Early response to the effect of iron fortification in the Venezuelan population

Thiamine deficiency disorders in women and children

Thiamine (vitamin B1) is available in common foods such as the outer husk of rice and is necessary for normal cardiovascular, neurological and metabolic processes. Thiamine deficiency is common in many parts of Asia and Africa, affecting up to a third or more of children and women of child-bearing age. The diagnosis is based on clinical suspicion, especially when noting heart failure in infants, encephalopathy in patients of any age, and peripheral neuropathy in older children and adults. Blood tests for whole-blood thiamine diphosphate (the quantity of biologically active thiamine present) and erythrocyte transketolase activity (the functional impact of thiamine) are not always readily available in areas where thiamine deficiency is common. Treatment is safe and effective, although dosing guidelines vary widely; 50 mg daily for 5 days is probably effective for treating acute thiamine deficiency disorders, and ongoing adequate thiamine intake is also needed. Prevention efforts depend on local and regional circumstances, including dietary diversification, food fortification, and/or supplementation of children and women at risk.Abbreviations: HIC: high-income countries; LMIC: low- and middle-income countries; MRI: magnetic resonance imaging; TDD: thiamine deficiency disorders.

Food Consumption of People with Sickle Cell Anemia in a Middle-Income Country

Sickle cell anemia (SCA) is a genetic and hemolytic disease globally characterized by social vulnerability. Food consumption has been insufficiently analyzed in SCA. Secondary iron overload is often observed. This leads to unreliable recommendations for dietary iron restriction. We assessed food consumption and iron intake among adults with SCA. Considering the guidelines for healthy eating, foods were grouped according to the NOVA classification. This transversal study included 74.4% of eligible patients who were registered in the reference center for SCA treatment in Rio de Janeiro, Brazil, in 2019. Data on food consumption were collected through 24 h recall. The monthly household income of 82.3% of patients was less than $770. The consumption of fresh or minimally processed foods was directly associated with monthly household income (p < 0.0001; η₂ = 0.87). Ultra-processed foods provided more than one-third of the total energy intake (35.2%). The prevalence of inadequate iron intake was about 40% among women, while that of iron intake above the tolerable upper limit was 0.8%. People from lower socioeconomic classes had the lowest iron intake. Strategies to encourage the consumption of fresh or minimally processed foods are needed considering the requirement of an antioxidant diet in SCA. These findings highlight the need for health equity to ensure food security and healthy eating in SCA.

Temporal Relation between Double Fortification of Wheat Flour with Iron and Folic Acid, and Markers and Prevalence of Anemia in Children

Fortification of wheat flour with iron and folic acid became mandatory in Ivory Coast in 2007. The purpose of this study was to determine the time trend relation between mandatory double fortification of wheat flour with iron and folic acid and markers and prevalence of anemia by comparing the data between pre- and post-fortification periods in Ivory Coast children. Data were derived from the pediatric unit of the University Hospital of Treichville, Abidjan, Ivory Coast. Medical records of 467 children from 5 to 14 years old were analyzed from the years 2004 through 2010. Periods from 1 January 2004 to 31 December 2006 and 1 January 2008 to 31 December 2010 were considered as pre- and post-fortification periods, respectively. Data on hemoglobin, hematocrit, red blood cell count (RBC), mean corpuscular volume (MCV), and anemia between pre- and post-fortification periods were compared. There were no significant differences in hemoglobin, hematocrit, RBC, and prevalence of anemia between pre- and post-fortification periods. However, MCV in post-fortification period was significantly higher compared to pre-fortification period in all subjects (77.6 fL vs. 76.8 fL; p = 0.02) and in young girls (79.1 fL vs. 75.2 fL; p = 0.01). Lack of significant differences in anemia and in markers of anemia between pre- and post-fortification periods need further investigation in children of Ivory Coast.

Wheat flour fortification with iron and other micronutrients for reducing anaemia and improving iron status in populations

BACKGROUND

Anaemia is a condition where the number of red blood cells (and consequently their oxygen-carrying capacity) is insufficient to meet the body's physiological needs. Fortification of wheat flour is deemed a useful strategy to reduce anaemia in populations.

OBJECTIVES

To determine the benefits and harms of wheat flour fortification with iron alone or with other vitamins and minerals on anaemia, iron status and health-related outcomes in populations over two years of age.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, 21 other databases and two trials registers up to 21 July 2020, together with contacting key organisations to identify additional studies.

SELECTION CRITERIA

We included cluster- or individually-randomised controlled trials (RCTs) carried out among the general population from any country, aged two years and above. The interventions were fortification of wheat flour with iron alone or in combination with other micronutrients. We included trials comparing any type of food item prepared from flour fortified with iron of any variety of wheat DATA COLLECTION AND ANALYSIS: Two review authors independently screened the search results and assessed the eligibility of studies for inclusion, extracted data from included studies and assessed risks of bias. We followed Cochrane methods in this review.

MAIN RESULTS

Our search identified 3538 records, after removing duplicates. We included 10 trials, involving 3319 participants, carried out in Bangladesh, Brazil, India, Kuwait, Philippines, South Africa and Sri Lanka. We identified two ongoing studies and one study is awaiting classification. The duration of interventions varied from 3 to 24 months. One study was carried out among adult women and one trial among both children and nonpregnant women. Most of the included trials were assessed as low or unclear risk of bias for key elements of selection, performance or reporting bias. Three trials used 41 mg to 60 mg iron/kg flour, three trials used less than 40 mg iron/kg and three trials used more than 60 mg iron/kg flour. One trial used various iron levels based on type of iron used: 80 mg/kg for electrolytic and reduced iron and 40 mg/kg for ferrous fumarate. All included studies contributed data for the meta-analyses. Iron-fortified wheat flour with or without other micronutrients added versus wheat flour (no added iron) with the same other micronutrients added Iron-fortified wheat flour with or without other micronutrients added versus wheat flour (no added iron) with the same other micronutrients added may reduce by 27% the risk of anaemia in populations (risk ratio (RR) 0.73, 95% confidence interval (CI) 0.55 to 0.97; 5 studies, 2315 participants; low-certainty evidence). It is uncertain whether iron-fortified wheat flour with or without other micronutrients reduces iron deficiency (RR 0.46, 95% CI 0.20 to 1.04; 3 studies, 748 participants; very low-certainty evidence) or increases haemoglobin concentrations (in g/L) (mean difference MD 2.75, 95% CI 0.71 to 4.80; 8 studies, 2831 participants; very low-certainty evidence). No trials reported data on adverse effects in children (including constipation, nausea, vomiting, heartburn or diarrhoea), except for risk of infection or inflammation at the individual level. The intervention probably makes little or no difference to the risk of Infection or inflammation at individual level as measured by C-reactive protein (CRP) (mean difference (MD) 0.04, 95% CI -0.02 to 0.11; 2 studies, 558 participants; moderate-certainty evidence). Iron-fortified wheat flour with other micronutrients added versus unfortified wheat flour (nil micronutrients added) It is unclear whether wheat flour fortified with iron, in combination with other micronutrients decreases anaemia (RR 0.77, 95% CI 0.41 to 1.46; 2 studies, 317 participants; very low-certainty evidence). The intervention probably reduces the risk of iron deficiency (RR 0.73, 95% CI 0.54 to 0.99; 3 studies, 382 participants; moderate-certainty evidence) and it is unclear whether it increases average haemoglobin concentrations (MD 2.53, 95% CI -0.39 to 5.45; 4 studies, 532 participants; very low-certainty evidence). No trials reported data on adverse effects in children. Nine out of 10 trials reported sources of funding, with most having multiple sources. Funding source does not appear to have distorted the results in any of the assessed trials.

AUTHORS' CONCLUSIONS

Fortification of wheat flour with iron (in comparison to unfortified flour, or where both groups received the same other micronutrients) may reduce anaemia in the general population above two years of age, but its effects on other outcomes are uncertain. Iron-fortified wheat flour in combination with other micronutrients, in comparison with unfortified flour, probably reduces iron deficiency, but its effects on other outcomes are uncertain. None of the included trials reported data on adverse side effects except for risk of infection or inflammation at the individual level. The effects of this intervention on other health outcomes are unclear. Future studies at low risk of bias should aim to measure all important outcomes, and to further investigate which variants of fortification, including the role of other micronutrients as well as types of iron fortification, are more effective, and for whom.

Wheat flour fortification with iron for reducing anaemia and improving iron status in populations

BACKGROUND

Anaemia is a condition where the number of red blood cells (and consequently their oxygen-carrying capacity) is insufficient to meet the body's physiologic needs. Fortification of wheat flour is deemed a useful strategy to reduce anaemia in populations.

OBJECTIVES

To determine the benefits and harms of wheat flour fortification with iron alone or with other vitamins and minerals on anaemia, iron status and health-related outcomes in populations over two years of age.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, and other databases up to 4 September 2019.

SELECTION CRITERIA

We included cluster- or individually randomised controlled trials (RCT) carried out among the general population from any country aged two years and above. The interventions were fortification of wheat flour with iron alone or in combination with other micronutrients. Trials comparing any type of food item prepared from flour fortified with iron of any variety of wheat were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the search results and assessed the eligibility of studies for inclusion, extracted data from included studies and assessed risk of bias. We followed Cochrane methods in this review.

MAIN RESULTS

Our search identified 3048 records, after removing duplicates. We included nine trials, involving 3166 participants, carried out in Bangladesh, Brazil, India, Kuwait, Phillipines, Sri Lanka and South Africa. The duration of interventions varied from 3 to 24 months. One study was carried out among adult women and one trial among both children and nonpregnant women. Most of the included trials were assessed as low or unclear risk of bias for key elements of selection, performance or reporting bias. Three trials used 41 mg to 60 mg iron/kg flour, two trials used less than 40 mg iron/kg and three trials used more than 60 mg iron/kg flour. One trial employed various iron levels based on type of iron used: 80 mg/kg for electrolytic and reduced iron and 40 mg/kg for ferrous fumarate. All included studies contributed data for the meta-analyses. Seven studies compared wheat flour fortified with iron alone versus unfortified wheat flour, three studies compared wheat flour fortified with iron in combination with other micronutrients versus unfortified wheat flour and two studies compared wheat flour fortified with iron in combination with other micronutrients versus fortified wheat flour with the same micronutrients (but not iron). No studies included a 'no intervention' comparison arm. None of the included trials reported any other adverse side effects (including constipation, nausea, vomiting, heartburn or diarrhoea). Wheat flour fortified with iron alone versus unfortified wheat flour (no micronutrients added) Wheat flour fortification with iron alone may have little or no effect on anaemia (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.61 to 1.07; 5 studies; 2200 participants; low-certainty evidence). It probably makes little or no difference on iron deficiency (RR 0.43, 95% CI 0.17 to 1.07; 3 studies; 633 participants; moderate-certainty evidence) and we are uncertain about whether wheat flour fortified with iron increases haemoglobin concentrations by an average 3.30 (g/L) (95% CI 0.86 to 5.74; 7 studies; 2355 participants; very low-certainty evidence). No trials reported data on adverse effects in children, except for risk of infection or inflammation at the individual level. The intervention probably makes little or no difference to risk of Infection or inflammation at individual level as measured by C-reactive protein (CRP) (moderate-certainty evidence). Wheat flour fortified with iron in combination with other micronutrients versus unfortified wheat flour (no micronutrients added) Wheat flour fortified with iron, in combination with other micronutrients, may or may not decrease anaemia (RR 0.95, 95% CI 0.69 to 1.31; 2 studies; 322 participants; low-certainty evidence). It makes little or no difference to average risk of iron deficiency (RR 0.74, 95% CI 0.54 to 1.00; 3 studies; 387 participants; moderate-certainty evidence) and may or may not increase average haemoglobin concentrations (mean difference (MD) 3.29, 95% CI -0.78 to 7.36; 3 studies; 384 participants; low-certainty evidence). No trials reported data on adverse effects in children. Wheat flour fortified with iron in combination with other micronutrients versus fortified wheat flour with same micronutrients (but not iron) Given the very low certainty of the evidence, the review authors are uncertain about the effects of wheat flour fortified with iron in combination with other micronutrients versus fortified wheat flour with same micronutrients (but not iron) in reducing anaemia (RR 0.24, 95% CI 0.08 to 0.71; 1 study; 127 participants; very low-certainty evidence) and in reducing iron deficiency (RR 0.42, 95% CI 0.18 to 0.97; 1 study; 127 participants; very low-certainty evidence). The intervention may make little or no difference to the average haemoglobin concentration (MD 0.81, 95% CI -1.28 to 2.89; 2 studies; 488 participants; low-certainty evidence). No trials reported data on the adverse effects in children. Eight out of nine trials reported source of funding with most having multiple sources. Funding source does not appear to have distorted the results in any of the assessed trials.

AUTHORS' CONCLUSIONS

Eating food items containing wheat flour fortified with iron alone may have little or no effect on anaemia and probably makes little or no difference in iron deficiency. We are uncertain on whether the intervention with wheat flour fortified with iron increases haemoglobin concentrations improve blood haemoglobin concentrations. Consuming food items prepared from wheat flour fortified with iron, in combination with other micronutrients, has little or no effect on anaemia, makes little or no difference to iron deficiency and may or may not improve haemoglobin concentrations. In comparison to fortified flour with micronutrients but no iron, wheat flour fortified with iron with other micronutrients, the effects on anaemia and iron deficiency are uncertain as certainty of the evidence has been assessed as very low. The intervention may make little or no difference to the average haemoglobin concentrations in the population. None of the included trials reported any other adverse side effects. The effects of this intervention on other health outcomes are unclear.

Food fortification with multiple micronutrients: impact on health outcomes in general population

BACKGROUND

Vitamins and minerals are essential for growth and maintenance of a healthy body, and have a role in the functioning of almost every organ. Multiple interventions have been designed to improve micronutrient deficiency, and food fortification is one of them.

OBJECTIVES

To assess the impact of food fortification with multiple micronutrients on health outcomes in the general population, including men, women and children.

SEARCH METHODS

We searched electronic databases up to 29 August 2018, including the Cochrane Central Register of Controlled Trial (CENTRAL), the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register and Cochrane Public Health Specialised Register; MEDLINE; Embase, and 20 other databases, including clinical trial registries. There were no date or language restrictions. We checked reference lists of included studies and relevant systematic reviews for additional papers to be considered for inclusion.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-RCTs, quasi-randomised trials, controlled before-after (CBA) studies and interrupted time series (ITS) studies that assessed the impact of food fortification with multiple micronutrients (MMNs). Primary outcomes included anaemia, micronutrient deficiencies, anthropometric measures, morbidity, all-cause mortality and cause-specific mortality. Secondary outcomes included potential adverse outcomes, serum concentration of specific micronutrients, serum haemoglobin levels and neurodevelopmental and cognitive outcomes. We included food fortification studies from both high-income and low- and middle-income countries (LMICs).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened, extracted and quality-appraised the data from eligible studies. We carried out statistical analysis using Review Manager 5 software. We used random-effects meta-analysis for combining data, as the characteristics of study participants and interventions differed significantly. We set out the main findings of the review in 'Summary of findings' tables, using the GRADE approach.

MAIN RESULTS

We identified 127 studies as relevant through title/abstract screening, and included 43 studies (48 papers) with 19,585 participants (17,878 children) in the review. All the included studies except three compared MMN fortification with placebo/no intervention. Two studies compared MMN fortification versus iodised salt and one study compared MMN fortification versus calcium fortification alone. Thirty-six studies targeted children; 20 studies were conducted in LMICs. Food vehicles used included staple foods, such as rice and flour; dairy products, including milk and yogurt; non-dairy beverages; biscuits; spreads; and salt. Fourteen of the studies were fully commercially funded, 13 had partial-commercial funding, 14 had non-commercial funding and two studies did not specify the source of funding. We rated all the evidence as of low to very low quality due to study limitations, imprecision, high heterogeneity and small sample size. When compared with placebo/no intervention, MMN fortification may reduce anaemia by 32% (risk ratio (RR) 0.68, 95% confidence interval (CI) 0.56 to 0.84; 11 studies, 3746 participants; low-quality evidence), iron deficiency anaemia by 72% (RR 0.28, 95% CI 0.19 to 0.39; 6 studies, 2189 participants; low-quality evidence), iron deficiency by 56% (RR 0.44, 95% CI 0.32 to 0.60; 11 studies, 3289 participants; low-quality evidence); vitamin A deficiency by 58% (RR 0.42, 95% CI 0.28 to 0.62; 6 studies, 1482 participants; low-quality evidence), vitamin B2 deficiency by 64% (RR 0.36, 95% CI 0.19 to 0.68; 1 study, 296 participants; low-quality evidence), vitamin B6 deficiency by 91% (RR 0.09, 95% CI 0.02 to 0.38; 2 studies, 301 participants; low-quality evidence), vitamin B12 deficiency by 58% (RR 0.42, 95% CI 0.25 to 0.71; 3 studies, 728 participants; low-quality evidence), weight-for-age z-scores (WAZ) (mean difference (MD) 0.1, 95% CI 0.02 to 0.17; 8 studies, 2889 participants; low-quality evidence) and weight-for-height/length z-score (WHZ/WLZ) (MD 0.1, 95% CI 0.02 to 0.18; 6 studies, 1758 participants; low-quality evidence). We are uncertain about the effect of MMN fortification on zinc deficiency (RR 0.84, 95% CI 0.65 to 1.08; 5 studies, 1490 participants; low-quality evidence) and height/length-for-age z-score (HAZ/LAZ) (MD 0.09, 95% CI 0.01 to 0.18; 8 studies, 2889 participants; low-quality evidence). Most of the studies in this comparison were conducted in children. Subgroup analyses of funding sources (commercial versus non-commercial) and duration of intervention did not demonstrate any difference in effects, although this was a relatively small number of studies and the possible association between commercial funding and increased effect estimates has been demonstrated in the wider health literature. We could not conduct subgroup analysis by food vehicle and funding; since there were too few studies in each subgroup to draw any meaningful conclusions. When we compared MMNs versus iodised salt, we are uncertain about the effect of MMN fortification on anaemia (R 0.86, 95% CI 0.37 to 2.01; 1 study, 88 participants; very low-quality evidence), iron deficiency anaemia (RR 0.40, 95% CI 0.09 to 1.83; 2 studies, 245 participants; very low-quality evidence), iron deficiency (RR 0.98, 95% CI 0.82 to 1.17; 1 study, 88 participants; very low-quality evidence) and vitamin A deficiency (RR 0.19, 95% CI 0.07 to 0.55; 2 studies, 363 participants; very low-quality evidence). Both of the studies were conducted in children. Only one study conducted in children compared MMN fortification versus calcium fortification. None of the primary outcomes were reported in the study. None of the included studies reported on morbidity, adverse events, all-cause or cause-specific mortality.

AUTHORS' CONCLUSIONS

The evidence from this review suggests that MMN fortification when compared to placebo/no intervention may reduce anaemia, iron deficiency anaemia and micronutrient deficiencies (iron, vitamin A, vitamin B2 and vitamin B6). We are uncertain of the effect of MMN fortification on anthropometric measures (HAZ/LAZ, WAZ and WHZ/WLZ). There are no data to suggest possible adverse effects of MMN fortification, and we could not draw reliable conclusions from various subgroup analyses due to a limited number of studies in each subgroup. We remain cautious about the level of commercial funding in this field, and the possibility that this may be associated with higher effect estimates, although subgroup analysis in this review did not demonstrate any impact of commercial funding. These findings are subject to study limitations, imprecision, high heterogeneity and small sample sizes, and we rated most of the evidence low to very low quality. and hence no concrete conclusions could be drawn from the findings of this review.

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.

Monitoring of the National Oil and Wheat Flour Fortification Program in Cameroon Using a Program Impact Pathway Approach

BACKGROUND

Since 2011 Cameroon has mandated the fortification of refined vegetable oil with vitamin A and wheat flour with iron, zinc, folic acid, and vitamin B-12. In 2012, measured fortification levels for flour, and particularly oil, were below target.

OBJECTIVES

We assessed Cameroon's food fortification program using a program impact pathway (PIP) to identify barriers to optimal performance.

METHODS

We developed a PIP through literature review and key informant interviews. We conducted interviews at domestic factories for refined vegetable oil (n = 9) and wheat flour (n = 10). In 12 sentinel sites distributed nationally, we assessed availability and storage conditions of fortified foods in markets and frequency of consumption of fortified foods among women and children (n = 613 households). Food samples were collected from factories, markets, and households for measurement of micronutrient content.

RESULTS

Two-thirds of factories presented quality certificates for recent premix purchases. All factories had in-house capacity for micronutrient analysis, but most used qualitative methods. Industries cited premix import taxes and access to external laboratories as constraints. Mean vitamin A levels were 141% (95% CI: 116%, 167%), 75% (95% CI: 62%, 89%), and 75% (95% CI: 60%, 90%) of target in individual samples from factories, markets, and households, respectively. Most industry flour samples appeared to be fortified, but micronutrient levels were low. Among composite flour samples from markets and households, the mean iron and zinc content was 25 mg/kg and 43 mg/kg, respectively, ∼45% of target levels; folic acid (36%) and vitamin B-12 (29%) levels were also low. In the previous week, the majority of respondents had consumed "fortifiable" oil (63% women and 52% children) and wheat flour (82% women and 86% children).

CONCLUSIONS

In Cameroon, oil fortification program performance appears to have improved since 2012, but fortification levels remain below target, particularly for wheat flour. Consistent regulatory monitoring and program support, possibly through premix procurement and micronutrient analysis, are needed.

Thiamin deficiency in low- and middle-income countries: Disorders, prevalences, previous interventions and current recommendations

BACKGROUND

Thiamin deficiency is a major public health concern in several low- and middle-income countries (LMICs)-current attention to the problem is lacking.

AIM

This review discusses prevalence of thiamin insufficiency and thiamin-deficiency disorders (TDDs) in LMICs, outlines programmatic experience with thiamin interventions, and offers recommendations to improve public-health and research attention to thiamin in LMICs.

DISCUSSION

Thiamin insufficiency, i.e. low-blood-thiamin status, is endemic among several Southeast Asian countries: Cambodia (70-100% of infants and 27-100% of reproductive-age women); Laos (13% of hospitalized infants); Thailand (16-25% of children and 30% of elderly adults). Thiamin deficiency accounts for up to 45% of under-5 deaths in Cambodia, 34% of infant deaths in Laos, and 17% of infant deaths in Myanmar. Deficiency also exists in Africa, Asia, and the Americas, but these instances have typically been isolated. Exclusively breastfed infants of thiamin-deficient mothers are at highest risk for TDD and related death. Intervention strategies that have been employed to combat thiamin deficiency include food processing, fortification, supplementation, dietary diversification, and dietary behaviors, all of which have shown varying levels of effectiveness.

CONCLUSIONS

We recommend universal thiamin-fortification of context-specific staple-foods in LMICs as a promising solution, as well as thiamin supplementation, particularly for pregnant and lactating women. Food processing regulations, dietary diversification, and modification of dietary behaviors to increase consumption of thiamin-rich foods may provide benefits in some circumstances, especially in countries without universal fortification programs or in populations dependent on food aid.

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.

Iron and Folate Status in Urban and Rural Costa Rican Teenagers

This study evaluated the iron and folate status of Costa Rican adolescents and their dietary intake of these micronutrients. Hematological data, serum ferritin, serum folate and iron and folate intakes were evaluated in 307 adolescents aged 13 to 17 years. The prevalence of anemia was 4%. Iron deficiency was found in 3% of adolescents and iron-deficiency anemia in 2% or less. The prevalence of deficient serum folate levels was less than 1%. Over 50% of females and around 20% of males did not consume 66.7% of the recommended daily allowance (RDA) for iron. Iron bioavailability in the diet of urban adolescents was intermediate, whereas it was low in the diet of rural adolescents. Approximately 53% of adolescents did not consume two-thirds of the RDA for folate. It is necessary to modify adolescents’ food habits in order to ensure an adequate iron and folate intake.

Effects of Health and Nutrition on Cognitive and Behavioural Development in Children in the First Three Years of Life: Part 2: Infections and Micronutrient Deficiencies: Iodine, Iron, and Zinc

The following paper and its accompanying paper (Grantham-McGregor SM, et al. Effects of health and nutrition on cognitive and behavioural development in children in the first three years of life. Part 1: Low birthweight, breastfeeding, and protein-energy malnutrition. Food Nutr Bull 1999;20:53–75) review the literature on the conditions that are prevalent and considered to be likely to affect child development and are therefore of public health importance. the reviews are selective, and we have generally focused on recent work, particularly in areas that remain controversial. the reviews are restricted to nutritional and health insults that are important in the first three years of life. Where possible, we have discussed the better studies. This paper considers the effects of infections and the major micronutrient deficiencies: iodine, iron, and zinc.

Recent Experience with Fortification of Foods and Beverages with Iron for the Control of Iron-Deficiency Anemia in Brazilian Children

Iron-deficiency-anemia affects 30% of the world population. Women of reproductive age and children are the most affected. Iron supplementation in the form of tablets and syrups has not been successful in developing countries, and iron deficiency is still the most important deficiency related to malnutrition. Iron-deficiency anemia affects physical and cognitive development at an early age in children, often resulting in irreversible outcomes. Studies from the last two decades have shown that the prevalence of iron-deficiency anemia can be reduced given adequate investments and political will directed at iron fortification of foods and liquids. A successful low-cost iron-fortification program incorporates implementation and strategic use of communication for program inception where education is in the forefront. A review of the available reports from experience in Brazil with iron fortification of foods and liquids is presented.

Prevalence of Iron Deficiency, Anaemia, and Iron-deficiency Anaemia in High-school Students in Jolfa, East Azerbaijan

Iron deficiency is the most prevalent nutritional problem in the world. We determined the prevalence of iron deficiency, anaemia, and iron-deficiency anaemia in 652 high-school students (340 girls and 312 boys) who were selected by stepwise random sampling from 16 high schools in Jolfa, East Azerbaijan. Iron deficiency was defined as having transferrin saturation and/or serum ferritin values below normal. Anaemia was defined as having haemoglobin levels below normal. Iron-deficiency anaemia was taken to be the combination of both. The prevalences of iron deficiency, anaemia, and iron-deficiency anaemia were 60.7%, 12.6%, and 11.5%, respectively. The respective prevalences of these conditions were 66.5%, 13.6%, and 13% in girls and 54.5%, 11.6%, and 10.3% in boys. The prevalences of these conditions were higher among 15- and 16-year-old boys than among girls. Among boys, age was inversely related to the prevalence of iron deficiency (r = −0.88, p < . 05) and anaemia (r = −0.79, p < . 07). Among girls, age was directly related to the prevalence of anaemia (r = 0.96, p<. 001) and iron-deficiency anaemia (r = 0.99, p < . 001).

Impact of Fortification of Flours with Iron to Reduce the Prevalence of Anemia and Iron Deficiency among Schoolchildren in Caracas, Venezuela: A Follow-up

In Venezuela, a severe economic crisis starting in 1983 provoked a progressive reduction in the quantity and quality of food consumed by people from the low socio-economic strata of the population. This situation resulted in a continuous increase in the prevalence of iron deficiency in the 1980s and 1990s. In 1993, an iron-fortification program was started, in which precooked corn and white wheat flours were enriched with iron, vitamin A, thiamine, niacin, and riboflavin. White wheat flour was enriched with the same nutrients, except for vitamin A. In 1996 we published the results of the impact of fortification of precooked corn and white wheat flours on the prevalence of anemia and iron deficiency in the population. A survey carried out in Caracas in 307 children aged 7, 11, and 15 years showed that the prevalence of iron deficiency measured by serum ferritin concentration dropped from 37% in 1992 to 16% in 1994, only one year after the iron-fortification program began. The prevalence of anemia, as measured by the hemoglobin concentration, diminished from 19% to 10% during the same period. This article reports the results of three other surveys carried out in 1997, 1998, and 1999 on children of the same age and socioeconomic groups that were evaluated in 1990, 1992, and 1994. There were no significant differences in anemia or iron deficiency among the last three surveys. The prevalence results from the last seven years seem to indicate that, after a dramatic reduction in 1994, iron deficiency tended to stabilize, while the prevalence of anemia increased to the same level found in 1992, before the fortification program started.

Micronutrient Policies for Agriculture in Latin America

A key distinguishing feature of Latin America is that 75% of the population is urban, and this proportion is projected to rise to 82% by 2025. Because markets for processed foods are more developed in urban than in rural areas, fortification has a comparative advantage in Latin America relative to other regions. In fact, fortification has been highly successful in Latin America. Salt iodination programmes are the most widespread, followed by fortification of sugar with vitamin A; fortification of wheat with thiamine, riboflavin, niacin, and folic acid; and fortification of margarine. At least 13 Latin American countries now have vitamin A supplementation programmes, which are relatively new to Latin America. A mix of types of fortification, supplementation, and food-based interventions will be needed in the future. Efforts should continue in the implementation of activities such as home gardens, small-animal production, and promotion of edible, native plants. Genetic manipulation through plant-breeding can alter in a positive way desirable functional properties of foods as well as the concentration and properties of macro- and micronutrients. The benefits of functional characteristics bred into plants have been clearly demonstrated (e.g., fatty acid profiles, delayed ripening), but not the benefits for human nutrition, except in laboratory situations. The plant-breeding approach needs additional, interdisciplinary research at various points in the food chain to establish the benefit for human nutrition.

Double-blind cluster randomised controlled trial of wheat flour chapatti fortified with micronutrients on the status of vitamin A and iron in school-aged children in rural Bangladesh

Food fortification is a cost-effective and sustainable strategy to prevent or correct micronutrient deficiencies. A double-blind cluster (bari) randomised controlled trial was conducted in a rural community in Bangladesh to evaluate the impact of consumption of chapatti made of micronutrient-fortified wheat flour for 6 months by school-aged children on their vitamin A, haemoglobin and iron status. A total of 43 baris (group of households) were randomly selected. The baris were randomly assigned to either intervention or control group. The intervention group received wheat flour fortified with added micronutrients (including 66 mg hydrogen-reduced elemental iron and 3030 μg retinol equivalent as retinyl palmitate per kilogram of flour), while the control group received wheat flour without added micronutrients. A total of 352 children were enrolled in the trial, 203 in the intervention group and 149 in the control group. Analyses were carried out on children who completed the study (191 in the intervention group and 143 in the control group). Micronutrient-fortified wheat flour chapatti significantly increased serum retinol concentration at 6 months by 0.12 μmol L(-1) [95% confidence interval (CI): 0.06, 0.19; P < 0.01]. The odds of vitamin A deficiency was significantly lower for children in the intervention group at 3 months [odds ratio (OR) = 0.26; 95% confidence interval (CI): 0.07, 0.89; P < 0.05] and 6 months (OR = 0.21; 95% CI: 0.06, 0.68; P < 0.01). No demonstrable effect of fortified chapatti consumption on iron status, haemoglobin levels or anaemia was observed. Consumption of fortified chapattis demonstrated a significant improvement in the vitamin A status, but not in iron, haemoglobin or anaemia status.

A question mark on iron deficiency in 185 million people of Pakistan: its outcomes and prevention

Micronutrient deficiency especially the iron deficiency is the bane of our lives, affecting all strata of society. Unfortunately, the women during pregnancy, adolescence, and children are under this curse particularly in developing countries like Pakistan. It is one of the biggest reasons of complications during pregnancy and malnourished children under five years of age. Maternal death, still-births, and underweight births are most common consequences of iron deficiency and these outbreaks as iron-deficiency anemia in Pakistan. Disastrous nature of iron deficiency requires an urgent call to eradicate it. Hence, the solution should not be frail comparing with the huge economic loss and other incompatibilities. Flour fortification, supplementation, dietary diversification, and especially maternal education are possible solutions for combating this micronutrient deficiency.

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.

Iron-fortified wheat flour and iron deficiency among women

BACKGROUND

Iron deficiency is estimated to impact more than 1.6 billion individuals worldwide, affecting child, maternal, and perinatal mortality. Iron supplementation, fortification, and dietary diversification are strategies to reduce the prevalence of iron deficiency. However, there are relatively few studies demonstrating the effectiveness of iron-fortified wheat flour as an intervention.

OBJECTIVE

To assess the relationship between average monthly per capita household consumption of iron-fortified wheat flour and iron deficiency among women of childbearing age in Oman.

METHODS

Data were obtained from the National Micronutrient Status and Fortified Food Coverage Survey, 2004. Iron deficiency status was compared between women living in households with a monthly per capita consumption of iron-fortified wheat flour of 1 kg or more and women living in households with a monthly per capita consumption of iron-fortified wheat flour of less than 1 kg. The analyses excluded women with elevated or unknown levels of C-reactive protein and controlled for characteristics of the women and household demographics.

RESULTS

Consumption of iron-fortified wheat flour was associated with a lower prevalence of iron deficiency among women in our sample (adjusted odds ratio, 0.60), after controlling for age, employment status, marital status, intake of iron or multivitamin supplements, self-reported presence of a blood disorder, household income, educational level of head of household, and family size.

CONCLUSIONS

These results suggest that women in our study living in households with a greater consumption of iron-fortified wheat flour have a lower prevalence of iron deficiency; however, additional study is needed.

Consumption of potentially fortifiable foods by women and young children varies by ecological zone and socio-economic status in Cameroon

In preparation for a proposed large-scale food fortification program in Cameroon, we completed a nationally representative, cross-sectional, cluster survey to assess the consumption patterns of four potentially fortifiable foods (refined vegetable oil, wheat flour, sugar, and bouillon cube) by women and children. Thirty clusters were randomly chosen in each of three ecologic zones (south, north, and large cities) and 10 households (HH) per cluster were selected, each with a child 12-59 mo old and a primary female caregiver 15-49 y old (total 1002 HH). Blood samples were collected and food consumption was assessed by FFQ and 24-h dietary recall. Anemia (39% of women, 58% of children) and deficiencies of iron (15-32%, 21-70%), zinc (77%, 70%), vitamin A (22%, 35%), and vitamin B-12 (28%, 27%) were common, especially in the north and among HH with lower socio-economic status (SES). Oil was consumed by 54% of HH, whereas >75% of HH consumed wheat flour, sugar, and bouillon cube. For most foods, coverage was lower among HH with lower SES. On average, oil, wheat flour, and sugar were consumed once per day and bouillon cube was consumed twice per day. Median intakes of oil, wheat flour, sugar, and bouillon cube (among consumers) were 19.8, 79.4, 30.0, and 1.9 g/d for women and 12.0, 49.4, 19.4, and 0.9 g/d for children, respectively. Food consumption patterns of high risk population subgroups must be considered, along with technical feasibility and cost, for the selection of appropriate vehicles for food fortification.

Identifying potential programs and platforms to deliver multiple micronutrient interventions

This article reviews the potential of four broad types of platforms, health, agriculture, market-based, and social protection programs, to deliver multiple micronutrient (MMN) interventions (supplementation, fortification, and dietary modification). We assessed the platforms' potential based on seven performance criteria related to programs within these platforms: 1) targeting, 2) efficacy of interventions, 3) quality of implementation, 4) utilization, 5) impact, 6) coverage, and 7) sustainability. We highlight one type of program per platform to illustrate strengths and weaknesses for delivering MMN interventions, identify critical knowledge gaps, and highlight what is needed to increase effectiveness for delivering MMN interventions. We found that all four platforms have the potential to effectively deliver MMN interventions if the following key program elements are addressed: 1) strong behavior change communication strategies to increase demand and proper utilization of services/products; 2) supply side interventions to ensure consistent availability of high quality interventions, products, and well-trained staff; 3) rigorous evaluations of effectiveness, quality of delivery, and impact pathways to generate best practices for replication and scale-up; and 4) timely dissemination of evaluation results to ensure use by program implementers and policy makers. The diversification of delivery platforms, which simultaneously addresses multiple determinants of MMN deficiencies and expands coverage, is needed to accelerate progress in reducing MMN deficiencies.

Short-term evaluation of the impact of a food program on the micronutrient nutritional status of Argentinean children under the age of six

This study was undertaken to evaluate the impact of Plan Más Vida (PMV) on the micronutrient nutritional condition of children aged 1 to 6 years 1 year after PMV implementation. The food program was intended for low-income families from the province of Buenos Aires, Argentina and provided supplementary diets. A prospective, nonexperimental study was carried out. Children (472 at baseline and 474 after 1 year) were divided into two groups (1-2 and 2-6 years of age). Biochemical tests (hemogram, ferritin, zinc, vitamin A, and folic acid), anthropometric assessments (weight and height), and dietary surveys (24-h recall) were performed. Chronic growth retardation (-2 height/age Z-score) was present in 2.8% and 8.7% of 1-2- and 2-6-year-old children, respectively; 14.4% in the former and 8.8% in the latter group had overweight/obesity. No significant changes were recorded 1 year after PMV implementation. Whereas anemia values decreased (55.3% to 39.1%, p = 0.003) and serum zinc values increased in 1-2-year-old children, the risk for vitamin A deficiency decreased significantly in both age groups. The evaluation of the early impact of PMV actions provided important nutritional data that should be used by provincial health authorities to conduct future evaluations.

Anemia em gestantes brasileiras antes e após a fortificação das farinhas com ferro

OBJETIVO: Comparar prevalência de anemia e valores de hemoglobina (Hb) em gestantes brasileiras, antes e após a fortificação das farinhas com ferro. MÉTODOS: Estudo de avaliação de painéis repetidos, desenvolvido em serviços públicos de saúde de municípios das cinco regiões brasileiras. Dados retrospectivos foram obtidos de 12.119 prontuários de gestantes distribuídas em dois grupos: antes da fortificação, com parto anterior a junho de 2004, e após a fortificação, com última menstruação após junho de 2005. Anemia foi definida como Hb < 11,0 g/dL. Valores de Hb/idade gestacional foram avaliados segundo dois referenciais da literatura. Foram utilizados teste qui-quadrado, t de Student e regressão logística, com nível de 5% de significância. RESULTADOS: Na amostra total, anemia caiu de 25% para 20% após fortificação (p < 0,001), com médias de Hb significativamente maiores no grupo "após" (p < 0,001). Observaram-se, entretanto, diferenças regionais importantes: reduções significativas nas regiões Nordeste (37% para 29%) e Norte (32% para 25%), onde as prevalências de anemia eram elevadas antes da fortificação, e reduções menores nas regiões Sudeste (18% para 15%) e Sul (7% para 6%), onde as prevalências eram baixas. Os níveis de Hb/idade gestacional de ambos os grupos se mostraram discretamente mais elevados nos primeiros meses, porém bem mais baixos após o terceiro ou quarto mês, dependendo da referência utilizada para comparação. Análise de regressão logística mostrou que grupo, região geográfica, situação conjugal, trimestre gestacional, estado nutricional inicial e gestação anterior associaram-se com anemia (p < 0,05). CONCLUSÕES: A prevalência de anemia diminuiu após a fortificação, porém continua elevada nas regiões Nordeste e Norte. Embora a fortificação possa ter tido papel nesse resultado favorável, há que se considerar a contribuição de outras políticas públicas implementadas no período estudado.

Efficacy of pandesal baked from wheat flour fortified with iron and vitamin a in improving the iron and anthropometric status of anemic schoolchildren in the Philippines

OBJECTIVE

To determine the efficacy of pandesal baked from wheat flour fortified with iron, with or without vitamin A (VA), in improving anemic schoolchildren's iron and anthropometric status.

METHODS

Anemic 6- to 12-year-old Filipino children (n = 250) received two 60 g pandesal daily for 8 months. They were randomized into 1 of 4 groups: (1) iron-fortified (with hydrogen-reduced iron at 80 mg/kg, electrolytic iron at 80 mg/kg, or ferrous fumarate at 40 mg/kg), (2) iron and VA-fortified, (3) VA-fortified (at 490 RE/100 g), and (4) nonfortified flour. Hemoglobin (Hb) and zinc protoporphyrin (ZnPP) concentrations and weight and height were determined before and after intervention. Analyses of variance and chi-square and multiple regression analyses were performed.

RESULTS

Mean Hb increased by 1.3 g/dL (p < 0.001) and mean ZnPP decreased by 24.4 micromol/mol (p < 0.001) after 8 months. Anemia decreased to 26% and iron deficiency decreased from 58% to 12%. After controls were applied for baseline concentration, age, and gender, Hb concentration at post intervention was significantly higher in the Iron + VA group than in the nonfortified group (coefficient = 0.37; p = 0.034). The odds of being iron deficient at post intervention were significantly lower in the Iron group than in the nonfortified group after controls were applied for age, gender, and baseline prevalence (coefficient = 0.12; p = 0.006). None of the 3 fortified groups had significantly different weight-for-age z-score, body mass index-for-age z-score, or height-for-age z-score compared with the nonfortified group after controls were applied for baseline z-scores, age, and gender.

CONCLUSIONS

Our study shows that in a non-malaria-endemic area, iron fortification of flour significantly reduced the prevalence of iron deficiency among anemic schoolchildren, and double fortification with iron and VA significantly improved Hb status.

Serum ferritin concentrations in Africans with low dietary iron

In the setting of high dietary, several studies have provided evidence for a strong effect of both high dietary iron and an unidentified genetic locus on iron stores in Africans. To investigate whether these effects are discernible in the setting of low dietary iron, serum ferritin concentrations were measured in 194 Zimbabwean men >30 years of age and 299 postmenopausal women who consumed a non-iron-fortified diet and who did not drink iron-rich traditional beer or other alcoholic beverages. Comparisons were made with non-alcohol drinking African-Americans studied in the third National Health and Nutritional Examination Survey (NHANES III) who consume an iron-fortified diet. As stratified by age and sex, serum ferritin concentrations were significantly lower in the 493 Zimbabweans studied than in 1,380 comparable African-Americans (P < 0.0005). Nevertheless, nine Zimbabwean subjects (1.8% of all cases) had modestly elevated serum ferritin concentrations not associated with evidence of inflammation or hepatic dysfunction. These data suggest that mild serum ferritin concentration elevations may occur among Zimbabweans not exposed to high dietary iron and that iron fortification of the diet may have substantial effects on serum ferritin concentration.

The potential effect of iron defortification on iron-deficiency anaemia in the US population

Objective

To quantify the potential effect of iron defortification in the USA on iron-deficiency anaemia (IDA).

Methods

Monte Carlo models were built to simulate iron nutrition in the US population. A hypothetical cohort of 15 000 persons from the general population was used in 15-year simulations to compare the prevalence of IDA with and without fortification.

Results

With iron fortification, the prevalence of IDA was 2.4% for children aged 3–5 years, 5.4% for women aged 20–49 years, and 0.14% for men aged 20–49 years. The corresponding IDA estimates under iron defortification were 4.5%, 8.2% and 0.46%, respectively. Defortification had little effect on the distribution of iron indicators at or above the 50th percentile within each of these three groups and little effect on the distributions of iron indicators among adult men.

Conclusion

Iron defortification is likely to increase IDA among children and women of reproductive age, but is not likely to have meaningful effects on the iron status of men or the majority of women and children.

Efeito da fortificação de farinhas com ferro sobre anemia em pré-escolares, Pelotas, RS

OBJETIVO: A fortificação de farinhas com ferro foi estabelecida por lei no Brasil, em 2004. O objetivo do estudo foi avaliar o impacto da fortificação sobre nível de hemoglobina em crianças menores de seis anos. MÉTODOS: O estudo foi realizado em Pelotas, RS, sendo uma série temporal com três avaliações a cada 12 meses. Em maio de 2004, antes da fortificação das farinhas, foram medidos níveis de hemoglobina em amostra probabilística de 453 crianças. Após 12 e 24 meses, foram estudadas amostras de 923 e 863 crianças, respectivamente. RESULTADOS: Os três grupos estudados foram comparáveis em relação a características demográficas e socioeconômicas. No estudo de linha de base, as médias de hemoglobina foram 11,3±2,8 g/dL. Após a fortificação esses valores foram 11,2±2,8 (12 meses) e 11,3±2,5 g/dL (24 meses), não havendo diferença estatisticamente significativa entre os três momentos estudados (p=0,16). CONCLUSÕES: Nenhum efeito da fortificação foi observado nos níveis de hemoglobina das crianças estudadas, o que pode ser parcialmente explicado pelo consumo insuficiente de farinhas e/ou pela baixa biodisponibilidade do ferro adicionado.

Age and gender as factors in the distribution of global micronutrient deficiencies

Although micronutrient deficiency is a global problem, the burden is not evenly shared within affected households. This review suggests that there are important non-linearities in relationships among food intake, sharing, and caring behavior within the household. Since micronutrient status relates to interactions among biological, social, behavioral, economic, and environmental processes, outcomes are not always predictable by age, gender, or location. Understanding such variability is crucial to identifying appropriate solutions. This review represents an exploratory first step toward unmasking population-specific variations that are important for better understanding the nature of micronutrient deficiencies and for improving the focus of public health action.

The importance of bioavailability of dietary iron in relation to the expected effect from iron fortification

BACKGROUND

The most common method of combating iron deficiency is iron fortification, especially in developing countries. However, few studies have shown a significant effect on iron status following iron fortification of low bioavailability diets.

OBJECTIVE

To investigate how iron fortification and dietary modifications affect iron absorption and rates of changes in iron stores.

METHODS

Research has made it possible to predict both iron absorption and the effects of iron fortification and diet modifications on iron stores using recently developed algorithms. Iron absorption and rate of change in iron stores were calculated from nine diets representing a broad range of iron bioavailability and iron contents. The calculations were related to the main target group for iron fortification, that is, women of reproductive age having empty stores but normal haemoglobin concentrations.

RESULTS

As the only measure, iron fortification has practically no effect on iron status if the original diet has low bioavailability. However, after dietary modifications such a diet shows a positive effect on iron stores. The combined action of fortification (6 mg/day) and modest bioavailability changes in a low bioavailability diet results approximately in 40 and 70% greater increases in iron stores than through iron fortification or dietary modification alone.

CONCLUSIONS

It is difficult to achieve good effects on iron status from iron fortification as the only measure if the diet has low bioavailability. Both dietary modifications as well as iron fortification are required to improve effectively the iron status of a population.

Wheat flour fortification is unlikely to benefit the neediest in Guatemala

The potential impact of wheat flour fortification with iron and folic acid was assessed using data about food purchases from the nationally representative 2000 Guatemalan Living Standards Measurement Survey. Of 7265 households, 35% were indigenous and 57% rural; 11% were extremely poor, 35% were poor, and 54% were nonpoor. The percentage of households that purchased wheat flour, sweet bread, French rolls, and sliced bread in the previous 15 d was 10, 88, 59, and 11%, respectively. The median amount of fortified wheat flour equivalents in purchased foods was 50 g/d per adult equivalent; fortified wheat flour equivalents were 7, 25, and 110 g/d for the poverty groups, 16 g/d in indigenous households and 24 g/d in rural households. Wheat flour fortification contributed 2.3 mg/d of iron and 90 microg/d of folic acid per adult equivalent. Assuming 5% bioavailability, wheat flour fortification provided 2% of the recommended dietary allowance (RDA) and 6% of estimated average requirement (EAR) iron levels for women of reproductive age; values were 1, 3, and 12% of EAR levels for the poverty groups, respectively. Wheat flour fortification met 26% of folic acid RDA and 33% of EAR levels for women; values were 5, 16, and 71% of EAR levels for the poverty groups, respectively. In conclusion, the impact of fortification is likely to be substantial for folate status in nonpoor and urban women but limited in the case of iron status among all social groups. The poorest, rural, indigenous populations who suffer the highest burden of nutritional deficiencies likely benefit least from wheat flour fortification.

An evaluation of EDTA compounds for iron fortification of cereal-based foods

Fe absorption was measured in adult human subjects consuming different cereal foods fortified with radiolabelled FeSO4, ferrous fumarate or NaFeEDTA, or with radiolabelled FeSO4or ferric pyrophosphate in combination with different concentrations of Na2EDTA. Mean Fe absorption from wheat, wheat–soyabean and quinoa (Chenopodium quinoa) infant cereals fortified with FeSO4or ferrous fumarate ranged from 0·6 to 2·2 %. For each infant cereal, mean Fe absorption from ferrous fumarate was similar to that from FeSO4(absorption ratio 0·91–1·28). Mean Fe absorption from FeSO4-fortified bread rolls was 1·0 % when made from high-extraction wheat flour and 5·7 % when made from low-extraction wheat flour. Fe absorption from infant cereals and bread rolls fortified with NaFeEDTA was 1·9–3·9 times greater than when the same product was fortified with FeSO4. Both high phytate content and consumption of tea decreased Fe absorption from the NaFeEDTA-fortified rolls. When Na2EDTA up to a 1:1 molar ratio (EDTA:Fe) was added to FeSO4-fortified wheat cereal and wheat–soyabean cereal mean Fe absorption from the wheat cereal increased from 1·0 % to a maximum of 5·7 % at a molar ratio of 0·67:1, and from the wheat–soyabean cereal from 0·7 % to a maximum of 2·9 % at a molar ratio of 1:1. Adding Na2EDTA to ferric pyrophosphate-fortified wheat cereal did not significantly increase absorption (P>0·05). We conclude that Fe absorption is higher from cereal foods fortified with NaFeEDTA than when fortified with FeSO4or ferrous fumarate, and that Na2EDTA can be added to cereal foods to enhance absorption of soluble Fe-fortification compounds such as FeSO4.

Efeito da fortificação de alimentos com ferro sobre anemia em crianças: um estudo de revisão

Uma revisão sistemática da literatura foi conduzida com o objetivo de identificar estudos que avaliassem o efeito da fortificação de alimentos com ferro sobre a ocorrência de anemia em crianças. As bases de dados pesquisadas foram MEDLINE, LILACS e sites da Organização Mundial da Saúde e Organização Pan-Americana da Saúde, sem limite de tempo, incluindo estudos publicados em português, inglês ou espanhol, utilizando os seguintes unitermos e suas combinações: food fortification, iron, effectiveness, efficacy, anemia, flour, staple foods, interventions e children. Dos 21 estudos revisados, apenas um não mostrou efeito positivo da intervenção, indicando a possibilidade de existência de viés de publicação. Os estudos apresentaram limitações metodológicas importantes. Os dois estudos com os melhores escores metodológicos mostraram resultados discordantes, evidenciando a necessidade de explorar essa hipótese em ensaios maiores e com maior rigor metodológico.

Efficacy of iron fortification compared to iron supplementation among Vietnamese schoolchildren

The effect of iron fortification is generally assumed to be less than iron supplementation; however, the magnitude of difference in effects is not known. The present study aims to compare the efficacy of these two strategies on anaemia and iron status. After screening on low Hb, 425 anaemic children in six primary schools in Tam Nong district of Phu Tho province were included in a randomized, placebo-controlled trial comparing two groups receiving iron fortified instant noodles or iron supplementation for 6 months and a control group, with children in all groups having been dewormed. Blood samples were collected before and after intervention for haemoglobin, serum ferritin (SF), serum transferrin receptor (TfR), C-reactive protein (CRP), and haemoglobinopathies analysis. Regression analysis was used to assess the effect of iron fortification and iron supplementation on haemoglobin concentration, SF, TfR, body iron, and anaemic status as outcome variables. The improvement of haemoglobin, SF, and body iron level in the group receiving iron fortification was 42% (2.6 g/L versus 6.2 g/L), 20% (23.5 microg/L versus 117.3 microg/L), and 31.3% (1.4 mg/kg versus 4.4 mg/kg) of that in the iron supplementation group. The prevalence of anaemia dropped to 15.1% in the control group, with an additional reduction of anaemia of 8.5% in the iron supplementation group. The additional reduction due to iron fortification was 5.4%, which amounts to well over 50% of the impact of supplementation. In conclusion, the efficacy of iron fortification based on reduction of prevalence of anaemia, and on the change in haemoglobin level, is about half of the maximum impact of supplementation in case of optimal compliance. Thus, in a population of anaemic children with mild iron deficiency, iron fortification should be the preferred strategy to combat anaemia.

The role of enriched foods in infant and child nutrition

Since the last century, fortified and enriched foods are products whose original composition has been modified-through addition of essential nutrients-to satisfy specific population needs. For the fortification of foods to have a positive impact on nutritional status, the micronutrients added must be well absorbed and utilized by the organism (bioavailability). Diverse factors affect bioavailability, such as the nutritional status of individuals, the presence in the diet of substances which facilitate or inhibit its absorption, interactions among micronutrients, illnesses, and chemical characteristics of the compound used for fortification. In countries such as Chile, Venezuela and Mexico, important effects have been demonstrated in reducing iron deficiency anaemia in children under 5 years of age. In less than a decade, the salt iodization programme has also proven its effectiveness. Other programmes have fortified foods with Zn, vitamin A and folic acid, which are deficient in infants and children of many populations. In summary, food fortification is a low-cost, relatively simple strategy that may reach a wide range of people, and contribute to reducing the high prevalence of micronutrient deficiencies affecting children, especially in poor countries. The costs due to losses of human capital and their repercussions on health and future development are very high. Building links among academic researchers, politicians, food manufacturers and consumers is essential in order for food fortification to be efficacious and effective, and therefore should be considered as part of an integral strategy to combat micronutrient deficiencies.

The economics of food fortification

This paper summarizes some of the literature on the cost effectiveness and cost benefit of food fortification with selected micronutrients most relevant for developing countries. Micronutrients covered include iron, iodine, vitamin A, and zinc. The main focus is on commercial fortification, although home fortification and biofortification are mentioned. Fortification with iron, vitamin A, and zinc averts significant numbers of infant and child deaths and is a very attractive preventive health-care intervention. Fortification with iron, iodine, and potentially zinc provides significant economic benefits and the low unit cost of food fortification ensures large benefit:cost ratios, with effects via cognition being very important for iron and iodine. Fortification will not reach all individuals and is most attractive as an investment where there is a convenient food vehicle, where processing is more centralized, and where either the deficiency is widespread or the adverse effects are very costly even though only a small group is affected.

Cooking and Fe Fortification Have Different Effects on Fe Bioavailability of Bread and Tortillas

OBJECTIVE

To identify iron sources for wheat- (WF) and corn-flour (CF) fortification taking into account the effect of cooking.

METHODS

Sixty-six Fe-depleted rats were replete with various Fe sources. Fe bioavailability and utilization in wheat bread (WB) and corn tortillas (CT) fortified with various Fe sources was assessed after the depletion and repletion periods.

RESULTS

Baking decreased the phytates content of WF by 97%. Improvements in Hb and FeHb were greater in rats fed unfortified WB than in those fed unfortified WF. Fe fortification had no benefit. In contrast, phytates content was unchanged by tortilla preparation, but fortification improved iron availability. Iron bioavailability indicators were best in rats fed CT fortified with ferrous sulfate and NaFe(III)EDTA than in those fed unfortified CT or CT plus reduced Fe.

CONCLUSION

We concluded that baking WF bread improved the bioavailability of native Fe with no further effect of fortification. Pan-cooking of lime-treated CF did not improve Fe bioavailability, but addition of Ferrous sulfate or NaFe(III)EDTA did it, despite the high phytate and calcium content of tortillas.

Nutrient Addition to Corn Masa Flour: Effect on Corn Flour Stability, Nutrient Loss, and Acceptability of Fortified Corn Tortillas

Background

Iron, zinc, and vitamin B complex are among the most prevalent nutritional deficiencies in Mexico, with iron deficiency being the leading cause of anemia. Mexico has the highest per capita consumption of corn in the world, consumed mainly as tortilla. Thus, corn flour for making tortillas has been suggested as an effective strategy to overcome malnutrition in developing countries such as Mexico where corn is a staple food. The stability of micronutrients added to food is an important factor for the success of fortification programs.

Objective

The aim of this study was to evaluate the stability of corn flour fortified with micronutrients, and to measure the effect of micronutrient fortification on the sensory quality and stability of the fortificants in fresh and stored tortilla.

Methods

A commercially homogenized nonfortified corn flour (NCFC) produced from degermed white corn was fortified with a premix containing iron, zinc, thiamin, and riboflavin. Changes in thiamin, riboflavin, iron, and zinc content in fortified corn flour (FCF) and nonfortified corn flour (NFCF) during storage were investigated. Vitamin B1 and B2 content was determined by fluorescence spectroscopy while iron and zinc content was analyzed by atomic absorption.

Results

Thiamin content in FCF and NFCF showed a significant ( p < .05) decrease (24% and 37%, respectively) after 90 days of storage. Riboflavin losses of 18% and 22% were observed for FCF and NFCF, respectively. FCF retained over 90% of iron, while zinc content remained constant. Losses of thiamin (27 to 39%) and riboflavin (37%) were produced during the process to convert corn masa flour into tortillas.

Conclusions

Storage time slightly affected the stability of riboflavin and thiamin in FCF while the cooking process produced considerable losses of both vitamins. Tortillas made from FCF were well accepted by Mexican adults. We conclude that the addition of vitamins and minerals in the forms and quantities used in this study do not modify the shelf-life of corn flour, and neither do they cause sensorial changes in tortillas made from FCF.

Iron availability: An updated review

Iron is an essential trace element in human nutrition and its deficiency is a world nutritional problem. Due to the high prevalence of anaemia in developing and industrialized countries, it is necessary to maintain a suitable iron intake through diet in order to achieve an appropriate status of this element in the body. For this reason, accurate knowledge of iron availability of foods is essential in order to plan intervention strategies that improve deficient situations of this nutrient. Regarding to the two forms of iron present in foods, heme iron has greater availability than non-heme iron. Beside this, non-heme iron availability is conditioned by several dietary factors, such as classic factors (meat, ascorbic acid, fibre, phytic acid, polyphenols) and new factors (caseinophosphopeptides and fructo-oligosaccharides with prebiotic characteristics). For that reason, the aim of this paper is to accurately review all investigations reported in the past decade related to dietetic factors that influence the bioavailability of different iron forms.

Micronutrient fortification of foods--rationale, application and impact

Deficiencies in intake of essential vitamins and minerals (commonly referred to as micronutrients) that are essential for efficient energy metabolism and other functions of the human body (commonly termed as micronutrients) are severe and widespread in many parts of the world. They cause an immeasurable burden on individuals, on health services, education systems and families caring for children who are disabled or mentally impaired. Studies by World Bank have shown that countries whose populations suffer from micronutrient deficiencies encounter economic losses as high as 5% of gross domestic product (GDP). The solution to control and prevent micronutrient deficiencies is available and affordable. At a national level, micronutrient malnutrition can be addressed by implementing programmes designed to educate people to diversify their diets (where appropriate foods are available), or by fortifying commonly eaten foods with the missing micronutrients or providing nutrient supplements through targeted distribution programmes. Food fortification is increasingly recognized as an effective means of delivering micronutrients. Fortification of foods can provide meaningful amounts of the nutrient at normal consumption of the food vehicle. Proper choice of fortificant and processing methods could ensure the stability and bioavailability of the nutrient. The level of fortification should take into account variations in food consumption to ensure safety for those at the higher end of the scale and impact for those at the lower end. Fortification needs to be supported by adequate food regulations and labeling, quality assurance and monitoring to ensure compliance and desired impact. In industrialized countries food fortification has played a major role in the substantial reduction and elimination of a number of micronutrient deficiencies. Although a growing number of large scale fortification programmes in different parts of the world are beginning to demonstrate impact at the biochemical level and are leading to the elimination of several nutrient deficiencies, food fortification remains an underutilized opportunity in many developing countries where micronutrient malnutrition remains a public health problem.

Co-existence of anemia, vitamin A deficiency and growth retardation among children 24-84 months old in Maracaibo, Venezuela

Iron deficiency anemia has been associated with alterations in child development and psychomotor function, being myelination and dopaminergic functioning especially vulnerable. Iron deficiency, at different ages, has different reversible and irreversible effects on CNS. Anemia has also been related to vitamin A deficiency (VAD) and growth retardation. The aim of the present paper was to determine the coexistence of micronutrient deficiency, iron and vitamin A, and macronutrient deficiency (growth retardation). The sample consisted of 202 Venezuelan children, aged 24-84 month old, (104 girls, 98 boys); Anemia, VAD and growth retardation was evaluated by means of blood hemoglobin concentration analysis, HPLC serum retinol (values <20 microg/dl reveal VAD) and height/age and weight/age Z scores (< or = - 2 SD express stunting and underweight). Prevalence of anemia was 38.11%; VAD, 21.78%; stunting, 14.36% and underweight, 9.40%. Anemia and VAD clustered in 7.92%; anemia + stunting or + underweight coexisted in 5.94% and 2.97%, respectively. Stunting and underweight clustered with VAD in 2.97% and 1.48%. The three-way combination with anemia was only seen with stunting in 0.99% of the sample. The prevalence of micronutrient deficiencies remain as significant public health problems which should be simultaneously treated as virtually independent, giving priority to infant, toddler and preschool age groups.