Use of iron-fortified rice reduces anemia in infants

Effects of Nutrition-Specific Interventions to Prevent and Control Nutrition-Related Anemia in Infants, Children, and Adolescents: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Anemia is a prevalent health issue among children and adolescents worldwide, with malnutrition being among the most common causes. Nutrition-related anemia can be prevented or controlled through targeted interventions.

OBJECTIVE

This study aimed to evaluate the effects of nutrition interventions on ferritin concentration, hemoglobin concentration, anemia prevalence, and nutrition-related anemia prevalence in infants, children, and adolescents-and to compare outcomes by intervention and age group using network meta-analysis of randomized controlled trials.

METHODS

Web of Science, PubMed, Scopus, EBSCO, the Cochrane Library, China National Knowledge Infrastructure Database, Weipu Database, and Wanfang Database were comprehensively searched to identify randomized controlled trials on the effects of nutrition interventions (micronutrient supplementation, macronutrient supplementation, and nutrition education) until September 30, 2023. Two groups of researchers screened the literature and extracted data based on set inclusion and exclusion criteria. Reviewers used the Cochrane tool for assessing risk-of-bias in randomized controlled trials and used the Grading of Recommendations, Assessment, Development, and Evaluation for evaluating the strength of evidence for inclusion in network meta-analysis. The study population was categorized into infants and preschool-aged children (aged 6 to 59 months), school-aged children (aged 6 to 11 years), and adolescents (aged 12 to 18 years). The study evaluated the mean difference, risk ratio, and 95% credible interval of outcomes for each intervention across different age groups using network meta-analysis.

RESULTS

Sixty-one randomized controlled trials were included in this analysis. In network meta-analysis, micronutrient supplementation, macronutrient supplementation, and nutrition education were found to have significant effects on hemoglobin concentrations in infants and preschool-aged children. Lipid-based nutrient supplementation resulted in the highest increase in hemoglobin concentration, whereas multiple micronutrient supplementation resulted in the largest reduction in risk of anemia and iron deficiency anemia. In school-aged children, iron supplementation increased hemoglobin concentration, whereas micronutrient supplementation also increased hemoglobin concentration and reduced anemia risk. In adolescents, iron supplementation improved hemoglobin concentration and lowered anemia risk.

CONCLUSIONS

The effectiveness of nutrition interventions in improving nutrition-related anemia varies across intervention types and age groups. Micronutrient and iron supplementation consistently improved hemoglobin levels and related indicators, with evidence quality ranging from low to moderate. MMN and LNS had positive effects on hemoglobin concentrations and anemia in infants and preschool-aged children, which is supported by low-to-moderate quality evidence. For adolescents, although micronutrient and iron supplementation showed positive effects, the overall evidence quality was generally low, highlighting the need for further high-quality clinical research to validate these findings.

Health outcomes associated with micronutrient-fortified complementary foods in infants and young children aged 6–23 months: a systematic review and meta-analysis

Background

Appropriate feeding of infants and young children is essential for healthy growth and the prevention of stunting, wasting, and overweight. We aimed to assess the beneficial versus harmful effects of providing fortified complementary foods to children in the complementary feeding period.

Methods

In this systematic review and meta-analysis, we searched the databases Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, Global Index Medicus, Web of Science, ClinicalTrials.gov, and WHO International Clinical Trials Registry Platform from inception to March 9, 2021. We included randomised controlled trials and controlled clinical trials done in infants and children aged 6–23 months with no identified health problems. Consumption of foods fortified centrally (ie, during industrial processing) with one micronutrient or a combination of vitamins, minerals, or both was compared with the same complementary foods, but without micronutrient fortification. Two review authors independently screened studies for eligibility, extracted data, assessed risk of bias, and rated the certainty of the evidence. The main outcomes were growth (measured by Z scores for weight for age, weight for height or length, and height or length for age, or other growth measures), stunting, wasting, nutrient adequacy or excess, anaemia, haemoglobin concentration, iron status, serum zinc concentration, and serum retinol concentration. We used a random-effects meta-analysis for combining data. This study is registered with PROSPERO, CRD42021245876.

Findings

We included 16 studies with 6423 participants, 13 of which were done in malaria-endemic areas. Overall, 12 studies were included in the quantitative syntheses. We identified five further ongoing studies. There was no difference between participants who received fortified complementary foods and those who received non-fortified complementary foods in weight-for-age Z scores (mean difference −0·01, 95% CI −0·07 to 0·06; five trials; 1206 participants; moderate-certainty evidence), weight-for-height or length Z scores (−0·05, −0·19 to 0·10; four trials; 1109 participants; moderate-certainty evidence), and height or length-for-age Z scores (−0·01, −0·21 to 0·20; four trials; 811 participants; low-certainty evidence); stunting and wasting were not assessed in any study as outcomes. Moderate-certainty evidence from six trials with 1209 patients showed that providing fortified complementary foods to children aged 6–23 months reduced the risk of anaemia (risk ratio 0·57, 95% CI 0·39 to 0·82). Those who received fortified complementary foods compared with those who did not had higher haemoglobin concentrations (mean difference 3·44 g/L, 95% CI 1·33 to 5·55; 11 trials; 2175 participants; moderate-certainty evidence) and ferritin concentration (0·43 μg/L on log scale, 0·14 to 0·72; six trials; 903 participants; low-certainty evidence). The intervention led to no effects on serum zinc concentration (−0·13 g/dL, −0·82 to 0·56; two trials; 333 participants; low-certainty evidence) and serum retinol concentration (0·03 μmol/L, −0·02 to 0·08; five trials; 475 participants; moderate-certainty evidence).

Interpretation

Fortified complementary foods are effective strategies to prevent anaemia in infants and young children aged 6–23 months in malaria-endemic regions. Effects of complementary food fortification should be further investigated in low-income and middle-income countries, but should also be assessed in high-income countries, and in regions where malaria is not endemic.

Funding

WHO.

Consumption of Sinlek Rice Drink Improved Red Cell Indices in Anemic Elderly Subjects

Iron fortifications are used for the treatment of iron-deficiency anemia; however, iron dosing may cause oxidative damage to the gut lumen. Thai Sinlek rice is abundant in iron and contains phytochemicals. We aimed at evaluating the effect of an iron-rice (IR) hydrolysate drink (100 mL/serving) on neurological function, red cell indices and iron status in elders. Healthy elderly subjects were divided into three non-anemic groups and one anemic group. The non-anemic groups consumed one WR (2 mg iron/serving) and two IR drinks (15 and 27 mg iron/serving) (groups A, B and D, respectively), while the anemic group consumed one IR drink (15 mg iron serving) (group C) every day for 30 days. There were no significant differences in the MMSE Thai 2002 and PHQ9 test scores for members of all groups, while the nutrition scores and body weight values of group D subjects were significantly increased. Hemoglobin (Hb) and mean corpuscular hemoglobin concentrations increased significantly only in group C. Serum iron and transferrin saturation levels tended to increase in group A, while these levels were decreased in members of group C. Serum antioxidant activity levels were increased in all groups, and were highest in group C. Thus, consumption of an IR drink for 15 days functioned to increase Hb and antioxidant capacity levels in anemic elders.

Considerations for improvising fortified extruded rice products

Micronutrient fortification of rice by extrusion is an effective strategy to enhance micronutrient levels within rice-consuming individuals. The success of extrusion-based fortification is associated with micronutrient retention, enhanced bioavailability, low postprocessing losses, prolonged storage stability, and minimal sensory changes. The success of an optimally fortified product is primarily reliant upon the compositional considerations, but many attributes of extrudates can be indebted to the processing parameters too. Hence, an exhaustive investigation of this technology has been taken-up here, emphasizing on the compositional parameters in association with process parameters, which influence the final quality attributes like nutrient stability, bioavailability, and sensory properties. Based on these attributes of the end product, a collected data have been presented here to bring out the optimal compositional requirements. These together with cooking processes, extrusion process parameters, and storage conditions will enable formulate a product with enhanced sensory acceptance, better retention during cooking and storage, improved texture, and acceptable color. This review will thus help to optimize a need-based product, its quality, and enhance benefits of fortified extruded rice products.

Micronutrient Supplementation and Fortification Interventions on Health and Development Outcomes among Children Under-Five in Low- and Middle-Income Countries: A Systematic Review and Meta-Analysis

Micronutrient deficiencies continue to be widespread among children under-five in low- and middle-income countries (LMICs), despite the fact that several effective strategies now exist to prevent them. This kind of malnutrition can have several immediate and long-term consequences, including stunted growth, a higher risk of acquiring infections, and poor development outcomes, all of which may lead to a child not achieving his or her full potential. This review systematically synthesizes the available evidence on the strategies used to prevent micronutrient malnutrition among children under-five in LMICs, including single and multiple micronutrient (MMN) supplementation, lipid-based nutrient supplementation (LNS), targeted and large-scale fortification, and point-of-use-fortification with micronutrient powders (MNPs). We searched relevant databases and grey literature, retrieving 35,924 papers. After application of eligibility criteria, we included 197 unique studies. Of note, we examined the efficacy and effectiveness of interventions. We found that certain outcomes, such as anemia, responded to several intervention types. The risk of anemia was reduced with iron alone, iron-folic acid, MMN supplementation, MNPs, targeted fortification, and large-scale fortification. Stunting and underweight, however, were improved only among children who were provided with LNS, though MMN supplementation also slightly increased length-for-age z-scores. Vitamin A supplementation likely reduced all-cause mortality, while zinc supplementation decreased the incidence of diarrhea. Importantly, many effects of LNS and MNPs held when pooling data from effectiveness studies. Taken together, this evidence further supports the importance of these strategies for reducing the burden of micronutrient malnutrition in children. Population and context should be considered when selecting one or more appropriate interventions for programming.

Fortification of rice with vitamins and minerals for addressing micronutrient malnutrition

BACKGROUND

Rice fortification with vitamins and minerals has the potential to increase the nutrition in rice-consuming countries where micronutrient deficiencies exist. Globally, 490 million metric tonnes of rice are consumed annually. It is the dominant staple food crop of around three billion people.

OBJECTIVES

To determine the benefits and harms of rice fortification with vitamins and minerals (iron, vitamin A, zinc or folic acid) on micronutrient status and health-related outcomes in the general population.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, and 16 other databases all up to 10 December 2018. We searched ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform (ICTRP) on 10 December 2018.

SELECTION CRITERIA

We included randomised and quasi-randomised trials (with either individual or cluster randomisation) and controlled before-and-after studies. Participants were populations older than two years of age (including pregnant women) from any country. The intervention was rice fortified with at least one micronutrient or a combination of several micronutrients (iron, folic acid, zinc, vitamin A or other vitamins and minerals) compared with unfortified rice or no intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently screened studies and extracted data.

MAIN RESULTS

We included 17 studies (10,483 participants) and identified two ongoing studies. Twelve included studies were randomised-controlled trials (RCTs), with 2238 participants after adjusting for clustering in two cluster-RCTs, and five were non-randomised studies (NRS) with four controlled before-and-after studies and one cross-sectional study with a control (8245 participants). Four studies were conducted in India, three in Thailand, two in the Philippines, two in Brazil, one each in Bangladesh, Burundi, Cambodia, Indonesia, Mexico and the USA. Two studies involved non-pregnant, non-lactating women and 10 involved pre-school or school-age children. All 17 studies reported fortification with iron. Of these, six studies fortified rice with iron only; 11 studies had other micronutrients added (iron, zinc and vitamin A, and folic acid). One study had one arm each with vitamin A alone and carotenoid alone. Elemental iron content ranged from 0.2 to 112.8 mg/100 g uncooked rice given for a period varying from two weeks to 48 months. Thirteen studies did not clearly describe either sequence generation or allocation concealment. Eleven studies had a low attrition rate. There was no indication of selective reporting in the studies. We considered two RCTs at low overall risk of bias and 10 at high overall risk of bias. One RCT was at high or unclear risk of bias for most of the domains. All controlled before-and-after studies had a high risk or unclear risk of bias in most domains. The included studies were funded by Government, private and non-governmental organisations, along with other academic institutions. The source of funding does not appear to have altered the results. We used the NRS in the qualitative synthesis but we excluded them from the quantitative analysis and review conclusions since they provided mostly contextual information and limited quantitative information. Rice fortified with iron alone or in combination with other micronutrients versus unfortified rice (no micronutrients added) Fortification of rice with iron (alone or in combination with other micronutrients) may make little or no difference in the risk of having anaemia (risk ratio (RR) 0.72, 95% confidence interval (CI) 0.54 to 0.97; I² = 74%; 7 studies, 1634 participants; low-certainty evidence) and may reduce the risk of iron deficiency (RR 0.66, 95% CI 0.51 to 0.84; 8 studies, 1733 participants; low-certainty evidence). Rice fortification may increase mean haemoglobin (mean difference (MD) 1.83, 95% CI 0.66 to 3.00; I² = 54%; 11 studies, 2163 participants; low-certainty evidence) and it may make little or no difference to vitamin A deficiency (with vitamin A as one of the micronutrients in the fortification arm) (RR 0.68, 95% CI 0.36 to 1.29; I² = 37%; 4 studies, 927 participants; low-certainty evidence). One study reported that fortification of rice (with folic acid as one of the micronutrients) may improve serum or plasma folate (nmol/L) (MD 4.30, 95% CI 2.00 to 6.60; 215 participants; low-certainty evidence). One study reported that fortification of rice with iron alone or with other micronutrients may slightly increase hookworm infection (RR 1.78, 95% CI 1.18 to 2.70; 785 participants; low-certainty evidence). We are uncertain about the effect of fortified rice on diarrhoea (RR 3.52, 95% CI 0.18 to 67.39; 1 study, 258 participants; very low-certainty evidence). Rice fortified with vitamin A alone or in combination with other micronutrients versus unfortified rice (no micronutrients added) One study had one arm providing fortified rice with vitamin A only versus unfortified rice. Fortification of rice with vitamin A (in combination with other micronutrients) may increase mean haemoglobin (MD 10.00, 95% CI 8.79 to 11.21; 1 study, 74 participants; low-certainty evidence). Rice fortified with vitamin A may slightly improve serum retinol concentration (MD 0.17, 95% CI 0.13 to 0.21; 1 study, 74 participants; low-certainty evidence). No studies contributed data to the comparisons of rice fortification versus no intervention. The studies involving folic acid and zinc also involved iron in the fortification arms and hence we reported them as part of the first comparison.

AUTHORS' CONCLUSIONS

Fortification of rice with iron alone or in combination with other micronutrients may make little or no difference in the risk of having anaemia or presenting iron deficiency and we are uncertain about an increase in mean haemoglobin concentrations in the general population older than 2 years of age. Fortification of rice with iron and other micronutrients such as vitamin A or folic acid may make little or no difference in the risk of having vitamin A deficiency or on the serum folate concentration. There is limited evidence on any adverse effects of rice fortification.

Micronutrient Fortification at Child-Care Centers Reduces Anemia in Young Children

The aim of this study was to evaluate the effectiveness of NutriSUS micronutrient fortification, in infants aged 12-36 months, for the prophylaxis and treatment of iron deficiency anemia. In this cluster-randomized clinical trial study, we evaluated infants aged 12-36 months. Length of intervention was 12 weeks. Children were cluster randomized to either NutriSUS micronutrient fortification (Group A) or control (Group B). Primary outcome variables were change in hemoglobin concentration and anemia prevalence. Two biochemical evaluations were performed to determine hemoglobin concentrations: before and after intervention. This study was conducted in eight child-care centers located within the urban perimeter of the municipality of Sobral, Ceará, in the northeast of Brazil. For Group A, baseline mean hemoglobin concentration was 11.4 ± 1.01 g/dL; after intervention it was 11.9 ± 0.90 g/dL (p = .006); 15 of 20 participants who were anemic at baseline had normal Hb levels after intervention. Number needed to treat = 2. In group B, mean baseline hemoglobin was 11.9 ± 0.89 g/dL; after intervention it was 12.2 ± 0.92 g/dL (p = .58); 4 of 5 participants who were anemic at baseline remained anemic after intervention. In our study, NutriSUS micronutrient fortification provided a beneficial effect on Hb values, reducing the prevalence of anemia. However, further studies are necessary to confirm the effectiveness of this intervention in populations on a larger scale.

Effect of multi-micronutrient-fortified rice on cognitive performance depends on premix composition and cognitive function tested: results of an effectiveness study in Cambodian schoolchildren

Objective

Even though current policy is strongly focused on the crucial first ‘1000 days’, it might be still possible to enhance cognitive function during the pre-adolescent and adolescent years by improving micronutrient status. In Cambodia, nutritional status is poor. Provision of rice fortified with micronutrients through a school meal programme (SMP) could be a cost-effective strategy to help improve health and school performance. The present study aimed to evaluate the effect of three different micronutrient-fortified rice formulations on cognitive function in Cambodian children.

Setting

Sixteen Cambodian schools receiving SMP.

Design

The FORISCA-UltraRice®+NutriRice®study was a randomized, double-blind, placebo-controlled trial. Four groups of four schools were randomly allocated to receive normal rice, UltraRice®Original, UltraRice®New or NutriRice®. Within each school, 132 children were randomly selected. Data on cognitive performance (picture completion, block design and Raven’s coloured progressive matrices (RCPM)), anthropometry, parasite infestation and micronutrient status were collected before the intervention and after 6 months.

Subjects

Cognitive data were available for 1796 children aged 6–16 years.

Results

All cognitive scores improved after 6 months (P<0·001). Block design score improvement was significantly higher in children consuming UltraRice®Original (P=0·03) compared with the other fortified rice groups and placebo. No difference among groups was found on RCPM or picture completion scores. Stunting, parasite infestation and inflammation negatively affected the impact of the intervention.

Conclusions

Combined with other interventions, using SMP to distribute fortified rice to schoolchildren may be a cost-effective way to increase cognitive performance and thereby improve school performance and educational achievements.

A Blinded, Cluster-Randomized, Placebo-Controlled School FeedingTrial in Burundi Using Rice Fortified With Iron, Zinc, Thiamine, and Folic Acid

BACKGROUND

Iron-deficiency anemia is a major public health problem among school-aged children in sub-Saharan Africa.

OBJECTIVE

To evaluate the effectiveness of micronutrient-fortified rice to increase hemoglobin (Hb) concentration and reduce the prevalence of anemia among schoolchildren.

METHODS

Nine hundred four schoolchildren participated in this cluster-randomized trial during a 7-month intervention period. The study was conducted in 12 primary schools in rural Burundi. Hemoglobin, socioeconomic status, febrile illness, and dietary diversity were measured at baseline and follow-up. The changes in Hb concentration and anemia status were analyzed using linear and logistic mixed models, respectively. The micronutrient formulation contained an iron-to-zinc molar ratio of approximately 2.2.

RESULTS

There was no significant difference in Hb concentration between the intervention and control groups (β = .09 g/dL; 95% confidence interval: -0.21 to 0.38) following the 7-month intervention. Nearly half the children reported having a fever within 2 weeks prior to baseline or follow-up. Children with febrile illness preceding follow-up were less than half as likely to show improvement in anemia status (odds ratio = 0.47, P < .001), with an average 0.56 g/dL smaller improvement in Hb at follow-up (P < .001).

CONCLUSION

The high prevalence of fever and low iron-to-zinc molar ratio of the Ultra Rice formulation may have contributed to the lack of improvement in Hb. Alternatively, the detected anemia may not have been due to nutrient deficiencies. Anemia interventions in Burundi should implement multiple strategies to eliminate both iron deficiency and infectious causes of anemia.

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.

Body iron delocalization: the serious drawback in iron disorders in both developing and developed countries

Over 2 billion people in both developing as well as developed countries - over 30% of the world's population - are anaemic. With the classical preconception that oral iron administration or the intake of foods rich in iron increase haemoglobin concentration and reduce the prevalence of anaemia, specific programs have been designed, but iron supplementations have been less effective than expected. Of note, this hazardous simplification on iron status neglects its distribution in the body. The correct balance of iron, defined iron homeostasis, involves a physiological ratio of iron between tissues/secretions and blood, thus avoiding its delocalization as iron accumulation in tissues/secretions and iron deficiency in blood. Changes in iron status can affect the inflammatory response in multiple ways, particularly in the context of infection, an idea that is worth remembering when considering the value of iron supplementation in areas of the world where infections are highly prevalent. The enhanced availability of free iron can increase susceptibility and severity of microbial and parasitic infections. The discovery of the hepcidin-ferroportin (Fpn) complex, which greatly clarified the enigmatic mechanism that supervises the iron homeostasis, should prompt to a critical review on iron supplementation, ineffective on the expression of the most important proteins of iron metabolism. Therefore, it is imperative to consider new safe and efficient therapeutic interventions to cure iron deficiency (ID) and ID anaemia (IDA) associated or not to the inflammation. In this respect, lactoferrin (Lf) is emerging as an important regulator of both iron and inflammatory homeostasis. Oral administration of Lf in subjects suffering of ID and IDA is safe and effective in significantly increasing haematological parameters and contemporary decreasing serum IL-6 levels, thus restoring iron localization through the direct or indirect modulation of hepcidin and ferroportin synthesis. Of note, the nuclear localization of Lf suggests that this molecule may be involved in the transcriptional regulation of some genes of host inflammatory response. We recently also reported that combined administration of oral and intravaginal Lf on ID and IDA pregnant women with preterm delivery threat, significantly increased haematological parameters, reduced IL-6 levels in both serum and cervicovaginal fluid, cervicovaginal prostaglandin PGF2α, and suppressed uterine contractility. Moreover, Lf combined administration blocked further the shortening of cervical length and the increase of foetal fibronectin, thus prolonging the length of pregnancy until the 37th-38th week of gestation. These new Lf functions effective in curing ID and IDA through the restoring of iron and inflammatory homeostasis and in preventing preterm delivery, could have a great relevance in developing countries, where ID and IDA and inflammation-associated anaemia represent the major risk factors of preterm delivery and maternal and neonatal death.