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Supplement: Forging Effective Strategies to Combat Iron Deficiency

Summary and Recommendations^{1 ,2}

Frederick Trowbridge^*,3 and Reynaldo Martorell

^* Trowbridge & Associates, Inc., Decatur, GA 30033; and Rollins School of Public Health, Emory University, Atlanta, GA 30322

	ABSTRACT

TOP ABSTRACT INTRODUCTION Policy issues Intervention strategies Fortification Supplementation Food-based strategies Public health measures Multiple and integrated... Country-level experiences Communications CONCLUSION AND RECOMMENDATIONS LITERATURE CITED

 
Iron deficiency affects the well being of > 1 billion people worldwide, with a range of adverse health and social consequences, yet efforts to address the problem have had only limited success. To better assess this issue and define more effective strategies, an international conference was convened in Atlanta, GA, in May 2001. Key policy issues discussed included setting a global goal for prevention and control of iron deficiency, building partnerships, and identifying ways to mobilize financial and human resources. The strengths and limitations of specific intervention strategies were discussed including iron fortification of staple foods and condiments, supplementation, dietary diversification, application of biotechnology to increase micronutrient content of staple foods, and public health measures such as infection control and provision of health care services. The importance of utilizing multiple and integrated strategies was emphasized. Representatives from several countries reported successful intervention programs as well as promising results in implementing new strategies. The critical role of effective communications was also emphasized, both to increase awareness of the impact of iron deficiency and to advocate for policy changes and resources to address the problem. The conference concluded with specific recommendations for action.

KEY WORDS: • iron deficiency • iron fortification • iron supplementation

	INTRODUCTION

TOP ABSTRACT INTRODUCTION Policy issues Intervention strategies Fortification Supplementation Food-based strategies Public health measures Multiple and integrated... Country-level experiences Communications CONCLUSION AND RECOMMENDATIONS LITERATURE CITED

 
Iron deficiency affects the health of > 1 billion people worldwide, with a range of adverse health and social consequences, including anemia, reduced work capacity, impaired immune response, delayed development and increased maternal and infant mortality (1 –4 ). Most seriously affected are women and children living in developing countries (5 ,6 ), where traditional diets provide little available iron and where malaria and other infections compound the problem by increasing losses. Significant iron deficiency continues to be observed even in the United States and other developed countries, especially among pregnant women, infants and young children from low-income families.

To better address this critical global health issue, an international conference was held in Atlanta, GA, in May 2001 involving > 200 participants from 45 countries. The central objective of the conference was to focus attention on the urgent need to implement effective strategies to prevent iron deficiency and its health consequences. Although the impact of iron deficiency on health has long been recognized by nutrition and health professionals, efforts to address the problem have been limited by a number of inter-related factors. These factors include low awareness of the problem on the part of the public and policy makers, limited evaluation of program effectiveness to confirm the impact of intervention and identify the key factors associated with program success, and limited financial and human resources to initiate and sustain effective interventions.

The conference brought together key scientists, policy makers, program managers and food industry leaders to discuss these issues and to consider ways to improve global and national strategies. This article summarizes key issues relating to policy development, intervention strategies, communications and research that were discussed at the meeting and presents recommendations for future actions to more effectively address the prevention and control of iron deficiency.

	Policy issues

TOP ABSTRACT INTRODUCTION Policy issues Intervention strategies Fortification Supplementation Food-based strategies Public health measures Multiple and integrated... Country-level experiences Communications CONCLUSION AND RECOMMENDATIONS LITERATURE CITED

 
Several key issues were discussed relating to the development of effective policies at the national and international levels, including setting a global goal for iron deficiency, building partnerships, developing human resources and mobilizing financial resources and support (7 ,8 ).

Setting a global goal.

At the international level, perhaps the most critical issue identified was the need to clarify the global goal relating to iron deficiency. Setting a global goal is essential to motivate political leaders to take action. In forming the global goal, however, several issues arise in regard to defining the appropriate focus for intervention. Should the aim be to address all anemia or to focus on more severe levels in which morbidity and mortality effects are more evident? Should the goal be defined in terms of iron deficiency anemia alone or in terms of all nutritional anemia? Should the goal be stated in terms of anemia or iron deficiency or both? Should specific goals be set for different target populations, such as infants, adolescents or women of reproductive age? These issues are complex, but many conference participants favored a goal that called for reduction of both anemia and iron deficiency and cited target groups including both women and children. A suggested goal was to aim for "a substantial reduction in anemia and iron deficiency in children and women by 2010."

Building partnerships.

If iron deficiency is to be addressed effectively, it will be essential to adopt policies that promote the development of partnerships among international agencies, governments and the food industry, at both national and international levels. International agencies will need to coordinate their efforts so that the resources allocated in a given region or country are complementary and supportive of those of other agencies. Governments must develop legislation and regulations that make it feasible and economically profitable for food companies to invest in the development and marketing of iron-fortified products adapted to the food preferences of specific populations. Food companies must be ready to join in partnership with government efforts to implement and sustain intervention efforts.

Mobilizing resources.

Governments, especially in developing countries, must deal with severe economic constraints as they set development priorities. In this setting, how can policy makers be convinced to position iron deficiency high enough among competing priorities so that it receives adequate support? Many conference participants pointed to the need for more effective communication and advocacy to policy makers about the prevalence and impact of iron deficiency and the feasibility of addressing the problem. Also critical are communication efforts directed at the public to raise awareness of the problem and to create a demand for preventive and treatment services.

Building human resources.

A limiting factor to the success of programs in developing countries is often the lack of skilled program managers and health workers. Lack of trained personnel can restrict the ability of country programs to use their limited resources effectively. The keynote speaker and many conference participants pointed to the need to find additional resources to provide training that can improve overall management skills and strengthen the supervision of field workers who implement intervention programs at the community level. It is critical that policy makers recognize the need for human resource development and generate policies that support increased training opportunities.

	Intervention strategies

TOP ABSTRACT INTRODUCTION Policy issues Intervention strategies Fortification Supplementation Food-based strategies Public health measures Multiple and integrated... Country-level experiences Communications CONCLUSION AND RECOMMENDATIONS LITERATURE CITED

 
A wide range of country level experiences were reported at the conference describing successful efforts to increase iron intake through a variety of strategies, including fortification, supplementation, dietary diversification and public health measures. Representatives from many countries described plans that included a combination of strategies tailored to the needs of specific populations. Each of these strategies can contribute to the solution of the problem of iron deficiency, but each strategy also raises key issues and challenges that need to be addressed. The following summarizes some of the key issues identified in relation to each strategy.

	Fortification

TOP ABSTRACT INTRODUCTION Policy issues Intervention strategies Fortification Supplementation Food-based strategies Public health measures Multiple and integrated... Country-level experiences Communications CONCLUSION AND RECOMMENDATIONS LITERATURE CITED

 
Fortification of staple foods and commonly used condiments is a highly promising strategy to address iron deficiency. Many country experiences have demonstrated both the feasibility and effectiveness of this strategy. However, many issues remain to be addressed to realize the full potential of iron fortification (9 ,10 ). One fundamental issue is the limited number of well-designed studies demonstrating the effectiveness of fortification. A number of conference participants pointed to the need to conduct more studies to demonstrate the effectiveness of specific fortificants and food vehicles in reducing iron deficiency. A related issue is the need to better understand both the potential and the limitations of multiple micronutrient fortification. Conference participants pointed out that some interactions (such as with vitamin A) may be positive and enhance the effectiveness of iron fortification, while others (such as with zinc) may be potentially negative. There are also technical problems relating to the instability of some forms of iron in fortified products, potentially leading to color or taste changes that would make the food less acceptable. All of these issues need to be addressed in the context of the specific environment in which a specific fortification strategy is planned.

Other issues relating to fortification include the question of cost and the access of the target population to the fortified product. A number of conference participants pointed out that fortification is relatively inexpensive and generally adds only a small increment to the cost of the fortified food. However, even a small increment in cost that is passed along to the consumer may make the product less appealing to an individual with very limited resources. And, even if the costs were low, fortified products may not be widely available in more remote areas, where iron deficiency is most prevalent. These realities indicate that fortification strategies must be implemented carefully to ensure both the feasibility of getting the fortified product to the consumer and the efficacy of the product once it is consumed.

Infants and toddlers will not be reached effectively by fortification of staple foods, such as wheat flour, because levels of consumption of these products are low. Special efforts are necessary, therefore, to enrich the foods that young children consume. Experiences with fortified complementary foods appear promising but need to be evaluated carefully. An issue in most settings is how to make these products available and affordable to the children of the poor.

	Supplementation

TOP ABSTRACT INTRODUCTION Policy issues Intervention strategies Fortification Supplementation Food-based strategies Public health measures Multiple and integrated... Country-level experiences Communications CONCLUSION AND RECOMMENDATIONS LITERATURE CITED

 
The use of iron supplements is a strategy that has been widely used to provide additional iron to women during pregnancy, but also to increase the iron intakes of children. If the supplements are taken as intended, they can be highly effective. Still, many issues were identified by conference participants that need to be considered (11 ,12 ). Some of the key issues are the cost of the supplements and the difficulty in delivering them regularly to the intended recipients, particularly in rural areas with limited health services. Another major issue is the compliance of the consumer with the recommended dosage and frequency of taking the supplement. Compliance may be affected by side effects or by the perception that the supplements are a treatment and that once one starts to feel better, it is not important to continue taking the pills. Finally, there are important questions about the cost-effectiveness of taking multiple micronutrient supplements. As with fortification, there may be positive interactions between iron and other nutrients as well as negative ones. A pressing research need is the evaluation of efficacy and effectiveness of iron supplementation alone compared with iron plus other nutrients, including commonly consumed multiple micronutrient supplements.

Despite the challenges encountered in implementing supplementation, this strategy undoubtedly has an important role to play in an overall plan for iron deficiency prevention and control. Many populations do have access to sites such as health services or schools where supplements can be distributed in a well controlled manner. The cost of supplements is relatively low when purchased in bulk quantities. Moreover, the possibility of addressing multiple micronutrient needs simultaneously, such as iron and folic acid, makes this strategy appealing.

	Food-based strategies

TOP ABSTRACT INTRODUCTION Policy issues Intervention strategies Fortification Supplementation Food-based strategies Public health measures Multiple and integrated... Country-level experiences Communications CONCLUSION AND RECOMMENDATIONS LITERATURE CITED

 
A variety of food-based approaches to improve iron status were discussed at the conference. One strategy is consumer education to encourage diversification of the diet to include iron-rich foods, including animal products, and foods that contain vitamin C to enhance iron absorption. Other approaches include behavior modification to encourage women to avoid consuming tea with meals because tea can interfere with iron absorption. Other food-based strategies discussed at the conference involve molding agricultural policies to promote crops with higher iron content (7 ). In this regard, an important potential strategy under development is the use of biotechnology to develop varieties of staple crops with increased levels of iron and other micronutrients. Biotechnology may also provide crops with decreased phytate content and, hence, less interference with iron absorption. These innovative approaches hold great promise as additional strategies to address iron deficiency.

	Public health measures

TOP ABSTRACT INTRODUCTION Policy issues Intervention strategies Fortification Supplementation Food-based strategies Public health measures Multiple and integrated... Country-level experiences Communications CONCLUSION AND RECOMMENDATIONS LITERATURE CITED

 
Other strategies that can contribute indirectly to combating iron deficiency include public health measures, such as infection control and provision of health care services. Parasitic infections, such as hookworm, can cause substantial blood loss, and the prevention and treatment of these infections have been demonstrated to improve iron status. Malaria is also a major cause of anemia in some populations, complicating the anemia of iron deficiency. Chronic, recurrent infections can also affect the status of iron and other nutrients. Treatment of these infections in health services or prevention through immunization can have a positive impact. Although these indirect measures to improve iron status were not widely discussed at the conference, they remain important adjuncts to an overall iron deficiency control and prevention strategy.

	Multiple and integrated approaches

TOP ABSTRACT INTRODUCTION Policy issues Intervention strategies Fortification Supplementation Food-based strategies Public health measures Multiple and integrated... Country-level experiences Communications CONCLUSION AND RECOMMENDATIONS LITERATURE CITED

 
Participants recognized that national programs need to adopt a variety of strategies. It should not be an issue of selecting one strategy over another, but of finding cost-effective, mutually reinforcing approaches. Even in highly developed societies such as the United States, where diets are varied and rich in foods with high iron content, multiple strategies are pursued that include supplementation as well as fortification of flours and complementary foods. The success in reducing anemia over time is no doubt due to the combination of strategies and approaches.

	Country-level experiences

TOP ABSTRACT INTRODUCTION Policy issues Intervention strategies Fortification Supplementation Food-based strategies Public health measures Multiple and integrated... Country-level experiences Communications CONCLUSION AND RECOMMENDATIONS LITERATURE CITED

 
It is clear from many reports of country-level experiences that significant successes have been documented and promising new approaches are under development. For example, reports at the conference cited data showing the major impact of the introduction of iron fortified formula on the iron status of infants from low-income families in the United States (13 ). Similarly, a highly effective program of fortification and supplementation has been implemented and sustained over many years in Chile. In China, a promising intervention is being field tested using iron fortified soy sauce, and in Vietnam, recent studies have reported an important potential for fortified fish sauce to impact iron deficiency (14 ). Effective, broad-based community interventions for iron deficiency were reported in Thailand (15 ).

Although significant progress and promising developments were reported, many countries also cited serious barriers that limit program effectiveness. Some barriers are technical in nature, dealing with the lack of adequate science-based information on the effectiveness of different compounds for use in fortification, or the interactions that may occur in processing or storage of fortified foods. Other barriers relate to the limited information on the effectiveness of interventions as they move from initial, carefully monitored trials to larger scale implementation. These barriers indicate the need for ongoing research while at the same time reinforcing efforts to move ahead with intervention strategies based on current knowledge.

	Communications

TOP ABSTRACT INTRODUCTION Policy issues Intervention strategies Fortification Supplementation Food-based strategies Public health measures Multiple and integrated... Country-level experiences Communications CONCLUSION AND RECOMMENDATIONS LITERATURE CITED

 
Many speakers stressed the importance of enhanced communications to support any intervention effort. Of critical importance is communication with consumers, especially women, to inform and encourage them to consume iron-rich foods, follow supplement recommendations, and avoid dietary habits, such as tea drinking with meals, which can reduce the availability of dietary iron. Another critical area of communications is with policy makers to help them appreciate both the scale of the economic and health impact of iron deficiency and the corresponding benefits to be derived from investment of resources for prevention. Finally, there is an urgent need for expanded communication between the public sector and the food industry. It is the food industry that will develop and market the fortified products that are needed to increase iron intakes. Communication is needed to encourage production and marketing of iron-rich and iron-fortified foods at affordable prices and to resolve industry concerns in regard to legislation and regulations that affect their businesses (16 ).

	CONCLUSION AND RECOMMENDATIONS

TOP ABSTRACT INTRODUCTION Policy issues Intervention strategies Fortification Supplementation Food-based strategies Public health measures Multiple and integrated... Country-level experiences Communications CONCLUSION AND RECOMMENDATIONS LITERATURE CITED

 
Multiple and integrated strategies.

Emerging from the conference discussions was a realistic but optimistic assessment of the potential to achieve improved prevention and control of iron deficiency (17 ). Many programmatic and technical challenges exist, but much can be done through the application of current knowledge and experience, while at the same time moving forward with needed research to evaluate program effectiveness and to develop new and improved intervention strategies (18 ).

The most effective approach for dealing with the high prevalence of iron deficiency and anemia characteristic of developing countries is through a combination of multiple and integrated strategies to reach all vulnerable groups. As illustrated in a graphic prepared for the conference (Fig. 1 ), available strategies include: dietary education to improve iron intakes of deficient populations; oral supplementation of vulnerable groups, such as pregnant women and young children; iron fortification of staple foods, such as wheat, rice and corn and of commonly used condiments, such as soy sauce in China and fish sauce in Vietnam; control of infections that further undermine the health of iron deficient persons; and public health measures, such as vaccination and prenatal and infant healthcare to identify and treat deficiencies. In addition, the use of fortified complementary foods for toddlers was presented as a strategy for reaching this vulnerable group.

View larger version (92K): [in this window] [in a new window]   Figure 1. Available strategies for addressing iron deficiency.

Key action steps.

The concluding session of the conference focused on future directions to address iron deficiency more effectively. Broad consensus was reached on key action steps, with support from a wide range of individuals and organizations. The recommended action steps were:

1. Given the extent and severity of iron deficiency and its multiple and serious functional consequences, governments, international and bilateral agencies, non-government organizations, the private sector and civil society need to give a higher priority and resource allotment to the prevention of iron deficiency.
   
2. National governments have an economic, social and moral obligation to implement and support the effective and affordable measures now available for prevention of iron and related micronutrient deficiencies.
   
3. Piecemeal and pilot efforts alone are not sufficient. Nationally appropriate approaches must be multiple, integrating fortification of cereal flours and other foods with preventive multi-nutrient supplementation of vulnerable groups complemented by dietary diversification and public health measures.
   
4. Preventive programs of iron, folate and other appropriate micronutrients should be implemented in all developing countries by fortification of cereal flours and other suitable vehicles and supplementation of infants and children, adolescent girls and women of childbearing age, especially during pregnancy.
   
5. The document "A World Fit for Children," the outcome document of the upcoming United Nations General Assembly Special Session on Children, must include a goal stating the following: "A substantial reduction in anemia including iron deficiency in children and women by 2010."
   

The above recommendations emphasize the urgency felt by the conference participants to raise awareness of the global extent and impact of iron deficiency and to move forward with intervention efforts based on current knowledge and resources. At the same time, further research and technical development are also necessary to place interventions within a science-based framework. There is an urgent need for action. The ongoing social, economic and personal health consequences of iron deficiency are too great to be ignored.

	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 their organizations and do not necessarily reflect those of ILSI CHP.

³ Address correspondence to Dr. Frederick Trowbridge, 2254 Fair Oaks Road, Decatur, GA 30033. E-mail: rtrowbridge{at}mindspring.com.

	LITERATURE CITED

TOP ABSTRACT INTRODUCTION Policy issues Intervention strategies Fortification Supplementation Food-based strategies Public health measures Multiple and integrated... Country-level experiences Communications CONCLUSION AND RECOMMENDATIONS LITERATURE CITED

 

1. Stoltzfus, R. J. (2001) Defining iron deficiency anemia in public health terms: a time for reflection. J. Nutr. 131:565S-567S.[Abstract/Free Full Text]

2. Oppenheimer, S. J. (2001) Iron and its relation to immunity and infectious disease. J. Nutr. 131:616S-635S.[Abstract/Free Full Text]

3. Grantham-McGregor, S. & Ani, C. (2001) A review of studies on the effect of iron deficiency on cognitive development in children. J. Nutr. 131:649S-668S.[Abstract/Free Full Text]

4. Haas, J. D. & Brownlie, I.V.T. (2001) Iron deficiency and reduced work capacity: a critical review of the research to determine a causal relationship. J. Nutr. 131:676S-690S.[Abstract/Free Full Text]

5. Brabin, B. J., Hakimi, M. & Pelletier, D. (2001) An analysis of anemia and pregnancy-related maternal mortality. J. Nutr. 131:604S-615S.[Abstract/Free Full Text]

6. Brabin, B. J., Premji, Z. & Verhoeff, F. (2001) An analysis of anemia and child mortality. J. Nutr. 131:636S-648S.[Abstract/Free Full Text]

7. Hunt, J. (2002) Reversing productivity losses from iron deficiency: the economic case. J. Nutr. 132:794S-801S.[Abstract/Free Full Text]

8. Yip, R. (2002) Prevention and control of iron deficiency: policy & strategy issues. J. Nutr. 132:802S-805S.[Abstract/Free Full Text]

9. Hurrell, R. (2002) Fortification: overcoming technical and practical barriers. J. Nutr. 132:806S-812S.[Abstract/Free Full Text]

10. Uauy, R., Hertrampf, E. & Reddy, M. (2002) Iron fortification of foods: overcoming technical and practical barriers. J. Nutr. 132:849S-852S.[Abstract/Free Full Text]

11. Allen, L. (2002) Iron supplements: scientific issues concerning efficacy, and implications for research and programs. J. Nutr. 132:813S-819S.[Abstract/Free Full Text]

12. Mora, J. O. (2002) Iron supplementation: overcoming technical and practical barriers. J. Nutr. 132:853S-855S.[Abstract/Free Full Text]

13. Yip, R., Binkin, N. J., Fleshood, L. & Trowbridge, F. L. (1987) Declining anemia prevalence among children enrolled in a public nutrition and health program in selected states. JAMA 256:2165.

14. Mannar, V. (2002) Iron fortification: country-level experiences and lessons learned. J. Nutr. 132:856S-858S.[Abstract/Free Full Text]

15. Winichagoon, P. (2002) Prevention and control of anemia: Thailand experiences. J. Nutr. 132:862S-866S.[Abstract/Free Full Text]

16. Griffiths, M. (2002) Communication strategies to optimize commitments and investments in iron programming. J. Nutr. 132:834S-838S.[Abstract/Free Full Text]

17. Martorell, R. (2002) Regional action priorities. J. Nutr. 132:871S-874S.[Abstract/Free Full Text]

18. Trowbridge, F. L. (2002) Prevention and control of iron deficiency: priorities and action steps. J. Nutr. 132:880S-882S.[Abstract/Free Full Text]

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