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Supplement: Forging Effective Strategies to Combat Iron Deficiency

Iron Fortification of Foods: Overcoming Technical and Practical Barriers^{1 ,2 ,3}

Ricardo Uauy^*, Eva Hertrampf^*4 and Manju Reddy

^* Instituto de Nutrición y Tecnología de los Alimentos (INTA), Universidad de Chile, Santiago, Chile; Department of Food Science and Human Nutrition, Iowa State University, Ames, IA 50011

⁴To whom correspondence should be addressed: INTA, P.O. Box 138-11, Av. Macul 5540, Santiago, Chile. E-mail: ehertram{at}uec.inta.uchile.cl

	ABSTRACT

TOP ABSTRACT INTRODUCTION Iron fortification of staple... Condiments and sauces Complementary foods Wheat and maize flour... General discussion Recommendations LITERATURE CITED

 
Iron fortification of food is a methodology utilized worldwide to address iron deficiency. A critical problem in some food fortification programs is the lack of bioavailability of iron compounds. This article reviews presentations on iron fortification programs in the Americas and the technical and practical barriers faced by the programs. Effective programmatic strategies will incorporate systematic consideration of sound program management, ensure consumption of fortified foods, and promote advocacy and supportive legislation. However, these factors are often overlooked or are not addressed coherently. Key components to consider in implementation of iron fortification programs include: utilization of foods and condiments containing fortificants that are bioavailable; program development and its implementation coordinated with targeted communications; utilizing resources from public/private sector partnerships; and operational research on how to overcome practical barriers for successful implementation of fortification.

KEY WORDS: • iron deficiency • iron fortification • technical barriers • practical barriers

	INTRODUCTION

TOP ABSTRACT INTRODUCTION Iron fortification of staple... Condiments and sauces Complementary foods Wheat and maize flour... General discussion Recommendations LITERATURE CITED

 
Fortification of foods with iron has been a commonly used strategy to combat iron deficiency throughout the world. However, there has been only limited documentation of the actual impact of fortification on the prevalence of iron deficiency at a population level. In contrast to the experience with iodine and vitamin A, the lack of successful fortification trials with iron has tended to cause skepticism in government agencies that has led to reduced efforts to implement effective iron fortification programs. The session on which this article is based identified multiple technical and practical barriers affecting the success of iron fortification efforts. This report integrates key points made in presentations and discussion during the session and presents summary recommendations.

	Iron fortification of staple foods: wheat, maize and rice

TOP ABSTRACT INTRODUCTION Iron fortification of staple... Condiments and sauces Complementary foods Wheat and maize flour... General discussion Recommendations LITERATURE CITED

 
Cereal flours (wheat and maize) are currently the most common vehicles for iron fortification to reach the general population (1 ). Fortification of rice requires additional research before it can be considered ready for program implementation. Young children are at risk for developing iron deficiency anemia (IDA)⁵ but they do not consume enough of the staples to benefit much from fortification. Implementation of complimentary food fortification or preventive supplementation is important to meet their daily iron requirements. Critical technical barriers determining potential effectiveness of fortification are the bioavailability of iron, selection of the vehicle (food/matrix), the balance of inhibitors and enhancers and total iron intake. Figure 1 summarizes these interactions. The most absorbable iron compounds are most reactive with the food matrix. This limits the amount of iron added to foods and determines in practice their potential biological impact.

View larger version (41K): [in this window] [in a new window]   Figure 1. Interaction of iron source and food matrix in determining the percentage of absorption, maximal iron load compatible with the matrix and the resulting effective absorbed iron from the consumption of 100 g of the food. Refined wheat flour of 70% extraction represents a matrix with low amount of inhibitors while maize-masa (produced industrially for tortilla manufacturing) is an example of a food matrix with a large content of inhibitors [phytates, Ca(OH)2]. Numbers on top of bars correspond to respective value. Potential biologic impact is the result of the percentage of absorbed iron and maximal iron load depending on compound and matrix. A small amount of iron derived from the matrix has been included in the final calculation. (Modified from O. Dary material presented at the meeting.)

	Condiments and sauces

TOP ABSTRACT INTRODUCTION Iron fortification of staple... Condiments and sauces Complementary foods Wheat and maize flour... General discussion Recommendations LITERATURE CITED

 
Condiments and sauces have several advantages as vehicles for iron fortification. They are traditionally part of the daily diet in most countries, widely consumed, reach vulnerable populations, can be added to multiple foods and can be combined with fortified staple foods. Iron fortification of condiments can have a significant contribution where central processing of staple foods is absent. However, successful experiences of fortified condiments have never gone beyond the pilot level: curry powder fortified with NaFeEDTA (2 ); sugar with NaFeEDTA (3 ); salt fortified with ferric orthophosphate, ferrous fumarate, sulfate, or bisglycine chelate (4 ,5 ); soy sauce and fish sauce fortified with NaFeEDTA (6 ,7 ); and seasoning in noodles with ferrous sulfate. Recent investigations have shown that fortification of salt with iron could be very useful and possible even when combined with iodine (8 ). Technical constraints do exist with salt fortification, but it is possible to overcome these limitations. Moisture can provoke discoloration; however, this can be prevented by the use of water-resistant packaging. Use of high bioavailability iron compounds is limited by the matrix; encapsulation of a soluble iron compound (ferrous fumarate or FeSO4), which disintegrates in the upper gastrointestinal tract, will solve this problem. Segregation by particle size of salt and fortificant can be solved through matching size of salt crystals and fortificant particles by agglomerating encapsulated fortificant. Practical constraints in condiment fortification relate to cost as determined by the price of premix, sustainability of local production, marketing strategies, packaging, targeting those in need according to variation in consumption and the monitoring of the process. Action-oriented research is in progress in India, Indochina, Kenya and Nigeria and the solutions should be forthcoming. Creation of a strong public–private partnership to implement large-scale fortification with appropriate quality assurance, monitoring and evaluation is fundamental for the success of the programs.

	Complementary foods

TOP ABSTRACT INTRODUCTION Iron fortification of staple... Condiments and sauces Complementary foods Wheat and maize flour... General discussion Recommendations LITERATURE CITED

 
The contribution of iron from fortified complementary foods has great potential because it may provide the major source of iron at a critical time in infant growth and brain development. There are two major technical constraints when cereals are selected as vehicles: high levels of phytic acid and the extreme sensitivity of unsaturated fat to oxidation during storage in the presence of highly reactive forms of iron (ferrous sulfate or fumarate). One option for increasing nonabsorption is to hydrolize the phytic acid in cereals, but nearly all of it needs to be removed (9 ). Activating natural phytases from legumes (example) and some cereals (rye, buckwheat, and wheat) helps to hydrolyze phytic acid. In the future, it may be possible to develop crops with low phytic acid through plant breeding to prevent fat oxidation and preserve organoleptic problems; infant cereals are usually fortified with elemental iron powders, which are not very reactive, but this form of iron has extremely poor bioavailability and should not be used in complementary foods. A new form of elemental iron (atomized iron) appears promising and is already being used. However, it should be evaluated for efficacy before recommending its continued use (10 ). The presence of inhibitors and enhancers should be critically assessed to ensure bioavailability. EDTA and ascorbate act as enhancers and have additive effects. Bioavailability studies are crucial in the selection of fortificant for specific complementary foods but do not ensure effectiveness of the fortified food product. Choice of iron fortificant should be based on compatibility and bioavailability within the specific food matrix. Ferrous sulfate, fumarate and electrolytic iron are the better choices, provided that the food matrix, packaging and storage conditions are compatible for shelf life.

	Wheat and maize flour fortification in the Americas

TOP ABSTRACT INTRODUCTION Iron fortification of staple... Condiments and sauces Complementary foods Wheat and maize flour... General discussion Recommendations LITERATURE CITED

 
For the most part, countries in the Americas are already fortifying with iron wheat flour, maize flour or both. Although the conditions for successful iron fortification programs are at hand, specific problems still exist. First, arbitrary criteria have often been adopted to select iron compounds. Second, fortification programs lack quality assurance systems, and countries have not implemented monitoring and surveillance systems. Third, legislation has not been adjusted in accordance with needed changes to mandate fortification with specific sources, to prevent contraband and to ensure monitoring and quality control. Because of the widespread use of elemental iron powders (reduced and atomized iron) with uncertain bioavailability, these programs are likely to have limited impact. In light of the current situation, a Pan American Health Organization/United States Agency for International Development/International Life Sciences Institute expert group (11 ) recently proposed the following recommendations for iron fortification in the Americas region.

• Wheat flour: fortificant, ferrous sulfate or fumarate or electrolytic iron at twice the amount; level, 45 ppm, but in countries where consumption of wheat products per capita is > 100 g/d, lower levels may be considered.
  
• Maize flour: fortificant, NaFeEDTA, ferrous fumarate; level: at least 5 mg/d of additional iron, but no < 25 ppm (above current level available).
  
• Complementary foods and school programs: fortificant, ferrous sulfate + ascorbic acid or ferrous fumarate + ascorbic acid; level: based on specific requirements for age.
  

	General discussion

TOP ABSTRACT INTRODUCTION Iron fortification of staple... Condiments and sauces Complementary foods Wheat and maize flour... General discussion Recommendations LITERATURE CITED

 
Most efforts in combating iron deficiency using fortification strategies have so far concentrated in overcoming technical barriers. These efforts are necessary but insufficient to ensure impact. Human and material resources have focused mainly on developing the right fortified foods, often neglecting the consideration of practical barriers that are crucial for success. The need for systematic consideration of sound program management, ensuring consumption of fortified foods, strong advocacy and supportive legislation are often overlooked or not addressed in a coherent manner. Once the concept of addressing iron deficiency has been accepted, the process of implementation is advanced with urgency but often in an uncoordinated manner. Different stakeholders make crucial decisions without the participation of the experts, while the experts neglect the practical aspects of program implementation. No formal evaluation is included, and readjustments are not considered. Lack of impact can become a self-fulfilling prophecy given the technical and practical barriers summarized in Figures 2 and 3 .

View larger version (41K): [in this window] [in a new window]   Figure 2. Technical barriers are impediments that need to be considered in the design, formulation, production and evaluation of fortified foods. It requires combined expertise of academic researchers, food technologists, marketing specialists and industry.

View larger version (46K): [in this window] [in a new window]   Figure 3. Practical barriers are impediments for effective implementation of food fortification. Policy aspects include program management, assuring consumption and require advocacy and legislation to support and sustain the programs. Partnerships between governments, industry and nongovernmental organizations are crucial for success.

	Recommendations

TOP ABSTRACT INTRODUCTION Iron fortification of staple... Condiments and sauces Complementary foods Wheat and maize flour... General discussion Recommendations LITERATURE CITED

 
Summarized below are issues and recommendations considered critical by the participants in the session:

• Fortification of staple/complementary foods and condiments can be successfully implemented with proper attention to the selection of fortificants that are bioavailable and with due consideration to the balance of inhibitors and enhancers.
  
• Product research and development, operational research, program planning, communication strategy, advocacy, private/public partnerships and legislation are vital for effectiveness.
  
• Operational research on how to overcome practical barriers for successful implementation of fortification, from which practical lessons can be learned, should be undertaken.
  
• Acknowledging the right to safe and nutritious food is vital. Fortification is one of several approaches to achieve this goal and, specifically, to combat iron deficiency. However, fortification should always be considered as one component of an integrated strategy.
  

	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.

³ Based on presentations by Dr. Omar Dary, Instituto de Nutricion de Centro America y Panama (INCAP), Guatamala; Dr. Erick Boy Gallego, Micronutrient Initiative, Canada; Dr. Richard Hurrell, Swiss Federal Institute of Technology, Switzerland; and Dr. Wilma Freire, Pan American Health Organization.

⁵ Abbreviation used: IDA, iron deficiency anemia.

	LITERATURE CITED

TOP ABSTRACT INTRODUCTION Iron fortification of staple... Condiments and sauces Complementary foods Wheat and maize flour... General discussion Recommendations LITERATURE CITED

 

1. A United Nations Children’s Fund/UNU/World Health Organization/MI Technical Workshop (1999) Preventing Iron Deficiency in Women and Children. Technical Consensus on Key Issues 1999:29-32 International Nutrition Foundation New York, NY. .

2. Ballot, D. E., MacPhail, A. P., Bothwell, T. H., Gillooly, M. & Mayet, F. G. (1989) Fortification of curry powder with Na Fe(III)EDTA: report of a controlled iron fortification trial. Am. J. Clin. Nutr. 49:162-169.[Abstract/Free Full Text]

3. Viteri, F., Alvarez, E., Batres, R., Torun, B., Pineda, O., Mejía, L. A. & Sylui, J. (1995) Fortification of sugar with iron sodium ethylenediaminotretacetate improves iron status in semirural Guatemalan populations. Am. J. Clin. Nutr. 61:1153-1163.[Abstract/Free Full Text]

4. Working Group on Fortification of Salt with Iron (1982) Use of common salt fortified with iron in the control and prevention of anemia: a collaborative study. Am. J. Clin. Nutr. 35:1142-1151.[Free Full Text]

5. Foy, H. (1976) Fortification of salt with iron. Am. J. Clin. Nutr. 29:935-936.[Free Full Text]

6. Yang, X., Tian, Y., Huo, J. & Piao, J. (2001) Iron absorption of NaFeEDTA in soy sauce in Chinese female. Presented at Forging Effective Strategies to Combat Iron Deficiency 2001 Atlanta, GA May 7–9, Abstract M8.

7. Thuy, P. V., Berger, J., Davidsson, L., Khan, N. C., Nga, T. T., Lam, N. T., Mai, T. T., Flowers, C., Nakanishi, Y., Cook, J. D., Hurrell, R. F. & Khoi, H. H. (2001) Regular consumption of NaFeEDTA fortified fish sauce improves iron status of anemic Vietnamese women. Presented at Forging Effective Strategies to Combat Iron Deficiency 2001 Atlanta, GA May 7–9, Abstract M10.

8. Lofti, M., Mannar, V., Merx, R. & Naber-van den Hauvel, P. (1996) Micronutrient Fortification of Foods: Current Practices, Research and Opportunities. The Micronutrient Initiative 1996 International Agriculture Centre Ottawa, Canada. .

9. Hurrell, R. (1999) Iron. Hurrell, R. eds. The Mineral Fortification of Foods 1999:74 Leatherhead International Ltd Leatherhead, England. .

10. The Micronutrient Initiative (2001) Guidelines for Iron Fortification of Cereal Food Staples 2001 Sharing US Technology to Aid in the Improvement of Nutrition Washington, DC. .

11. Pan American Health Organization (2001) Iron Fortification: Guidelines and Recommendations for Latin America and the Caribbean 2001 Pan American Health Organization Washington, DC. .

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