Iron and folate fortification in the Americas to prevent and control micronutrient malnutrition: an analysis

Improvement of Caciotta-like cheese nutritional value by means of enrichment with blackcurrant (Ribes nigrum) and Cornelian cherry (Cornus mas)

Introduction

In this study, we supplemented models of Caciotta-like cheese with blackcurrant (Ribes nigrum) and Cornelian cherry (Cornus mas), as they have a high content of polyphenols, known as phytochemicals associated with health benefits. We evaluated the microbial composition, organoleptic aspects, total phenolic content, and chemical composition of model cheeses enriched with blackcurrant and Cornelian cherry.

Methods

Two different suppliers have been tested: a conventional and an organic one. Two different conditions of preparation (freeze-dried and not freeze-dried) were tested in two different amounts (0.3 and 0.6% dry weight w/v milk volume). Polyphenols were determined using Folin-Ciocalteu reaction and spectrometry; microbial community was determined with selective 24 media and plate counts; composition was determined using nuclear magnetic resonance spectrometry. Organoleptic tests with an untrained panel have been performed.

Results

The enrichments with blackcurrant and Cornelian cherry increased the total polyphenol content in model cheeses, in particular, when blackcurrant and Cornelian cherry were from conventional farming. Blackcurrant-enriched cheeses showed higher counts of lactic acid bacteria, higher levels of organic acids, amino acids, gamma-aminobutyric acid, histamine, and lower amount of monosaccharides deriving from bacterial lactose fermentation in cheese, suggesting a positive effect of blackcurrant compounds on the growth and activity of lactic acid bacteria. The enrichments did not affect the acceptance of the cheese, neither by blackcurrant nor by Cornelian cherry incorporation, with the exception of the appearance.

Discussion

Overall, we showed that cheeses enriched with blackcurrant or Cornelian cherry from conventional farming increased the bioactive potential of the dairy product without having an adverse effect on the microbial community, physiochemical properties, or organoleptic properties.

Food fortification strategies to deliver nutrients for the management of iron deficiency anaemia

A rising trend in the global prevalence of anaemia is still prevailing. To combat micronutrient deficiencies, World Health Organisation/Food Agriculture Organisation (2006) guidelines recommended four chief strategies - supplementation, fortification, nutrition education and dietary diversity. Of the four strategies, food fortification has been considered as the most efficacious and economical approach. However, it is the directives themselves that highlight two major bottlenecks associated with conventional fortification - uniform dissemination of the fortifier in food vehicle that mostly include staple foods, and internal and external compliance evaluation of fortification regulations and standards by the producers. As a result, researchers envisaged a new strategy - Food-to-food fortification that complements conventional fortification. This strategy involves fortification of food vehicles with nutrient-rich food-based fortifiers. The major advantage of utilising food-based fortifiers is that they hold the potential of enhancing the bioavailability of the fortified food and providing additional nutrients and thus, resulting in dietary diversification. It also facilitates the utilisation of underutilised crops as food-based fortifiers. Underutilised crops have been recognised as potential beneficial food source accounting to their nutritional, ecological, and fiscal benefits. This review paper delves into the strengths and shortcomings of conventional iron fortification. It delineates the concept of food-to-food fortification, while precisely discussing about the best practices to be followed to address the possible challenges associated with this strategy. It also promotes the utilisation of underutilised iron rich foods to develop fortified foods and avert global food insecurity. Furthermore, it provides a summary of the studies conducted around the world to develop fortified foods using iron compounds and iron-rich foods, and to investigate their efficacy in managing iron deficiency anaemia.

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.

Anaemia prevalence may be reduced among countries that fortify flour

The effectiveness of flour fortification in reducing anaemia prevalence is equivocal. The goal was to utilise the existing national-level data to assess whether anaemia in non-pregnant women was reduced after countries began fortifying wheat flour, alone or in combination with maize flour, with at least Fe, folic acid, vitamin A or vitamin B12. Nationally representative anaemia data were identified through Demographic and Health Survey reports, the WHO Vitamin and Mineral Nutrition Information System database and other national-level nutrition surveys. Countries with at least two anaemia surveys were considered for inclusion. Within countries, surveys were excluded if altitude was not consistently adjusted for, or if the blood-draw site (e.g. capillary or venous) or Hb quantification method (e.g. HemoCue or Cyanmethaemoglobin) differed. Anaemia prevalence was modelled for countries that had pre- and post-fortification data (n 12) and for countries that never fortified flour (n 20) using logistic regression models that controlled for time effects, human development index (HDI) and endemic malaria. After adjusting for HDI and malaria, each year of fortification was associated with a 2·4 % reduction in the odds of anaemia prevalence (PR 0·976, 95 % CI 0·975, 0·978). Among countries that never fortified, no reduction in the odds of anaemia prevalence over time was observed (PR 0·999, 95 % CI 0·997, 1·002). Among both fortification and non-fortification countries, HDI and malaria were significantly associated with anaemia (P< 0·001). Although this type of evidence precludes a definitive conclusion, results suggest that after controlling for time effects, HDI and endemic malaria, anaemia prevalence has decreased significantly in countries that fortify flour with micronutrients, while remaining unchanged in countries that do not.

Concept of double salt fortification; a tool to curtail micronutrient deficiencies and improve human health status

Fortification of food with micronutrients such as vitamins and minerals is one of the main strategies used to combat micronutrient deficiencies. Fortification in common salt is a fruitful strategy because of the daily consumption of 5-12 g salt per person globally. Therefore double fortification of salt with iodine and iron could be a reasonable approach to prevent both iodine and iron deficiencies. It is reckoned that about two billion people are iodine-deficient worldwide. Iodine deficiency during pregnancy may affect the health status of both mother and fetus and increase infant mortality. Deficiencies of both these micronutrients during childhood affect somatic growth and cognitive and neurological function. Thyroid metabolism is negatively affected by iron deficiency and reduced effectiveness of iodine prophylaxis in areas of endemic goiter. High prevalence of iron deficiency among children may be reduced by the application of effective iodized salt programs. However, ensuring the stability and bioavailability of both iron and iodine as double-fortified salt is difficult. Iodine present in iodide or iodate form in dual-fortified salt is oxidized to free iodine in the presence of ferrous ions and oxygen and consequently loses its characteristics. Moreover, ferrous iron is more bioavailable but is readily oxidized to the less bioavailable ferric form. However, both forms of iron may lead to discoloration of the final product, which can be reduced by providing a physical barrier around the iron. Salt encapsulation is one of the best tools to provide a physical barrier for undesirable reactions and interactions during storage. In this review the concept of dual salt fortification, the impact of fortification on curing various life-threatening maladies, latest assessments of mineral deficiencies and the choice of fortificants are discussed.

Iron deficiency anemia in infancy exerts long-term effects on the tibialis anterior motor activity during sleep in childhood

OBJECTIVES

To explore the eventual connection between iron deficiency anemia (IDA) in infancy and altered leg movements during sleep in a 10-year follow-up study in children who did or did not have IDA in infancy.

SUBJECTS AND METHODS

Polysomnographic studies were performed in 32 10-year-old children (13 females and 19 males) who had IDA in infancy and 26 peers (10 females and 16 males) who were nonanemic controls. The time structure of their polysomnographically recorded leg movements (LM) was analyzed by means of an approach particularly able to consider their quantity, periodicity, and distribution during the night.

RESULTS

All LM indexes and those related to periodic LM during sleep (PLMS) were slightly higher in the former IDA group than in the control group, but not always significant. The Periodicity index during NREM sleep was higher and was reflected by a small but significant increase in PLMS separated by 10-50s intervals. PLMS index tended to be higher in former IDA children than in controls throughout the whole night.

CONCLUSION

The association between IDA in infancy, despite iron therapy, and PLMS in childhood could lead to new research in this area. Indeed, transient infantile IDA, a common nutritional problem among human infants, may turn out to be important for understanding the mechanisms of PLMS or restless legs syndrome, which are common in adulthood.

CE, Leite MS. Prevalência e fatores associados à anemia em mulheres indígenas Suruí com idade entre 15 e 49 anos, Amazônia, Brasil

OBJETIVOS: investigar a prevalência e os fatores associados à ocorrência de anemia em mulheres indígenas Suruí com idade entre 15 e 49 anos. MÉTODOS: estudo transversal realizado a partir de levantamento censitário em 2005 na terra indígena Sete de Setembro, localizada em Rondônia, Brasil. A dosagem de hemoglobina (Hb) foi realizada pelo aparelho β-hemoglobinômetro portátil. Pontos de corte de anemia: Hb <12,0 g/dL nas não gestantes; Hb <11,0 g/dL nas gestantes. Dados demográficos e de status socioeconômico (SSE) foram obtidos por meio da aplicação de questionário padronizado. A primeira etapa da análise estatística incluiu os testes: qui-quadrado; qui-quadrado de tendência linear; t de Student; linearidade e análise de variância. Na segunda etapa, o modelo logístico final foi ajustado. RESULTADOS: a prevalência global de anemia nas não gestantes foi de 67,3% e nas gestantes de 81,8%. A análise multivariada demonstrou que as mulheres com um ou dois filhos anêmicos com idade entre 6 e 35 meses tiveram três vezes mais chances de serem anêmicas; mulheres do estrato SSE baixo apresentaram 3,5 vezes mais chance de serem anêmicas. A chance de uma mulher Suruí do SSE baixo ter anemia aumentou em 26% em relação às do estrato SSE alto. CONCLUSÕES: a anemia é um grave problema de saúde nas mulheres Suruí e é influenciada por características familiares/domiciliares, incluindo descendentes com anemia e condições socioeconômicas. Argumenta-se que medidas de tratamento e prevenção voltadas ao controle da anemia nos Suruí devem considerar tais fatores.

Effectiveness of communication campaign on iron deficiency anemia in Kyzyl-Orda region, Kazakhstan: a pilot study

Background

In 2004, wheat flour fortification (WFF) with iron was implemented in Kazakhstan as a public health strategy to increase the iron intake of all women of childbearing age and of children. In 2003, before starting the flour fortification program, a communication campaign on health education took place in a region with a high prevalence of iron deficiency anemia (IDA). The present study aimed to evaluate the prevalence of anemia, iron deficiency and IDA before and after the campaign. In addition, knowledge about IDA and its prevention, as well as awareness about fortified wheat flour, was assessed.

Methods

The subjects of the study were women aged 15-49 years and children aged 2-14 years. The study was carried out in urban and rural areas of Kyzyl-Orda region in 2003 before (March) and after (December) the campaign. Blood samples were collected in order to measure hemoglobin and serum ferritin. In March 80 women and 57 children in the urban area, and 41 women and 41 children in the rural area, participated in the IDA testing. The corresponding participants in December numbered 62, 52, 52, and 57, respectively. The impacts of the communications and information received by participants during the campaign was surveyed with a questionnaire for 195 women in March and 198 women in December including some who participated in the IDA testing.

Results

In March, the prevalence of anemia was 52.0% among 121 women and 58.1% among 98 children, and those with low iron reserve were 63.6%, 49.1% and IDA 40.5%, 11.0%, respectively. In December, the prevalence of anemia had significantly decreased among rural women (from 65.9% to 48.0%, p < 0.05) and among urban children (from 63.1% to 11.5%, p < 0.001). The prevalence of iron deficiency was significantly reduced among the children (from 51.1% to 24.8%, p < 0.001). IDA prevalence was meaningfully decreased among women in urban and combined areas (from 37.5% to 15.0% and 40.5 to 14.8%, respectively, p < 0.001) and among urban children (from 7.1% to 2.1%, p < 0.05). The surveys found that most women knew about IDA and its prevention and that the numbers were similar both in March and in December. The knowledge of the anti-anemic effect of wheat fortified flour improved significantly over the period of the campaign among women both in urban (from 48.5% to 80.9%, p < 0.001) and rural (from 69.8% to 88.6%, p < 0.001) areas.

Conclusion

The study demonstrated that the communication campaign before implementation of WFF program was effectively carried out, giving a biological impact on hematological indices.

Risk of dementia associated with elevated plasma homocysteine in a latin american population

The relationship between total homocysteine (tHcy) and dementia risk remains controversial, as the association varies among populations and dementia subtypes. We studied a Venezuelan population that has high prevalence of both elevated tHcy and dementia. We tested the hypotheses that (1) elevated tHcy is associated with increased dementia risk, (2) the risk is greater for vascular dementia (VaD) than for Alzheimer's disease (AD), and (3) a history of stroke may partly explain this association. 2100 participants (≥55 years old) of the Maracaibo Aging Study underwent standardized neurological, neuropsychiatric, and cardiovascular assessments. Elevated tHcy was significantly associated with dementia, primarily VaD. When history of stroke and other confounding factors were taken into account, elevated tHcy remained a significant risk factor in older (>66 years), but not in younger (55–66 years) subjects. Ongoing studies of this population may provide insight into the mechanism by which tHcy increases risk for dementia.

Prevalência de anemia em gestantes e a fortificação de farinhas com ferro

Avaliou-se o impacto da fortificação das farinhas com ferro, na prevalência de anemia e concentração de hemoglobina de gestantes. Este estudo transversal retrospectivo foi desenvolvido em um Centro de Saúde Escola do município de São Paulo - SP. Os dados, colhidos de setembro a dezembro de 2006, foram obtidos de 750 prontuários de gestantes distribuídas em dois grupos (não fortificado e fortificado), antes e após a fortificação. Gestantes com nível de hemoglobina inferior a 11g/dl foram consideradas anêmicas. Realizou-se análise de regressão linear múltipla. A anemia afetava 9,2% e 8,6% das gestantes, antes e após a implantação do programa, respectivamente (p>0,05). A análise múltipla não evidenciou diferença estatística na média de hemoglobina entre os grupos (p=0,117). Os resultados indicaram uma baixa prevalência de anemia e médias de hemoglobina similares entre os grupos, fato que provavelmente não permitiu constatar o efeito da fortificação das farinhas.

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.

Fortificación de alimentos con hierro y zinc: pros y contras desde un punto de vista alimenticio y nutricional

La deficiencia nutricional de ciertos minerales como el hierro y zinc afectan a la población a escala mundial con graves efectos sobre la salud dependiendo fundamentalmente del grado de incidencia y de la magnitud de la deficiencia. La fortificación de alimentos ha resultado ser la estrategia más efectiva para corregir esta situación con inconvenientes que radican no solamente en la elección del alimento a utilizar como transporte para dichos nutrientes sino también en la correcta elección del compuesto a utilizar como fortificante ya que en general aquellos compuestos que poseen una adecuada biodisponibilidad presentan cambios en las características sensoriales de los alimentos fortificados poco aceptables para su consumo. Los compuestos inertes, que poseen propiedades optimas desde del punto de vista tecnológico poseen una baja absorción que los convierte en compuestos nutricionalmente poco útiles. En este trabajo se discute con mayor detalle estos aspectos con el fin de llegar a un entendimiento más profundo de la problemática antes mencionada.

Twenty-four-hour motor activity in human infants with and without iron deficiency anemia

Iron deficiency anemia (IDA) is a very common nutritional problem that alters motor activity. The aim of this study was to compare 24-h motor activity in the home in healthy 6-month-old infants with and without IDA. Activity was assessed via actigraphs on the leg during 24 continuous hours in 17 Chilean infants with IDA and 18 with normal hemoglobin levels. All infants were given oral iron, and activity was reassessed at 12 and 18 months. The frequency of movement units per minute was determined for each waking/sleep state during the day and night, and the duration of each state was computed. At 6 months of age, there were no differences between anemic and nonanemic infants in time per state. However, infants with IDA showed an overall increase in motor activity compared to controls. These differences were no longer observed at 12 and 18 months of age. Increased activity during the period of IDA raises the issue of a shared underlying mechanism with restless legs syndrome, a sensorimotor dysfunction where iron deficiency increases the severity of the symptoms and iron supplementation ameliorates them. Due to previous findings of decreased motor activity in the laboratory at 12 months during the waking time surrounding an afternoon nap, we also compared those data to a nap in the home. Infants with IDA were less active in the laboratory than in the home. The home versus laboratory results suggest that contextual factors affect the motor activity of IDA infants to a larger extent than controls.

The role of zinc in the growth and development of children

This review concerns the importance of zinc in growth, development, and cognitive function in children and the deleterious consequences of its deficiency on children's health. Possible strategies to overcome zinc deficiency and the results of some supplementation trials are discussed.

Fortification strategies to meet micronutrient needs: successes and failures

Food fortification is likely to have played an important role in the current nutritional health and well-being of populations in industrialized countries. Starting in the early part of the 20th century, fortification was used to target specific health conditions: goitre with iodized salt; rickets with vitamin D-fortified milk; beriberi, pellagra and anaemia with B-vitamins and Fe-enriched cereals; more recently, in the USA, risk of pregnancy affected by neural-tube defects with folic acid-fortified cereals. A relative lack of appropriate centrally-processed food vehicles, less-developed commercial markets and relatively low consumer awareness and demand, means it has taken about another 50 years for fortification to be seen as a viable option for the less-developed countries. The present paper reviews selected fortification initiatives in developing countries to identify different factors that contributed to their successful implementation, as well as the challenges that continually threaten the future of these programmes. Ultimately, the long-term sustainability of fortification programmes is ensured when consumers are willing and able to bear the additional cost of fortified foods. There has been an enormous increase in fortification programmes over the last couple of decades in developing countries. Considerable progress has been made in reducing vitamin A and I deficiencies, although less so with Fe, even as Zn and folic acid deficiencies are emerging as important public health problems. Food fortification based on sound principles and supported by clear policies and regulations can play an increasingly large role in this progress towards prevention and control of micronutrient malnutrition.

The impact of consuming iron from non-food sources on iron status in developing countries

OBJECTIVE

: To determine the impact of contaminant iron and geophagy on iron intake and status of persons living in developing countries.

DESIGN

: Literature for review was identified by searching Medline and Agricola, from appropriate other texts and from three reports from the Opportunities for Micronutrient Interventions (OMNI) Project of USAID.

SETTING

: The dietary intake of iron by people living in developing countries is generally high but iron deficiency remains prevalent. This apparent paradox is because the iron being consumed is predominantly in the non-haem form, which is poorly absorbed. Some of this non-haem iron is from contamination of food with iron from soil, dust and water; iron leaching into food during storage and cooking; contamination during food processing such as milling; and the practice of geophagy.

RESULTS

: Although the contribution of contaminant iron to overall iron intake is well documented, its absorption and thus its impact on iron status is not. To be available for absorption, contaminant iron must join the common non-haem pool, i.e. be exchangeable. The absorption of exchangeable contaminant iron is subject to the same interactions with other constituents in the diet as the non-haem iron that is intrinsic to food. The limited available evidence suggests wide variation in exchangeability. In situations where a significant fraction of the contaminating iron joins the pool, the impact on iron status could be substantial. Without a simple method for predicting exchangeability, the impact of contaminant iron on iron status in any particular situation is uncertain.

CONCLUSIONS

: Interventions known to increase the absorption of iron intrinsic to foods will also increase absorption of any contaminant iron that has joined the common pool. Any positive effect of geophagy resulting from an increased intake of iron is highly unlikely, due to inhibiting constituents contained in soils and clays. The efficacy of approaches designed to increase the intake of contaminant iron remains encouraging but uncertain. An approach using multiple interventions will continue to be essential to reduce iron deficiency anaemia.