wide CIs crossing the line of no effect for anaemia prevalence and haemoglobin concentration.

AUTHORS' CONCLUSIONS

It is uncertain whether fortifying maize flour with iron and other vitamins and minerals reduces the risk of anaemia or iron deficiency in children aged over 2 years or in adults. Moreover, the evidence is too uncertain to conclude whether iron-fortified maize flour, corn meal or fortified maize flour products have any effect on reducing the risk of anaemia or on improving haemoglobin concentration in the population.We are uncertain whether fortification of maize flour with iron reduces anaemia among the general population, as the certainty of the evidence is very low. No studies reported on any adverse effects.Public organisations funded three of the five included studies, while the private sector gave grants to universities to perform the other two. The presence of industry funding for some of these trials did not appear to positively influence results from these studies.The reduced number of studies, including only two age groups (children and women of reproductive age), as well as the limited number of comparisons (only one out of the four planned) constitute the main limitations of this review.

Scientific opinion on the evaluation of authorised ferric sodium EDTA as an ingredient in the context of Regulation (EC) 258/97 on novel foods and Regulation (EU) 609/2013 on food intended for infants and young children, food for special medical purposes and total diet replacement for weight control

The present opinion deals with the evaluation of the proposed increase of the currently authorised maximum amounts of ferric sodium ethylenediaminetetraacetic acid (EDTA) as a novel food ingredient used as a source of iron, and its extension of use in processed cereal‐based foods and baby foods. The applicant also provided information on two forms of ferric sodium EDTA, one previously assessed by EFSA and a new one of finer consistency. To support the proposed changes to the uses of ferric sodium EDTA, the applicant proposed a revision of the current acceptable daily intake (ADI) for EDTA, derived from that set for the food additive calcium disodium EDTA (E 385). The Panel confirmed that ferric sodium EDTA is a source from which iron is bioavailable. In assessing the safety of the proposed revision to the existing specifications for the novel food ingredient ferric sodium EDTA, the Panel noted that this would not discriminate between the previously evaluated substance and the one of finer consistency. In particular, the Panel noted that particle size was not one of the proposed parameters for the revised specifications. The Panel noted that it was not possible to determine whether particles of ferric sodium EDTA in the nano range were present in the product with finer consistency in the solid form. The toxicological data submitted did not add any new relevant information to the database on which the current ADI for EDTA is based. Consequently, the Panel concluded that there was no sound scientific justification to increase the ADI for EDTA and hence increase the use levels of ferric sodium EDTA or introduce additional uses as proposed by the applicant. The Panel recommended that additional toxicological data should be provided to address the shortcomings in the available toxicity database prior to the re‐evaluation of calcium disodium EDTA (E 385).

Iron Fortified Complementary Foods Containing a Mixture of Sodium Iron EDTA with Either Ferrous Fumarate or Ferric Pyrophosphate Reduce Iron Deficiency Anemia in 12- to 36-Month-Old Children in a Malaria Endemic Setting: A Secondary Analysis of a Cluster-Randomized Controlled Trial

Iron deficiency anemia (IDA) is a major public health problem in sub-Saharan Africa. The efficacy of iron fortification against IDA is uncertain in malaria-endemic settings. The objective of this study was to evaluate the efficacy of a complementary food (CF) fortified with sodium iron EDTA (NaFeEDTA) plus either ferrous fumarate (FeFum) or ferric pyrophosphate (FePP) to combat IDA in preschool-age children in a highly malaria endemic region. This is a secondary analysis of a nine-month cluster-randomized controlled trial conducted in south-central Côte d'Ivoire. 378 children aged 12-36 months were randomly assigned to no food intervention (n = 125; control group), CF fortified with 2 mg NaFeEDTA plus 3.8 mg FeFum for six days/week (n = 126; FeFum group), and CF fortified with 2 mg NaFeEDTA and 3.8 mg FePP for six days/week (n = 127; FePP group). The outcome measures were hemoglobin (Hb), plasma ferritin (PF), iron deficiency (PF < 30 μg/L), and anemia (Hb < 11.0 g/dL). Data were analyzed with random-effect models and PF was adjusted for inflammation. The prevalence of Plasmodium falciparum infection and inflammation during the study were 44-66%, and 57-76%, respectively. There was a significant time by treatment interaction on IDA (p = 0.028) and a borderline significant time by treatment interaction on iron deficiency with or without anemia (p = 0.068). IDA prevalence sharply decreased in the FeFum (32.8% to 1.2%, p < 0.001) and FePP group (23.6% to 3.4%, p < 0.001). However, there was no significant time by treatment interaction on Hb or total anemia. These data indicate that, despite the high endemicity of malaria and elevated inflammation biomarkers (C-reactive protein or α-1-acid-glycoprotein), IDA was markedly reduced by provision of iron fortified CF to preschool-age children for 9 months, with no significant differences between a combination of NaFeEDTA with FeFum or NaFeEDTA with FePP. However, there was no overall effect on anemia, suggesting most of the anemia in this setting is not due to ID. This trial is registered at clinicaltrials.gov (NCT01634945).

The MFFAPP Tanzania Efficacy Study Protocol: Newly Formulated, Extruded, Fortified Blended Foods for Food Aid

Fortified blended foods (FBFs) are micronutrient-fortified blends of milled cereals and pulses that represent the most commonly distributed micronutrient-fortified food aid. FBFs have been criticized due to lack of efficacy in treating undernutrition, and it has also been suggested that alternative commodities, such as sorghum and cowpea, be investigated instead of corn and soybean. The Micronutrient Fortified Food Aid Pilot Project (MFFAPP) Tanzania efficacy study was the culmination of economic, processing, sensory, and nutrition FBF research and development. MFFAPP Tanzania was a 20-wk, partially randomized cluster design conducted between February and July 2016 that enrolled children aged 6-53 mo in the Mara region of Tanzania with weight-for-height z scores >-3 and hemoglobin concentrations <10.3 mg/dL. The intervention was complementary feeding of newly formulated, extruded FBFs (white sorghum cowpea variety 1, white sorghum-cowpea variety 2, red sorghum-cowpea, white sorghum-soy blend, and corn-soy blend 14) compared with Corn Soy Blend Plus (CSB+), a current US Agency for International Development-distributed corn-soy blend, and a no-FBF-receiving control. Screened participants (n = 2050) were stratified by age group (6-23 and 24-53 mo) and allocated to 1 of 7 FBF clusters provided biweekly. Biochemical and anthropometric data were measured every 10 wk at weeks 0, 10, and 20. The primary objectives of this study were to determine whether newly formulated, extruded corn-, soy-, sorghum-, and cowpea-based FBFs result in equivalent vitamin A or iron outcomes compared with CSB+. Changes in anthropometric outcomes were also examined. Results from the MFFAPP Tanzania Efficacy Study will inform food aid producers and distributers about whether extruded sorghum- and cowpea-based FBFs are viable options for improving the health of the undernourished. This trial was registered at clinicaltrials.gov as NCT02847962.

Impact of fortified biscuits on micronutrient deficiencies among primary school children in Bangladesh

BACKGROUND

Micronutrient deficiencies can compromise the development potential of school-aged children, and their later health and productivity as adults. School feeding and school-based fortification approaches have been utilized globally to redress nutritional deficiencies in this age group.

OBJECTIVE

We explored the acceptability and micronutrient impact of a Bangladesh Government supported school-based micronutrient fortification program for children attending rural primary schools in 10 disadvantaged sub-districts.

METHODS

We applied a mixed methods approach. The quantitative component assessed the impact of micronutrient fortification on 351 children aged 6-11 years using a cohort pre-post research design with a control group. The qualitative component explored the acceptability of the intervention using focus group discussions, body mapping and semi-structured interviews with teachers, school-going children and school authorities.

RESULTS

Daily consumption of fortified biscuits by primary school children had a significant positive impact on mean levels of iron, folic acid, vitamin B12, retinol and vitamin D controlling for sex, baseline deficiency status, CRP, and H. pylori. Levels of anemia and vitamin D deficiency were also significantly reduced. Qualitative findings indicated the widespread acceptability of the daily biscuit. Teachers perceived students to be more attentive in class, less tired, and some attributed better school performance to biscuit consumption. Children reported similar improvements in concentration and energy levels.

CONCLUSIONS

This study is among the first in Bangladesh to comprehensively assess a school-based fortification program in terms of its acceptability and impact on micronutrient status of children aged 6-11 years of age. While results strongly support this modality of school feeding, research on the cognitive impacts of micronutrient fortified biscuits will help clarify the case for scaled-up investments in school- based feeding program in Bangladesh and other low and middle income countries.

In-home fortification with 2.5 mg iron as NaFeEDTA does not reduce anaemia but increases weight gain: a randomised controlled trial in Kenyan infants

In-home fortification of infants with micronutrient powders (MNPs) containing 12.5 mg iron may increase morbidity from infections; therefore, an efficacious low-dose iron-containing MNP might be advantageous. Effects of iron-containing MNPs on infant growth are unclear. We assessed the efficacy of a low-iron MNP on iron status and growth and monitored safety in a randomised, controlled, double-blind 1-year trial in 6-month-old infants (n = 287) consuming daily a maize porridge fortified with either a MNP including 2.5 mg iron as NaFeEDTA (MNP + Fe) or the same MNP without iron (MNP - Fe). At baseline, after 6 and 12 months, we determined haemoglobin (Hb), iron status [serum ferritin (SF), soluble transferrin receptor (sTfR) and zinc protoporphyrin (ZPP)], inflammation [C-reactive protein (CRP)] and anthropometrics. We investigated safety using weekly morbidity questionnaires asking for diarrhoea, cough, flu, bloody or mucus-containing stool and dyspnoea, and recorded any other illness. Furthermore, feeding history and compliance were assessed weekly. At baseline, 71% of the infants were anaemic and 22% iron deficient; prevalence of inflammation was high (31% had an elevated CRP). Over the 1 year, Hb increased and SF decreased in both groups, without significant treatment effects of the iron fortification. At end point, the weight of infants consuming MNP + Fe was greater than in the MNP - Fe group (9.9 vs. 9.5 kg, P = 0.038). Mothers of infants in the MNP + Fe group reported more infant days spent with cough (P = 0.003) and dyspnoea (P = 0.0002); there were no significant differences on any other of the weekly morbidity measures. In this study, low-dose iron-containing MNP did not improve infant's iron status or reduce anaemia prevalence, likely because absorption was inadequate due to the high prevalence of infections and the low-iron dose.

The Effects of an Oil and Wheat Flour Fortification Program on Pre-School Children and Women of Reproductive Age Living in Côte d'Ivoire, a Malaria-Endemic Area

Anemia and micronutrient deficiencies are widespread in sub-Saharan Africa, but the impact of food fortification is still debated. The objective of this study was to estimate the iron and vitamin A status of preschool children (PSC) and women of reproductive age (WRA) in households consuming fortified oil and wheat flour. The survey was cross-sectional in a rural and an urban area. Data on demographics, socioeconomic status, and fortified foods were collected at households. Hemoglobin (Hb), retinol binding protein (RBP), ferritin, soluble transferrin receptors (sTfR), subclinical inflammation, and Plasmodium spp. infection data were collected. In PSC, vitamin A deficiency (VAD) was prevalent, but for each 1 mg retinol equivalents (RE)/kg of oil consumed, RBP increased by 0.37 μmol/L (p = 0.03). In WRA, there was no significant VAD in the population (0.7%). Anemia was found in 92.2% of rural and 56.3% of urban PSC (p < 0.001). PSC with access to adequately fortified flour had Hb concentrations 15.7 g/L higher than those who did not (p < 0.001). Hb levels increased by +0.238 g/L per mg/kg increase in iron fortification levels (p < 0.001). The national program fortifying vegetable oil with vitamin A and wheat flour with iron and folic acid may have contributed to improved micronutrient status of PSC from two areas in Côte d’Ivoire.

Beyond Effectiveness--The Adversities of Implementing a Fortification Program. A Case Study on the Quality of Iron Fortification of Fish and Soy Sauce in Cambodia

Fortification of fish and soy sauces is a cost-effective strategy to deliver and increase iron intake in the Cambodian diet, as both are widely consumed by the entire population. In order to qualify as fortified sauces recognized by international regulations, iron content must be between 230 and 460 mg/L, whilst nitrogen and salt should contain no less than 10 g/L and 200 g/L respectively. This survey aims to analyze the progress of the fortification program. Through a better understanding of its obstacles and successes, the paper will then consider approaches to strengthen the program. Two hundred and fifty two samples were collected from 186 plants and 66 markets in various provinces. They were then analyzed for iron, nitrogen and salt content. The study demonstrates that 74% of fortified fish and soy sauces comply with Cambodian regulations on iron content. 87% and 53.6% of the collected samples do not have adequate level of nitrogen and salt content, respectively. The paper will discuss additional efforts that need to be implemented to ensure the sustainability of the project, including the need to: (i) comply with International Codex; (ii) adopt mandatory legislation; and (iii) ensure enforcement.

Integration to Implementation and the Micronutrient Forum: A Coordinated Approach for Global Nutrition. Case Study Application: Safety and Effectiveness of Iron Interventions

Paramount among the challenges to our ability to address the role of food and nutrition in health promotion and disease prevention is how to design and implement context-specific interventions and guidance. The Integration to Effective Implementation (I-to-I) concept is intended to address the complexities of the global health context through engagement of the continuum of stakeholders involved in the food and nutrition enterprise. The 2014 Micronutrient Forum (MNF) Global Conference held in Addis Ababa, Ethiopia, in June 2014 offered the opportunity to apply the I-to-I approach with the use of current concerns about the safety and effectiveness of interventions to prevent and treat iron deficiency (ID) as a case study. ID is associated with a range of adverse outcomes, especially in pregnant and nonpregnant women, infants, and primary school-age children. Strategies to combat ID include iron supplementation, multiple micronutrient powders, and food-based interventions to enhance dietary iron intake. Recent reports indicate potential increased adverse risks when iron is provided in areas with high infection burdens (e.g., malaria). This paradox has weakened iron intervention programs. Furthermore, the selection and interpretation of available biomarkers for assessing iron nutrition have been found to be compromised by the inflammatory process. These issues highlight the need for a comprehensive approach that considers basic biology, assessment, interventions, and how these can be translated into appropriate programs and policies. The application of the I-to-I with the use of the MNF offered an opportunity to explore how that might be achieved.

The High Burden of Malaria in Primary School Children in Southern Malawi

Malaria among school children has received increased attention recently, yet there remain few detailed data on the health and educational burden of malaria, especially in southern Africa. This paper reports a survey among school children in 50 schools in Zomba District, Malawi. Children were assessed for Plasmodium infection, anemia, and nutritional status and took a battery of age-appropriate tests of attention, literacy, and numeracy. Overall, 60.0% of children were infected with Plasmodium falciparum, 32.4% were anemic and 32.4% reported sleeping under a mosquito net the previous night. Patterns of P. falciparum infection and anemia varied markedly by school. In multivariable analysis, higher odds of P. falciparum infection were associated with younger age and being stunted, whereas lower odds were associated with reported net use, higher parental education, and socioeconomic status. The odds of anemia were significantly associated with P. falciparum infection, with a dose-response relationship between density of infection and odds of anemia. No clear relationship was observed between health status and cognitive and educational outcomes. The high burden of malaria highlights the need to tackle malaria among school children.

Impact of iron-fortified foods on Hb concentration in children (<10 years): a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To combine evidence from randomized controlled trials to assess the effect of Fe-fortified foods on mean Hb concentration in children (<10 years).

DESIGN

We conducted a meta-analysis of randomized, controlled, Fe-fortified feeding trials that evaluated Hb concentration. The weighted mean difference was calculated for net changes in Hb by using random-effects models. Meta-regression and covariate analyses were performed to explore the influence of confounders on the net pooled effect.

SETTING

Trials were identified through a systematic search of PubMed, the Cochrane Library and secondary references.

SUBJECTS

Eighteen studies covering 5142 participants were identified. The duration of feeding of fortified foods ranged from 6 to 12 months in these studies.

RESULTS

Eighteen studies were included and evaluated in the meta-analysis. The overall pooled estimate of Hb concentration showed a significant increase in the fortification group compared with the control group (weighted mean difference = 5·09 g/l; 95% CI 3·23, 6·95 g/l; I 2 = 90%, τ 2 = 18·37, P < 0·0001). Meta-regression analysis indicated that duration of feeding was positively related to the effect size (regression coefficient = 0·368; 95% CI 0·005, 0·731; P < 0·05). The net pooled effect size after removing the confounders was 4·74 (95% CI 3·08, 6·40) g/l.

CONCLUSIONS

We observed an association between intake of Fe-fortified foods and Hb concentration in children aged <10 years. Fe-fortified foods could be an effective strategy for reducing Fe-deficiency anaemia in children.

Reasons for raising the maximum acceptable daily intake of EDTA and the benefits for iron fortification of foods for children 6-24 months of age

The current maximum acceptable daily intake (ADI) of ethylenediaminetetraacetic acid (EDTA) of 1.9 mg day⁻¹ per kilogram bodyweight (mg day⁻¹ kgbw⁻¹) limits the daily intake of iron as iron EDTA [ferric sodium EDTA; sodium iron(III) EDTA] to approximately 2–2.5 mg day⁻¹ for children 6–24 months of age. This limit was defined by the Joint FAO/WHO Expert Committee on Food Additives (JECFA) in 1973 based on data from an animal‐feed study published in 1963. Other animal studies indicate that this limit can be raised to 4.4 or possibly up to 21.7 mg day⁻¹ kgbw⁻¹, which is 2.3–11.4 times higher than the current value. For nearly 50 years, iron EDTA has been used in France in medicinal syrup for infants 1–6 months of age. The maximum recommended dosage of this drug is 37 times higher than the maximum ADI of EDTA. No adverse health effects have been reported as a result of this medicinal consumption of iron EDTA. Raising the maximum ADI of EDTA to only 4.4 mg day⁻¹ kgbw⁻¹ would enable iron EDTA, an iron fortificant with proven bioavailability in phytate‐rich meals, to be added in adequate amounts to cereal‐based meals for children 6–24 months of age, who are at risk of iron deficiency.

Processing maize flour and corn meal food products

Corn is the cereal with the highest production worldwide and is used for human consumption, livestock feed, and fuel. Various food technologies are currently used for processing industrially produced maize flours and corn meals in different parts of the world to obtain precooked refined maize flour, dehydrated nixtamalized flour, fermented maize flours, and other maize products. These products have different intrinsic vitamin and mineral contents, and their processing follows different pathways from raw grain to the consumer final product, which entail changes in nutrient composition. Dry maize mechanical processing creates whole or fractionated products, separated by anatomical features such as bran, germ, and endosperm. Wet maize processing separates by chemical compound classification such as starch and protein. Various industrial processes, including whole grain, dry milling fractionation, and nixtamalization, are described. Vitamin and mineral losses during processing are identified and the nutritional impacts outlined. Also discussed are the vitamin and mineral contents of corn.

Delivering Sprinkles Plus through the Integrated Child Development Services (ICDS) to reduce anemia in pre-school children in India

OBJECTIVE

To assess the effectiveness of micronutrient powder (MNP) supplementation in reducing anemia levels in children aged 6 mo to 6 y in India.

METHODS

Sixty sachets of MNP (Sprinkles Plus) were administered flexibly over a 4 mo period to 17,124 children at anganwadi centers or at home through Integrated Child Development Services (ICDS). Compliance was monitored using compliance cards and an assessment of mother's recall at post-intervention survey. Hemoglobin was measured in separate random samples of 1,786 children before and 1,782 children after MNP supplementation.

RESULTS

Mean compliance rate was estimated at 56.4 % (based on mother's recall) and 91.7 % (based on compliance cards) for children who received MNP at home. Mean compliance was 96.9 % (based on compliance cards) for children who received MNP at anganwadis. A significant reduction in anemia (50 % to 33 % in boys; p-value <.000; 47.4 % to 34.2 % in girls) was seen following MNP supplementation.

CONCLUSIONS

Integration of a flexibly administered MNP supplementation into the ICDS is effective in reducing and treating anemia in children 6 mo to 6 y age.

Micronutrient fortification of food and its impact on woman and child health: a systematic review

BACKGROUND

Vitamins and minerals are essential for growth and metabolism. The World Health Organization estimates that more than 2 billion people are deficient in key vitamins and minerals. Groups most vulnerable to these micronutrient deficiencies are pregnant and lactating women and young children, given their increased demands. Food fortification is one of the strategies that has been used safely and effectively to prevent vitamin and mineral deficiencies.

METHODS

A comprehensive search was done to identify all available evidence for the impact of fortification interventions. Studies were included if food was fortified with a single, dual or multiple micronutrients and impact of fortification was analyzed on the health outcomes and relevant biochemical indicators of women and children. We performed a meta-analysis of outcomes using Review Manager Software version 5.1.

RESULTS

Our systematic review identified 201 studies that we reviewed for outcomes of relevance. Fortification for children showed significant impacts on increasing serum micronutrient concentrations. Hematologic markers also improved, including hemoglobin concentrations, which showed a significant rise when food was fortified with vitamin A, iron and multiple micronutrients. Fortification with zinc had no significant adverse impact on hemoglobin levels. Multiple micronutrient fortification showed non-significant impacts on height for age, weight for age and weight for height Z-scores, although they showed positive trends. The results for fortification in women showed that calcium and vitamin D fortification had significant impacts in the post-menopausal age group. Iron fortification led to a significant increase in serum ferritin and hemoglobin levels in women of reproductive age and pregnant women. Folate fortification significantly reduced the incidence of congenital abnormalities like neural tube defects without increasing the incidence of twinning. The number of studies pooled for zinc and multiple micronutrients for women were few, though the evidence suggested benefit. There was a dearth of evidence for the impact of fortification strategies on morbidity and mortality outcomes in women and children.

CONCLUSION

Fortification is potentially an effective strategy but evidence from the developing world is scarce. Programs need to assess the direct impact of fortification on morbidity and mortality.

Differences in Circulating Non-Transferrin-Bound Iron after Oral Administration of Ferrous Sulfate, Sodium Iron EDTA, or Iron Polymaltose in Women with Marginal Iron Stores

Background

The adverse interactions between iron supplements and malaria have driven the assessment of new therapeutic options for anemia prophylaxis in areas holoendemic for falciparum malaria.

Objective

To determine the responses of circulating non-transferrin-bound iron (NTBI) and plasma iron to three different oral iron compounds—ferrous sulfate, sodium iron ethylenediaminetetraacetate (NaFeEDTA), and iron polymaltose (IPM)—in women with marginal iron stores.

Methods

Serum samples from 10 Guatemalan women with marginal iron stores were collected every 90 minutes over a period of 270 minutes, after the individually randomized administration of 100 mg of iron from each of the three studied iron compounds or water alone. Serum iron concentration was quantified by the ferrozine method, and circulating NTBI concentration was determined with a fluorometric competitive binding assay. Kinetic responses and maximal cumulative changes in serum concentrations of iron and NTBI were compared between the four treatments. Comparison was made with data from the same protocol in iron-adequate men.

Results

The serum iron and NTBI responses to ferrous sulfate were significantly greater than those to water and the other two iron compounds. Serum iron responses to IPM did not differ from those to water alone.

Conclusions

The administration of the two “slow-release” iron compounds, NaFeEDTA and IPM, resulted in a highly significant suppression of the appearance of NTBI in the circulation in the postsupplement period. These two bioavailable forms of iron supplement could represent a safe option for supplementation in malarial areas. The slope of the iron—NTBI relationship is steeper in men than in women.

Screening for anti-nutritional compounds in complementary foods and food aid products for infants and young children

A range of compounds with negative nutritional impact - 'anti-nutrients' - are found in most plant foods. The contents of anti-nutrients in processed foods depend on the ingredients and processing. Anti-nutrients in complementary foods for children can have a negative impact on nutritional status. The aim of this study was to screen complementary foods from developing countries for the anti-nutritional compounds, phytate, polyphenols, inhibitors of trypsin and chymotrypsin, and lectins. Commercial products based on whole grain cereals were included as a 'worst-case' scenario for anti-nutrient exposure in Europe. Contents of minerals (iron, zinc and calcium), in which absorption or utilisation is affected by anti-nutrients, were analysed. Thirty-six products representing foods used in food aid programmes, local blended foods, fortified instant porridges and 'baby foods' were analysed. The content of minerals indicated that the fortification of a number of products did not meet the declared levels of iron, zinc and calcium. The phytate content ranged from 68 to 1536 mg/100 g, confirming a persistent problem of high levels of phytate in processed cereal- and legume-based products. The phytate : Fe molar ratio exceeded the recommended level of <1.0 in 32 of the 36 products. The total polyphenols varied from 1.3 to 9.3 mg gentisic acid equivalents g(-1) . Screening low-molecular weight soluble polyphenols may be more relevant in complementary foods than total polyphenolic compounds. Trypsin and chymotrypsin inhibitors and lectins were found in residual amounts in most products, indicating efficient degradation by heat processing. However, young infants and malnourished children may have reduced pancreatic function, and upper limits for residual trypsin inhibitors are needed.

Effect of wheat flour fortified with sodium iron EDTA on urinary zinc excretion in school-aged children

BACKGROUND

Foods fortified with sodium iron ethylenediaminetetraacetate (NaFeEDTA) have been shown to improve iron status in children, but little is known about the effect of this salt on urinary zinc excretion, particularly in children. This is particularly relevant, since zinc deficiency is known to limit growth and development in young children.

OBJECTIVE

To determine the effect of NaFeEDTA-fortified wheat flour on urinary zinc excretion.

METHODS

This study was a part of a randomized, controlled trial that was carried out among 6- to 13-year-old iron-depleted schoolchildren (n = 179) who had received either a NaFeEDTA-fortified wheat meal (iron group) or an identical control meal without added iron (control group) for a period of 7 months. Urinary zinc concentration was assessed at the end of the intervention period by spot urine samples.

RESULTS

Iron status in the iron group was significantly improved according to measurements of hemoglobin and serum ferritin (p < .001). However, there was no significant difference in urinary zinc excretion between the iron group (median, 38.4 microg/dL; 25th-75th percentiles, 18.2-67.1 microg/dL) and the control group (median, 33.1 microg/dL; 25th-75th percentiles, 12.4-54.2 microg/dL).

CONCLUSIONS

Iron fortification of foods with NaFeEDTA does not affect urinary zinc excretion in children.

Phytic acid-to-iron molar ratio rather than polyphenol concentration determines iron bioavailability in whole-cowpea meal among young women

Limited data exist on iron absorption from NaFeEDTA and FeSO(4) in legume-based flours. The current study compared iron absorption from NaFeEDTA and FeSO(4) as fortificants within and between red and white varieties of cowpea with different concentrations of polyphenols (PP) but similar phytic acid (PA)-to-iron molar ratios. We performed a paired crossover study in young women (n = 16). Red-cowpea (high-PP) and white-cowpea (low-PP) test meals (Tubani) were each fortified with ((57)Fe)-labeled NaFeEDTA or ((58)Fe)-labeled FeSO(4) and were randomly administered. Iron absorption was measured as erythrocyte incorporation of stable iron isotopes. Per serving, the mean (±SD) PP concentrations of the white- and red-cowpea-based meals were 74 ± 3.6 and 158 ± 1.8 mg, respectively, and the molar ratio of PA to iron was 3.0 and 3.3. Iron bioavailabilities from red and white cowpeas were 1.4 and 1.7%, respectively, in NaFeEDTA-fortified meals and 0.89 and 1.2%, respectively, in FeSO(4)-fortified meals. Compared with FeSO(4), fortification with NaFeEDTA increased the amount of iron absorbed from either of the cowpea meals by 0.05 to 0.08 mg (P < 0.05). Irrespective of the fortificant used, there was no significant difference in the amount of iron absorbed from the 2 varieties of cowpea. The results suggest that NaFeEDTA is more bioavailable in legume-based flours compared with FeSO(4). In cowpea-based flours, the major determinant of low iron absorption may be the high molar ratio of PA to iron and not variations in PP concentration.

Iron fortification of whole wheat flour reduces iron deficiency and iron deficiency anemia and increases body iron stores in Indian school-aged children

Wheat is the primary staple food for nearly one-third of the world's population. NaFeEDTA is the only iron (Fe) compound suitable for fortifying high extraction flours. We tested the hypothesis that NaFeEDTA-fortified, whole wheat flour reduces Fe deficiency (ID) and improves body Fe stores (BIS) and cognitive performance in Indian children. In a randomized, double-blind, controlled, school feeding trial, 6- to 15-y-old, Fe-depleted children (n = 401) were randomly assigned to either a daily wheat-based lunch meal fortified with 6 mg of Fe as NaFeEDTA or an otherwise identical unfortified control meal. Hemoglobin (Hb) and Fe status were measured at baseline, 3.5 mo, and 7 mo. Cognitive performance was evaluated at baseline and 7 mo in children (n = 170) at one of the study sites. After 7 mo, the prevalence of ID and ID anemia in the treatment group significantly decreased from 62 to 21% and 18 to 9%, respectively. There was a time x treatment interaction for Hb, serum ferritin, transferrin receptor, zinc protoporphyrin, and BIS (all P < 0.0001). Changes in BIS differed between the groups; it increased in the treatment group (0.04 ± 0.04 mmol/kg body weight) and decreased in the control group (-0.02 ± 0.04 mmol/kg body weight) (P < 0.0001). In sensory tests, NaFeEDTA-fortified flour could not be differentiated from unfortified flour. There were no significant differences in cognitive performance tests between the groups. NaFeEDTA-fortified wheat flour markedly improved BIS and reduced ID in Fe-depleted children. It may be recommended for wider use in national school feeding programs.

Whole cowpea meal fortified with NaFeEDTA reduces iron deficiency among Ghanaian school children in a malaria endemic area

Cowpeas, like other legumes, contain high amounts of native iron but are rich in phytic acid (PA) and polyphenols (PP) that inhibit iron absorption. NaFeEDTA may overcome the combined inhibitory effect of PA and PP. Our objective was to test the efficacy of NaFeEDTA-fortified cowpea meal in improving iron status of school children in a malaria endemic area. We conducted a double-blind, controlled trial with 5- to 12-y-old school children from 2 rural communities in northern Ghana (n = 241). Eligible children were randomly assigned to 2 treatment groups to receive either cowpea meal fortified with 10 mg Fe/meal as NaFeEDTA, or an identical but nonfortified cowpea meal. Meals were provided 3 d/wk for a period of ~7 mo under strict supervision. Mass deworming and malaria antigenemia screening and treatment were carried out at baseline and 3.5 mo into the trial. Consumption of cowpea flour fortified with NaFeEDTA resulted in improvement of hemoglobin (P < 0.05), serum ferritin (P < 0.001), and body iron stores (P < 0.001) and reduction of transferrin receptor (P < 0.001) compared with nonfortified flour. Fortification resulted in a 30 and 47% reduction in the prevalence of iron deficiency (ID) and iron deficiency anemia (IDA) (P < 0.05), respectively. The results indicate that fortification of cowpea flour with NaFeEDTA overcomes the combined inhibitory effect of PA and PP and, when used for targeted school-based fortification of cowpea flour, is effective in reducing the prevalence of ID and IDA among school children in malaria endemic rural northern Ghana.

Maize porridge enriched with a micronutrient powder containing low-dose iron as NaFeEDTA but not amaranth grain flour reduces anemia and iron deficiency in Kenyan preschool children

Few studies have evaluated the impact of fortification with iron-rich foods such as amaranth grain and multi-micronutrient powder (MNP) containing low doses of highly bioavailable iron to control iron deficiency anemia (IDA) in children. We assessed the efficacy of maize porridge enriched with amaranth grain or MNP to reduce IDA in Kenyan preschool children. In a 16-wk intervention trial, children (n = 279; 12-59 mo) were randomly assigned to: unrefined maize porridge (control; 4.1 mg of iron/meal; phytate:iron molar ratio 5:1); unrefined maize (30%) and amaranth grain (70%) porridge (amaranth group; 23 mg of iron/meal; phytate:iron molar ratio 3:1); or unrefined maize porridge with MNP (MNP group; 6.6 mg iron/meal; phytate:iron molar ratio 2.6:1; 2.5 mg iron as NaFeEDTA). Primary outcomes were anemia and iron status with treatment effects estimated relative to control. At baseline, 38% were anemic and 30% iron deficient. Consumption of MNP reduced the prevalence of anemia [-46% (95% CI: -67, -12)], iron deficiency [-70% (95% CI: -89, -16)], and IDA [-75% (95% CI: -92, -20)]. The soluble transferrin receptor [-10% (95% CI: -16, -4)] concentration was lower, whereas the hemoglobin (Hb) [2.7 g/L (95% CI: 0.4, 5.1)] and plasma ferritin [40% (95% CI: 10, 95)] concentrations increased in the MNP group. There was no significant change in Hb or iron status in the amaranth group. Consumption of maize porridge fortified with low-dose, highly bioavailable iron MNP can reduce the prevalence of IDA in preschool children. In contrast, fortification with amaranth grain did not improve iron status despite a large increase in iron intake, likely due to high ratio of phytic acid:iron in the meal.

Effect of iron-fortified foods on hematologic and biological outcomes: systematic review of randomized controlled trials

BACKGROUND

The utility of iron fortification of food to improve iron deficiency, anemia, and biological outcomes is not proven unequivocally.

OBJECTIVES

The objectives were to evaluate 1) the effect of iron fortification on hemoglobin and serum ferritin and the prevalence of iron deficiency and anemia, 2) the possible predictors of a positive hemoglobin response, 3) the effect of iron fortification on zinc and iron status, and 4) the effect of iron-fortified foods on mental and motor development, anthropometric measures, and infections.

DESIGN

Randomized and pseudorandomized controlled trials that included food fortification or biofortification with iron were included.

RESULTS

Data from 60 trials showed that iron fortification of foods resulted in a significant increase in hemoglobin (0.42 g/dL; 95% CI: 0.28, 0.56; P < 0.001) and serum ferritin (1.36 μg/L; 95% CI: 1.23, 1.52; P < 0.001), a reduced risk of anemia (RR: 0.59; 95% CI: 0.48, 0.71; P < 0.001) and iron deficiency (RR: 0.48; 95% CI: 0.38, 0.62; P < 0.001), improvement in other indicators of iron nutriture, and no effect on serum zinc concentrations, infections, physical growth, and mental and motor development. Significant heterogeneity was observed for most of the evaluated outcomes. Sensitivity analyses and meta-regression for hemoglobin suggested a higher response with lower trial quality (suboptimal allocation concealment and blinding), use of condiments, and sodium iron edetate and a lower response when adults were included.

CONCLUSION

Consumption of iron-fortified foods results in an improvement in hemoglobin, serum ferritin, and iron nutriture and a reduced risk of remaining anemic and iron deficient.

Oral Administration of Ferrous Sulfate, but not of Iron Polymaltose or Sodium Iron Ethylenediaminetetraacetic Acid (NaFeEDTA), Results in a Substantial Increase of Non-Transferrin-Bound Iron in Healthy Iron-Adequate Men

Background

Oral iron supplementation with ferrous sulfate (FeSO4) at dosage levels suggested by the international guidelines poses a safety hazard to young children with malaria. Exposure to loosely bound iron in the circulation has been advanced as a potential factor.

Objective

To evaluate the kinetics of circulating concentrations of plasma iron and non-transferrin-bound iron (NTBI) in response to oral iron administration in healthy adults.

Methods

Plasma samples were collected at 90-minute intervals over a period of 270 minutes from 10 healthy Guatemalan men after oral administration of water or 100 mg of iron from each of three iron compounds: FeSO4, sodium iron ethylenediaminetetraacetic acid (NaFeEDTA), and iron polymaltose. The four tests were administered in an individually randomized sequence. Serum iron concentration was measured spectrophotometrically by the ferrozine method, and NTBI concentration was measured by a fluorometric competitive binding assay. The kinetic response and the maximal and cumulative changes in circulating concentrations of the biomarkers of interest were compared.

Results

Serum iron and NTBI responses to oral administration of FeSO4 were significantly greater than responses to plain water or the other two iron compounds. NTBI concentrations after NaFeEDTA or iron polymaltose ingestion were not different from those determined after water intake.

Conclusions

Administration of two iron compounds of proven bioavailability, but with complex absorption characteristics, is associated with a negligible NTBI response, potentially mitigating the safety concerns associated with iron supplementation in malarial areas.

Plasmodium falciparum, anaemia and cognitive and educational performance among school children in an area of moderate malaria transmission: baseline results of a cluster randomized trial on the coast of Kenya

OBJECTIVES

Studies have typically investigated health and educational consequences of malaria among school-aged children in areas of high malaria transmission, but few have investigated these issues in moderate transmission settings. This study investigates the patterns of and risks for Plasmodium falciparum and anaemia and their association with cognitive and education outcomes on the Kenyan coast, an area of moderate malaria transmission.

METHODS

As part of a cluster randomised trial, a baseline cross-sectional survey assessed the prevalence of and risk factors for P. falciparum infection and anaemia and the associations between health status and measures of cognition and educational achievement. Results are presented for 2400 randomly selected children who were enrolled in the 51 intervention schools.

RESULTS

The overall prevalence of P. falciparum infection and anaemia was 13.0% and 45.5%, respectively. There was marked heterogeneity in the prevalence of P. falciparum infection by school. In multivariable analysis, being male, younger age, not sleeping under a mosquito net and household crowding were adjusted risk factors for P. falciparum infection, whilst P. falciparum infection, being male and indicators of poor nutritional intake were risk factors for anaemia. No association was observed between either P. falciparum or anaemia and performance on tests of sustained attention, cognition, literacy or numeracy.

CONCLUSION

The results indicate that in this moderate malaria transmission setting, P. falciparum is strongly associated with anaemia, but there is no clear association between health status and education. Intervention studies are underway to investigate whether removing the burden of chronic asymptomatic P. falciparum and related anaemia can improve education outcomes.