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Supplement: Forging Effective Strategies to Combat Iron Deficiency

Commentary: Experiences and Challenges in Industrialized Countries^{1 ,2}

H. J. Heinz Company, Pittsburgh, PA 15219

³To whom correspondence should be addressed. H. J. Heinz Company, 5700 Yonge Street, Suite 2100, Toronto, ON M2M 4K6 Canada. E-mail: david.yeung{at}hjheinz.com

	ABSTRACT

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Industrialized nations have been successful in reducing incidences of iron deficiency through utilization of multifaceted strategies that build on the capabilities of successful alliances between the public and private sectors. In comparison to developing nations, which have an estimated prevalence of iron deficiency of 40%, the prevalence in industrialized countries is 5%. Such low rates were achieved by various initiatives including widespread availability of affordable iron-fortified foods and implementation of national, science-based programs. Despite these successes, however, iron deficiency remains a critical problem among certain subpopulations (e.g., people of low socioeconomic status or recent immigrants who do not consume iron-fortified foods). Strengthening alliances among the private and public sectors and academia in communications efforts about iron deficiency and promoting iron-rich foods as well as iron-fortified foods is necessary to reduce iron deficiency in these populations.

KEY WORDS: • iron deficiency • iron deficiency anemia • industrialized nations • public health policy

	INTRODUCTION

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Dr. Usha Ramakrishnan has given comprehensive coverage on the experiences and challenges in industrialized countries, which permits this article to focus on the experiences and roles of the food industry in contributing to adequate iron intake. The emphasis of this article will be on infant and child nutrition and, therefore, complementary foods. It will cover, albeit briefly, the magnitude of iron deficiency (ID)⁴ in industrialized countries, the history in North America in overcoming ID, the role of the private sector in this endeavor and some unresolved issues that need to be addressed.

It has been repeatedly described in this workshop that ID is the most common nutrition disorder globally and remains the only nutrient deficiency of significance in virtually all industrialized countries. The estimated prevalence of iron deficiency anemia (IDA) among young children in developing countries is 40%. It is much lower, 5%, in industrialized countries (1 –3 ).

The prevalence of IDA among infants in industrialized nations has dropped significantly since the 1930s as a result of food fortification, improved food availability and accessibility, better nutrition knowledge and development of appropriate national food policies and programs.

Before the 1930s, malnutrition was one of the main causes of morbidity and mortality among infants and young children. IDA was rampant. Infants were fed paps when they were not satisfied with mothers’ milk alone. These paps provided bulk but not much else.

Pablum (Latin, pabulum meaning food) was invented at the Hospital for Sick Children in Toronto, Canada (4 ). It was originally made of wheat meal, oatmeal, wheat germ, bone meal, dried brewer’s yeast, alfalfa, iron and copper. The composition was not specific and the ingredients were added at levels to make Pablum edible. It required a long cooking time but proved efficacious in promoting infant growth and development. It contained good quality protein, vitamin A, thiamin, riboflavin, vitamins D and E, calcium, phosphorus, iron and copper. In 1931 a U. S. pharmaceutical company acquired Pablum. It was instantized and marketed widely in North America. The Hospital for Sick Children has been receiving a royalty for research since then. This was the beginning of commercialization of fortified complementary foods.

Iron fortified infant cereals are commonly recommended in North America as the first food to complement breast or formula feeding (5 ,6 ). They are perceived as staples for infants from 4 to 6 mo of age and older. They have been confirmed to be efficacious in preventing ID in infants (1 ).

In the 1970s, sodium iron pyrrophosphate added to infant cereals was found to have low and inconsistent bioavailability (7 ). It was replaced by electrolytically reduced iron of small particle size. To ensure adequate absorption, the North American pediatric societies suggested prolonged breastfeeding; avoidance of use of cow’s milk; and inclusion of facilitators of iron absorption, such as vitamin C-rich food, meat, fish and poultry in the infant diet. The infant-feeding industry adheres to these recommendations.

In 1972 the U. S. Department of Agriculture implemented the Special Supplementary Food Program for Women, Infants, and Children (WIC). One of the objectives was to improve nutrition in economically disadvantaged families. The WIC program provides iron-fortified infant formulas and cereals during the 1st y of the child’s life. This program has been effective in lowering the incidence of IDA. Studies have shown that the prevalence of IDA dropped from 22% in the 1960s to 3% in the mid-1990s (5 ,7 ).

The experience in infant feeding from North America exemplifies the success of partnership between academia and the private sectors. Table 1 describes the roles that the food industry can play in the elimination of micronutrient malnutrition. Clearly, the food industry has important roles to play in all aspects of delivering and promoting nutritious products that could improve the well-being of consumers. At the beginning of this conference, Dr. Joseph Hunt said that the benefits of eliminating ID to the industry are: improvement of food quality, involvement in public health, improvement of work efficiency of consumers, creation of demand for nutritious and quality food, and the satisfaction of "giving back to society."

	Challenges

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	CONCLUSIONS

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Industrialized countries have been successful in reducing the prevalence of ID and IDA in infants, although there remain pockets in society that require special attention. The lessons learned are the following:

• Utilize food-based approaches that are appropriate to cultures and environments. These approaches include dietary diversification and assurance of food availability and accessibility of iron-rich foods at affordable prices.
  
• Develop stronger national science-based policies for fortification. These involve mandatory food enrichment, broad categories of food fortification and timely turn around time for product approval.
  
• Strengthen partnerships among the private and public sectors and academia in social marketing of ID and the promotion of iron-rich foods as well as iron-fortified foods. Dr. William Foege reminded us at the beginning of the conference that we need "coalition in action not only in words."
  

The application of these principles in developing countries may help to lower ID to the levels that are experienced in industrialized countries.

	FOOTNOTES

 
¹ Presented at the Atlanta conference on Forging Effective Strategies to Combat Iron Deficiency held May 7–9, 2001 in Atlanta, GA. The proceedings of this conference are published as a supplement to The Journal of Nutrition. Supplement guest editors were Frederick Trowbridge, Trowbridge & Associates, Inc., Decatur, GA and Reynaldo Martorell, Rollins School of Public Health, Emory University, Atlanta, GA.

² This article was commissioned by the International Life Sciences Institute Center for Health Promotion (ILSI CHP). The use of trade names and commercial sources in this document is for purposes of identification only and does not imply endorsement. In addition, the views expressed herein are those of the individual authors and/or their organizations and do not necessarily reflect those of ILSI CHP.

⁴ Abbreviations used: ID, iron deficiency; IDA, iron deficiency anemia; WIC, Women, Infants and Children.

	LITERATURE CITED

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1. Sherry, B., Mei, Z. & Yip, R. (2001) Continuation of the decline in prevalence of anemia in low-income infants and children in five states. Pediatrics 107:677-682.[Abstract/Free Full Text]

2. Oti-Boateng, P., Seshandri, R., Petrick, S., Gibson, R. A. & Simmer, K. (1998) Iron status and dietary iron intake of 6—24-month-old children in Adelaide. J. Paediatr. Child Health 34:250-253.[Medline]

3. Padmanabhan, A., Thomas, S., Sheth, H. & Venugopalan, P. (2001) High prevalence of microcytic anaemia in Omani children: a prospective study. Ann. Trop. Paediatr. 21:45-49.[Medline]

4. Tisdall, F. F., Drake, T.G.H., Summerfeldt, P. & Brown, A. (1930) A new whole wheat irradiated biscuit containing vitamins and mineral elements. Can. Med. Assoc. J. 22:166-170.

5. Canadian Paediatric Society, Dietitians of Canada and Health Canada (1999) Nutrition for Healthy Term Infants 1999 Health Canada Publication Ottawa, Canada. .

6. American Academy of Pediatrics, Committee on Nutrition (1998) Supplemental foods for infants. Kleinman, R. E. eds. Pediatric Nutrition Handbook 4th ed. 1998:43-53 American Academy of Pediatrics Chicago, IL. .

7. Shah, B. G., Giroux, A. & Belonji, B. (1977) Specifications for reduced iron as a food additive. J. Agric. Food Chem. 25:592-594.[Medline]

8. Sawchuk, P., Rauliuk, M., Kotaska, A., Townsend, S., Wilson, E. & Starr, M. (1998) Infant nutrition program effectively prevents iron-deficiency anemia in a first nations community. Int. J. Circumpolar. Health 57(suppl. 1):189-193.

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