Iron fortification: Its efficacy and safety in relation to infections

Richard F. Hurrell
Abstract
Iron-fortification programs are efficacious and effective provided recent guidelines are followed: the iron compound is carefully chosen and its level in the food is based on target population requirements, the amount lacking in the diet, and the iron bioavailability of the diet and the compound. For monitoring, serum ferritin and transferrin receptor should be included in addition to hemoglobin. Thus, recent studies of provision of ironfortified salt to children in Morocco, rice to children in India, wheat flour to women in Thailand, and fish sauce in Vietnam have demonstrated efficacy and effectiveness. All were in nonmalarious areas, and intestinal parasites were uncommon except in India, where the children were dewormed. C-reactive protein was used to eliminate high ferritin values due to infection. An efficacy study of ironfortified salt in dewormed school-aged children in Cte dIvoire, where the prevalence of malaria parasitemia was 55%, found no change in hemoglobin after 6 months, but serum ferritin increased and transferrin receptor decreased significantly, and the increase in body iron and estimated iron absorbed compared favorably with the results of a study of similar design in Morocco, where the prevalence of iron-deficiency anemia decreased from 30% to 5% after 10 months. Hence, iron-fortification programs in malarious areas may not decrease anemia prevalence but will improve iron status and, presumably, iron-dependent health outcomes. Eight studies in nonmalarious areas, all but one in infants receiving iron-fortified formula, have found no evidence of increase in infections and some evidence of a decrease in respiratory infection. There have been no studies in malarious areas.

Key words: Efficacy, infection, iron fortification,

malaria

Introduction
Designing an efficacious iron-fortified food is a challenge, and there are several pitfalls that could lead to failure. First, the most well-absorbed iron compounds readily cause color and flavor problems in common food-fortification vehicles. This has led to the widespread use of insoluble iron compounds, such as elemental iron and ferric pyrophosphate, which cause little or no sensory changes but which only partially dissolve in the gastric juice and are thus less well absorbed [1]. In addition to this uncertain bioavailability of some common iron-fortification compounds, cereal- and legume-based diets, and some food-fortification vehicles themselves, contain phytic acid/or polyphenol compounds, which are potent inhibitors of iron absorption. Although ascorbic acid, added together with the iron compound, can adequately enhance iron absorption in the presence of phytate and polyphenols [1], it is readily degraded during processing and storage and is not suitable for addition to staple foods and condiments. For such fortification vehicles, sodium iron ethylenediaminetetraacetic acid (NaFeEDTA) may be a useful alternative [2]. Once the iron compound has been chosen, the level of fortification must be defined. This is dependent on dietary iron bioavailability, the bioavailability of the iron compound, the consumption of the food vehicle, and the amount of dietary iron lacking in the target population. The traditional way of fortifying wheat flour has been to restore the iron level in the milled grain to that in the whole grain. This has led to the addition of relatively low levels of elemental iron compounds of lower bioavailability, leading to suggestions that efficacy may not be adequate [3]. A further pitfall in demonstrating the efficacy of iron-fortified foods has been the choice of analytical
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The author is affiliated with ETH Zurich, Institute of Food Science and Nutrition, Zurich, Switzerland. Please address queries to the author: Richard F. Hurrell, Institute of Food Science and Nutrition, Laboratory of Human Nutrition, Schmelzbergstrasse 7, LFV D20, 8092 Zurich, Switzerland; e-mail: richard.hurrell@ilw.agrl.ethz.ch.

Food and Nutrition Bulletin, vol. 28, no. 4 (supplement) 2007, The United Nations University.

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methods with which to monitor iron status. Although hemoglobin alone has often been used to estimate the prevalence of iron-deficiency anemia, the values obtained are overestimations because they fail to take into account other causes of anemia, such as nutritional deficiencies, infectious disorders (particularly malaria and HIV infection), and hemoglobinopathies [4, 5]. Anemia not related to iron deficiency may represent half of anemia in sub-Saharan Africa [6] and will not respond to iron fortification. Alternative methods of determining iron status are available, but some, such as serum ferritin, are greatly influenced by infections and inflammatory disorders [6]. A careful choice of methods of determining iron status with which to monitor efficacy is therefore required. In addition to food composition, subject characteristics also influence the outcome of an efficacy study. Most important are deficiencies of the other micronutrients (vitamin A and riboflavin) and the presence of infections (malaria and intestinal parasites) and inflammatory disorders. Vitamin A is needed for erythropoiesis and for the mobilization of iron from the spleen and liver stores [7]. The erythropoietin gene contains a retinoic acid response element [8, 9], and it was recently demonstrated that vitamin Afortified salt increased erythropoietin formation in mildly vitamin Adeficient Moroccan schoolchildren [10]. Several supplementation and fortification trials have reported vitamin A to increase hemoglobin [11, 12] or to improve iron status indicators [13, 14]. Riboflavin also appears to interfere with iron handling, and several studies in women and schoolchildren have shown improved hematological response to iron supplements when riboflavin deficiency was corrected [15, 16]. It has long been known that iron metabolism is altered during infection and inflammation and that this results in the so-called anemia of chronic disease [17]. The recent discovery of the hormone hepcidin offers some explanation for this phenomenon. Hepcidin is a regulatory hormone secreted by the liver that inhibits both iron absorption and iron release from macrophages [18]. Hepcidin binds ferroportin at the basolateral membrane of the enterocyte, causing its internalization and degradation [19]. This decreases iron transfer into the blood, and more iron is lost in the sloughed enterocytes. Iron deficiency inhibits hepcidin release from the liver, thereby maximizing iron absorption [20, 21]. Inflammatory disorders appear to increase circulatory hepcidin levels via the cytokine interleukin-6 (IL-6) [22]. Inflammation secondary to malaria, intestinal parasites, or other infections would therefore be expected to increase circulating hepcidin levels and block iron absorption and the release of iron stored in macrophages. Several studies have shown that malaria and chronic worm infections increase markers of inflammation [23, 24]. In addition, intestinal worms

such as hookworm can negatively affect iron status by inducing blood loss [25] and impaired iron uptake at the site of absorption due to the presence of worms [26]. Frequent infections and inflammatory disorders might therefore be expected to blunt the efficacy of iron-fortified foods. This review will attempt to demonstrate that, provided current guidelines on iron fortification are followed, and provided there is no widespread infection or deficiency of micronutrients important for iron metabolism, iron-fortified foods will positively impact on iron status. After a discussion on the choice of iron compounds, the new World Health Organization (WHO) guidelines for iron compounds are presented [27], followed by a recommendation on how to set the iron-fortification level and on the methods of determining iron status to monitor iron-fortification efficacy studies. A series of efficacy studies that have followed these guidelines will be presented, including studies on iron-fortified wheat flour, rice, fish sauce, and salt. Only one study was conducted in a malarious region. Finally, the few studies that have monitored infectious morbidity during an iron-fortification intervention are reviewed. None of these studies, however, were conducted in malarious regions.
Choice of iron compounds

The bioavailability of iron compounds depends to a large extent on their solubility in the gastric juice during digestion. On the basis of their solubility, iron compounds have been divided into three categories, which predict their ability to dissolve in the gastric juice and thus their absorption. The three categories are water soluble, poorly soluble in water but soluble in dilute acid, and water insoluble and poorly soluble in dilute acid [3]. Ferrous sulfate is the most common water-soluble compound that readily dissolves in the gastric juice. It has become common to rank the absorption of iron compounds relative to that of ferrous sulfate (relative bioavailability [RBV] = 100). Other water-soluble compounds and compounds readily soluble in dilute acid (ferrous fumarate) also have a RBV of 100. In contrast, compounds poorly soluble in dilute acid (elemental iron and iron phosphates) have a lower and variable RBV (e.g., ferric pyrophosphate, RBV = 25 to 75) [1]. Encapsulation of the water-soluble compounds with hydrogenated oils with a capsule-to-iron compound ratio 60:40 can prevent sensory changes with little or no effect on absorption [28]. Although the use of iron compounds that do not completely dissolve in the gastrointestinal tract has been questioned [3], it has now been shown that by careful selection of the compound and by adjusting the fortification level, some insoluble iron compounds can be used to produce efficacious iron-fortified foods. The use of elemental iron compounds for wheat flour

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TABLE 1. Suggested iron-fortification compounds for different food vehicles Food vehicle Low-extraction (white) wheat flour or degermed corn flour Fortificant Dry ferrous sulfate Ferrous fumarate Electrolytic iron (2 amount) Encapsulated ferrous sulfate Encapsulated ferrous fumarate NaFeEDTA Ferrous fumarate (2 amount) Encapsulated ferrous sulfate (2 amount) Encapsulated ferrous fumarate (2 amount) Dry ferrous sulfate Ferric pyrophosphate (2 amount) Ferrous sulfate plus ascorbic acid Ferric ammonium citrate Ferrous bisglycinate Micronized dispersible ferric pyrophosphate Ferrous fumarate plus ascorbic acid Ferric pyrophosphate (2 amount) plus ascorbic acid Encapsulated ferrous sulfate Ferric pyrophosphate (2 amount) NaFeEDTA NaFeEDTA Ferrous sulfate plus citric acid Ferrous bisglycinate, ferrous lactate Micronized dispersible ferric pyrophosphate Micronized dispersible ferric pyrophosphate Ferrous sulfate Encapsulated ferrous sulfate Ferrous fumarate Electrolytic iron (2 amount) All with ascorbic acid ( 2:1 molar ratio of ascorbic acid:iron) Electrolytic iron (2 amount)

fortification presents the biggest challenge, since five different compounds manufactured by five distinct processes are being used. These are electrolytic, H-reduced, CO-reduced, atomized reduced, and carbonyl. An expert committee, however, concluded that based on current knowledge, only electrolytic iron powder could be recommended as an iron fortificant and that, because it is about half as well absorbed as ferrous sulfate, it should be added to provide double the amount of iron [3]. Similarly, when ferric pyrophosphate was added to salt at double the amount of encapsulated ferrous sulfate (to allow for an RBV of 50), it resulted in similar efficacy [29]. The new WHO guidelines and recommended iron compounds for different foods are given in table 1. In general, the preferred iron compound is ferrous sulfate. If ferrous sulfate is not acceptable organoleptically, then the preferred compounds, in order of preference, are ferrous fumarate, encapsulated sulfate or fumarate, electrolytic iron at double the concentration of ferrous sulfate, and ferric pyrophosphate at double the level of ferrous sulfate. NaFeEDTA is recommended for high-phytate foods and for fish sauce and soy sauce to prevent peptide precipitation. The use of a single RBV value to rank iron compounds has recently been questioned. First, studies in young children in Bangladesh [30] and Mexico [31] reported that ferrous fumarate added to complementary foods was absorbed only 30% to 35% as well as ferrous sulfate, indicating that perhaps children had less gastric acid production than adults. More recently, Moretti et al. [32] reported that the RBV of micronized, dispersible ferric pyrophosphate added to a rice meal varied widely from approximately 15 to 100 according to the iron status of the subjects. Ferrous sulfate absorption was far more sensitive to changes in iron status than that of micronized dispersible ferric pyrophosphate. These studies indicate that the fractional absorption of an iron compound, not its absorption relative to ferrous sulfate, should be used to assure the efficacy of an iron-fortified food.

AU: OK to change to provide double the amount of iron to ... at double the amount. ?

High-extraction wheat flour, corn flour, corn masa flour

Pasta Rice Dry milk Fluid milk

Cocoa products

Salt

Sugar Soy sauce, fish sauce Juice, soft drinks

Bouillon cubes Cereal-based complementary foods

Defining the fortification level

The recommended method for defining the level of micronutrient fortification is to ensure that the consumption of the fortified food shifts the nutrient intake distribution upwards so that the intake of the target nutrient is at least at the level of the EAR (estimated average requirement) [33], for all except 2% to 3% of the population. The method depends on a normal distribution of nutrient requirements and is not recommended for iron, since the iron requirements for menstruating adolescents and women are not normally distributed. The approach recommended for iron is termed the

Breakfast cereals

NaFeEDTA, sodium iron ethylenediaminetetraacetic acid Source: World Health Organization [27].

full probability approach [27]. At a given iron intake, the probability of inadequacy has been calculated for different population groups consuming diets with 5%,

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10%, or 15% estimated iron bioavailability. An example of an iron-intake distribution in menstruating women consuming a diet with 5% iron bioavailability is shown in table 2. For each intake range, a prevalence of inadequacy can be estimated by multiplying the percentage of the women within that range by the probability of inadequacy. The total prevalence of inadequacy is the sum of the individual values, in this example 66.6%. On the basis of the known consumption pattern of the fortified food, the level of iron fortification is adjusted to bring the total prevalence of inadequacy to less than 2.5%. This could be achieved in the current example by providing some 40 mg of extra iron per day. If this iron readily enters the common iron pool (i.e., has an RBV close to 100), then no adjustments are necessary. If the iron compound has a bioavailability less than the estimated bioavailability in the diet, then the level of fortification iron should be increased accordingly. As a rough approximation, it is recommended that electrolytic iron and ferric pyrophosphate be added at double the recommended level, thus compensating for their lower absorption. With better knowledge of fractional absorption from the fortified food, this approach can be further refined.

Choice of methods of determining iron status

As mentioned above, hemoglobin alone is often not a satisfactory outcome measure with which to monitor the impact of iron fortification or supplementation programs. In order to improve and help standardize the monitoring of such programs, after an expert consultation, the World Health Organization and the Centers for Disease Control and Prevention (WHO/ CDC) [34] issued guidelines for assessing the impact of interventions to control iron deficiency. Serum ferritin is selected as the best indicator, and it is recommended that serum ferritin should be measured with hemoglobin in all evaluations. Since serum ferritin is an acute-phase protein that increases during inflammation and infection, measurement of C-reactive protein and 1-acid glycoprotein (AGP) is suggested as a useful way to eliminate subjects with high ferritins due to infection or inflammation. Although its measurement is currently expensive, transferrin receptor, which is little influenced by infection [6], can be used to better define iron-deficiency anemia, and a combination of receptor and serum ferritin can be used to calculate body iron stores [35].

many years, attempts to demonstrate the efficacy of iron-fortified foods have, until recently, met with only mixed success. While early studies in Chile with ironfortified infant formulas [36, 37] and infant cereals [38] demonstrated efficacy, and NaFeEDTA-fortified fish sauce [39], curry powder [40], and sugar [41] modestly improved iron status, iron-fortified salt in India [42] and iron-fortified wheat flour in Sri Lanka [43] did not impact on hemoglobin concentrations. In recent years, however, with more rigorous study design and a better choice of iron status indicators, efficacy studies have clearly demonstrated improved iron status in children or young women fed iron-fortified wheat flour, salt, fish sauce, and rice. All studies have used a randomized, double-blind, controlled design, and some have preselected subjects with iron deficiency or iron-deficiency anemia. The fortification levels were chosen carefully based on current iron intake, iron requirement, intake of food vehicle, bioavailability of the regular diet, and bioavailability of the iron-fortification compound. Most importantly, the studies used a battery of iron status measures, including hemoglobin, serum ferritin, transferrin receptor, zinc protoporphyrin (ZPP), and C-reactive protein. Although there are no real effectiveness studies monitoring the iron status of populations consuming iron-fortified foods introduced onto the commercial market, some study designs are close to that of an effectiveness study.

TABLE 2. Example of calculations to estimate the prevalence of inadequate intakes for menstruating women consuming a diet with 5% average iron bioavailability % of menstruating women with intake in this range 2 10 10 10 15 20 10 8 5 5 3 2 0 0 Probability of inadequacy 1.00 0.96 0.93 0.85 0.75 0.65 0.55 0.45 0.35 0.25 0.15 0.08 0.04 0 Prevalence of inadequacy (%)a 2.0 9.6 9.3 8.5 11.3 13.0 5.5 3.6 1.8 1.3 0.5 0.2 0 0

Iron intake (mg/day) < 15.0 15.016.7 16.718.7 18.721.4 21.423.6 23.625.7 25.727.8 27.830.2 30.233.2 33.237.3 37.345.0 45.053.5 53.063.0 > 63.0
a.

Efficacy and effectiveness of iron-fortified foods

Although iron fortification has been practiced for

Overall prevalence of inadequacy 66.6% Source: World Health Organization [27].

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Salt

Two studies in northern Morocco have demonstrated the usefulness of salt as a vehicle for iron fortification. This part of Africa has no malaria and a low prevalence of intestinal parasites. In the first study [44], salt was fortified with encapsulated ferrous sulfate at 1 mg of iron per gram. The target group was school-aged children who had a daily iron intake of 9 to 15 mg and a daily salt intake of 7 to 12 g. The level of fortification assumed that the normal diet, based on wheat flour bread, fava beans, chick peas, and olives, had a 5% iron bioavailability. The salt was distributed monthly at the household level and added to common foods (mainly bread). Two groups of 80 children 6 to 15 years of age, receiving either the iron-fortified or the control salt, were followed for 40 weeks. Hemoglobin, serum ferritin, transferrin receptor, and ZPP were measured at baseline, 20 weeks, and 40 weeks. Iron-deficiency anemia was defined as low hemoglobin and two out of three iron status parameters outside the normal range. The prevalence of iron-deficiency anemia fell from 35% at baseline to 8% at 40 weeks (p < .001), with no change in the control group. Because the encapsulated ferrous sulfate turned the salt slightly yellow in the wet season, a second fortified salt was developed with finely ground ferric pyrophosphate [29]. Since this compound is about half as well absorbed as ferrous sulfate, the fortification level was increased to 2 mg of iron per gram. As before, the salt was provided monthly at the household level, added to the common foods, and fed for 10 months to two groups of 80 children 6 to 15 years of age in a randomized, double-blind, controlled design. Hemoglobin, serum ferritin, transferrin receptor, and ZPP were measured at 0.5 and 10 months, and iron-deficiency anemia was defined as before. The prevalence of iron-deficiency anemia fell from 30% at baseline to 5% at 10 months (p < .001), with no change in the control. Although the study was described by the authors as an efficacy study, the intake of the fortified salt was not controlled, and the design approaches that of an effectiveness study.
Fish sauce

blind, controlled study in two groups of approximately 60 anemic women consuming 9 mg of iron per day from a rice-based diet estimated to have moderate (10% to 15%) iron bioavailability. The fish sauce was fortified with NaFeEDTA at 1 mg iron/mL, and 10 mL was fed six times per week at lunch with a rice (or noodle) and vegetable meal. The women were factory workers and received their meal in a supervised setting. Hemoglobin, serum ferritin, and transferrin receptor were measured at baseline, 3 months, and 6 months, and iron-deficiency anemia was defined as low hemoglobin plus serum ferritin or transferrin receptor outside the normal range. The prevalence of iron-deficiency anemia fell from 70% at baseline to 20% at 6 months (p < .0001), with little or no change in the control group. In the subsequent effectiveness trial, the fish sauce was provided free of charge for 18 months to all households in 21 villages in the Red River Delta region of Vietnam. The villages were randomly assigned to the fortified sauce (11 villages) or the control sauce (10 villages). The sauce was fortified with NaFeEDTA at 0.5 mg of iron per milliliter. Hemoglobin and serum ferritin were measured at baseline and at 6, 12, and 18 months in two groups of 288 women. The prevalence of iron deficiency (serum ferritin < 12 g/L) in the women receiving the fortified sauce decreased from 22% at baseline to 4% at 18 months (p < .0001), and the prevalence of anemia fell from 25% to 8.5% (p < .02) over the same period. Hemoglobin and serum ferritin values in the control group did not change.
Wheat flour

The International Life Sciences Institute (ILSI) fish sauce studies in Vietnam are a classic example of how to develop an iron-fortified food. First, sensory studies demonstrated that NaFeEDTA was the only iron compound that gave an acceptable product and did not precipitate the fish sauce peptides. Stable isotope studies, indicating good absorption from rice-based meals [45], then preceded both efficacy [46] and effectiveness trials [47]. The efficacy study [46] was a randomized, double-

A recent efficacy study [48] was performed in 330 Thai women with low iron stores (serum ferritin < 25 g/L) randomly assigned to one of four groups who consumed snacks made from wheat flour fortified with electrolytic iron, H-reduced iron, ferrous sulfate, or no iron. The women worked in clothing factories and were fed the snack fortified with 12 mg of iron in a supervised setting at break time for 35 weeks. Hemoglobin, serum ferritin, and transferrin receptor were measured at baseline and 35 weeks. Body iron was calculated as described by Cook et al. [35]. At baseline, mean body iron in the different groups ranged from 1 to 1.5 mg/ kg. At 35 weeks, mean body iron was increased to 5.3 mg/kg in the ferrous sulfate group (p < .01), 4.2 mg/kg in the electrolytic iron group (p < .01), and 3.2 mg/kg in the H-reduced iron group (p < .01), with no significant change in the control group. The relative efficacy of electrolytic iron compared with ferrous sulfate was 79%, and the relative efficacy of H-reduced iron was 49%. The lower absorption of these elemental iron compounds should thus be taken into account when defining the fortification level of wheat flour.

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Because rice is usually consumed as intact grains, fortification with micronutrients is more difficult. Several iron-fortification technologies, including coating and extrusion of an iron-fortified premix, have been reported [49, 50], although to date none has been established on a large scale. The premix is diluted at a specific level with normal rice. Recently Moretti et al. [51] have reported an efficacy trial from Bangalore, India, where iron-fortified rice fed in a school lunch program was combined with deworming as a strategy to combat iron deficiency. In a 7-month, double-blind trial, iron-depleted 6- to 13-year-old children (N = 184) were randomized to receive a control nonfortified rice meal 6 days per week or the same meal fortified with 20 mg of iron as finely ground ferric pyrophosphate. The iron compound (10 mg iron/g) was contained in extruded artificial rice grains that were mixed at a 1:50 ratio with local rice. The children were dewormed at baseline and again at 3.5 months. About 80% of the children had iron deficiency at baseline, including around 30% with iron-deficiency anemia. The results are summarized in table 3. Although hemoglobin did not increase in the dewormed children consuming the fortified rice, there were significant increases in serum ferritin and body iron stores and a significant decrease in transferrin receptor. There were also significant changes in serum ferritin, transferrin receptor, and body iron stores in the dewormed control group, but for each parameter the change in this group was significantly less than for the dewormed children
TABLE 3. Indicators of iron status in dewormed Indian children fed iron-fortified or control rice Indicator Hemoglobin median SD (g/L) Treatment group Ironfortified Control Baseline 121 12a 121 13a 16.8 17a 15.4 13a 9.2 3.9a 8.7 3.2a 1.2 4.0a 0.9 3.7a 7 mo 119 9a 116 11b 26.3 19b* 17.7 17b 6.1 2.3b* 7.2 3.2b 4.1 3.4b** 2.0 4.2b

receiving the fortified rice. The increase in body iron between baseline and 7 months in the dewormed children receiving the fortified rice (2.7 mg/kg body weight) was significantly greater (p < .01) than the increase in the dewormed control children (1.2 mg/ kg body weight). It was somewhat surprising that the median hemoglobin level did not increase in the children consuming the iron-fortified rice. However, this could be explained by the relatively high infection rates observed. In contrast to the study in Morocco [29], where the prevalence of elevated C-reactive protein was only 4% to 6%, in Bangalore elevated C-reactive protein ranged between 8% and 20% at the different time points. This was due to a range of minor diseases and illnesses (table 4). There was no malaria. Morbidity in both study groups was assessed at weekly intervals. The children were asked by the study monitors to identify diseases or illnesses from a list and to quantify their severity by estimating the number of days they were affected by them. The results are shown in table 4. There was no significant evidence for an effect of iron fortification on the frequency and/or severity of infectious diseases, as measured by the questionnaire (p = .38).

Efficacy study with iron-fortified salt in Cte dIvoire

As a follow-up to the two highly successful efficacy studies with iron-fortified salt in Morocco [29, 44], a similar study was performed in Cte dIvoire, in an area with a known high prevalence of malaria and intestinal
TABLE 4. Self-reported morbidity in children fed ironfortified ricea Disease or sickness Fatigue Cold Fever Diarrhea Vomiting Stomach pain Ear pain Skin problem Eye infection Measles Throat pain Other Total Ironb 263 1,167 680 94 147 601 165 19 79 24 171 214 3,624 Control 210 1,175 734 184 194 692 207 47 178 9 107 254 3,991

Serum ferritin Irongeometric mean fortified SD (g/L) Control Transferrin recep- Irontor arithmetic fortified mean SD Control (mg/L) Body iron stores arithmetic mean SD (mg/kg) Ironfortified Control

Means within a row not sharing a common letter are significantly different (p <.001). *Significantly different from control (p < .05). **Significantly different from control (p < .01). Source: Moretti et al. [32].

a. The numbers represent the sum of the days affected by the specific disease or sickness. b. With a univariate general linear model, there was no significant evidence that iron had an effect on the prevalence of infectious diseases (p = .380). Source: Moretti et al. [32].

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parasites [52]. Malaria prevalence was reported to be 55%, elevated C-reactive protein 11%, and riboflavin deficiency 66%. Most children, however, had adequate vitamin A status. The study was a 6-month, doubleblind study in two groups of 60 schoolchildren 6 to 15 years of age with iron deficiency or iron-deficiency anemia. On their normal diet of plantains, rice, yams, and smoked fish, the children were estimated to have an iron intake of 10 mg/day. The salt was fortified at 3 mg iron/g with finely ground ferric pyrophosphate so as to provide 10 mg of extra iron per day in 3 to 4 g of salt. The salt was distributed to households and used mainly for sauce preparation. Unlike in Morocco, the children were treated for worms at baseline and 4 months. The results are shown in table 5. As in the Bangalore study [51], hemoglobin did not increase in the dewormed children fed the iron-fortified or the control salt. However, despite the high level of infections, as indicated by the high range in serum ferritin, the iron-fortified salt coupled with deworming resulted in a useful increase in serum ferritin (p < .05) and body iron (p < .001) and a decrease in transferrin receptor (p < .05). Deworming alone had no influence on the serum ferritin and transferrin receptor values. At 6

months, only the mean transferrin receptor value significantly differed in the dewormed children receiving the iron-fortified salt and those receiving the control salt. Interpretation is complicated because there was no randomization at baseline. For practical reasons, children were fed the control salt in two schools and the fortified salt in two other schools. Over a relatively short period, therefore, a combined deworming and iron-fortification program usefully improved iron status without influencing hemoglobin. Iron fortification plus deworming increased serum ferritin and iron stores and decreased transferrin receptor to a greater extent than deworming alone. The question now arises whether the efficacy of the iron-fortified salt in Cte dIvoire was decreased due to malaria, widespread infection, and riboflavin deficiency. In an attempt to answer this question, table 6 compares the change in iron status parameters from the similar saltfortification trial in school-aged children in Morocco [29] with that in Cte dIvoire [52]. In these studies, both salts were fortified with finely ground ferric pyrophosphate. The dietary iron bioavailability in Morocco was estimated at 5% and that in Cte dIvoire (low in phytate, high fish) at 10% to 15%. The major difference between the two sets of results is that after 5 months,

TABLE 5. Iron status of dewormed, Ivorian children at 6 months compared with Moroccan children at 5 months, both fed salt fortified with finely ground ferric pyrophosphate Indicator Hemoglobing/L Serum ferritin g/L Transferrin receptormg/L Body iron storesmg/kg Treatment group Iron-fortified Control Iron-fortified Control Iron-fortified Control Iron-fortified Control Cte dIvoire Baseline 117 (13) 112 (13) 48 (9397) 58 (10472) 9.2 (4.513.9) 9.1 (3.722.0) 4.6 (2.7) 5.5 (2.9) 6 mo 117 (12) 113 (11) 63 (6200)* 61 (11500) 8.2 (3.016.1)* 9.2 (4.716.6) 5.9 (2.7)** 5.6 (3.1) Baseline 113 (10) 116 (9) 15.5 (6.4, 28.1) 15.2 (7.1, 25.9) 7.7 (3.0) 7.5 (2.4) 1.26 (4.0) 1.23 (2.64) Morocco 5 mo 126 (10)** 116 (11) 29.8 (13.3, 78.5)** 19.0 (7.3, 38.2) 6.1 (1.7)** 7.0 (1.9)* 4.34 (2.48)** 2.21 (2.79)*

Significantly different from baseline (* p < .05, ** p < .01). Significantly different from control (p < .05). Source: Wegmller et al. [52] (Cte dIvoire), Zimmermann et al. [29] (Morocco).

[AU: For all values, please indicate whether mean, median, SD, range, etc. Compare table 3] TABLE 6. Influence of iron-fortified foods on infectious morbidity Episodes of infection/child-year Publication Brunser et al. [60] Power et al. [59] Javaid et al. [55] Hemminki et al. [61] Singhal et al. [62] Iron 256/57 469/53 432/58 504/164 889/122 Control 254/73 460/47 189/28 521/158 2001/248 Incidence rate ratio (95% CI) 1.29 (1.081.54) 0.90 (0.791.03) 1.10 (0.931.32) 0.94 (0.821.06) 0.91 (0.840.98)

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hemoglobin increased significantly in the Moroccan children, whereas in the Cte dIvoire children at 6 months there was no change in hemoglobin. The decrease in transferrin receptor was also slightly greater in the Moroccan children, and the gain in body iron at 5 months was threefold higher than that observed in the children from Cte dIvoire (who had additionally been dewormed). However, this could perhaps be explained by a twofold greater intake of fortification iron in Morocco: 20 mg/day compared with 10 mg/ day in Cte dIvoire. It should also be stressed that most iron in Morocco was added to bread, whereas in Cte dIvoire it was added to sauces. When absorption was calculated based on body iron increase compared with iron intake, 2% absorption was estimated for the Moroccan children [29] and 3% to 3.5% for the Ivorian children [52]. In conclusion, provided that fortification guidelines are carefully followed, iron-fortified foods are an efficacious and effective way to improve iron status in women and children in nonmalarious areas. In malarious areas or in areas of high infection, hemoglobin is more resistant to change, and iron-fortification programs may not decrease the prevalence of anemia or iron-deficiency anemia. However, iron status does improve even in malarious areas, and there is no clear evidence of a blunted response.

Effect of iron-fortified foods on the incidence of infectious morbidity in children

Two recent reports have comprehensively reviewed the influence of iron-fortified foods on infectious illness in children [53, 54]. In both reviews, the much smaller number of iron-fortification studies were analyzed together with the iron-supplementation studies. No further studies, apart from that of Moretti et al. [51], have been reported since these reviews, and none of the studies were carried out in malarious areas. Oppenheimer [53] included five iron-fortification studies in his evaluation. All had reported the incidence of infection in nonmalarious areas and involved the feeding of infants with iron-fortified infant formulas or iron-fortified complementary food [55]. Mackay [56] supplied 50 to 100 mg iron/day in infant formula and reported a fourfold decrease in respiratory infections during the winter months, but no effect in the summer months and no effect on diarrhea. In a similar 18-month study in the United States with formulas

containing 10 mg iron/L, Andelman and Sered [57] also reported an almost twofold decrease in respiratory infections. The three other studies followed infants fed infant formulas in Chile [58] and South Africa [59] or an infant cereal in Pakistan [55] and found no influence of iron fortification on the incidence of diarrhea or respiratory infections (the relative risk for iron vs. placebo ranged from 0.81 to 1.05). Oppenheimer [53] concluded that, although there was a strong case to support iron fortification of infant formula, there was no evidence that iron fortification increases infectious morbidity. In their analysis, Gera and Sachdev [54] identified 47 randomized, controlled trials of iron supplementation or iron fortification that were potentially eligible for inclusion; however, only 29 met their inclusion criteria, and only 5 of these studies had administered iron-fortified foods. Three studies included by Oppenheimer [53] were not retained; however, an additional three studies were included. All followed infants (6 to 10 months of age) were fed iron-fortified infant formulas (6.5 to 12 mg iron/L) in Chile [60], Hungary [61], and the United Kingdom [62] for a period of 6 to 10 months. The results of these studies are summarized in table 6. The incidence rate ratio varied from 0.91 to 1.29. Only Brunser et al. [60] in Chile reported that the incidence of diarrhea was higher (p < .025) in infants receiving the iron-fortified formula. The other four studies found no difference in diarrheal incidence with iron fortification. The same four studies also evaluated respiratory tract infections; according to Gera and Sachdev [54], there was evidence of a protective effect of the ironfortified formulas on the incidence of respiratory infections. The incident rate ratio was 0.92 (95% confidence interval [CI], 0.86 to 0.98; p = .02). The overall conclusion of Gera and Sachdev [54] was that oral supplementation with medicinal iron increased the incidence of diarrhea in children (incidence rate ratio, 1.11; 95% CI, 1.01 to 1.25; p = .04). However, as there was a near absence of an effect of iron-fortified foods, they speculated that because the lower dose in iron-fortified foods was closer to the physiologic situation, food fortification could be the safest public health intervention. It can be concluded that the consumption of ironfortified infant foods in nonmalarious areas does not increase the incidence of infectious morbidity; however, no conclusion can be made with respect to their safety in malarious areas, since no studies have been reported.

References
1. Hurrell RF. Fortification: Overcoming technical and practical barriers. J Nutr 2002;132(4 suppl):806S12S. 2. Bothwell TH, MacPhail AP. The potential role of NaFeEDTA as an iron fortificant. Int J Vitam Nutr Res 2004;74:42134. 3. Hurrell R, Bothwell T, Cook JD, Dary O, Davidsson L,

Iron fortification

S593
A, Ward DM, Ganz T, Kaplan J. Hepcidin regulates cellular iron efflux by binding to ferroportin and inducing its internalization. Science 2004;306:20903. Nicolas G, Chauvet C, Viatte L, Danan JL, Bigard X, Devaux I, Beaumont C, Kahn A, Vaulont S. The gene encoding the iron regulatory peptide hepcidin is regulated by anemia, hypoxia, and inflammation. J Clin Invest 2002;110:103744. Nemeth E, Valore EV, Territo M, Schiller G, Lichtenstein A, Ganz T. Hepcidin, a putative mediator of anemia of inflammation, is a type II acute-phase protein. Blood 2003;101:24613. Nemeth E, Rivera S, Gabayan V, Keller C, Taudorf S, Pedersen BK, Ganz T. IL-6 mediates hypoferremia of inflammation by inducing the synthesis of the iron regulatory hormone hepcidin. J Clin Invest 2004;113:12716. Mansor SM, Molyneux ME, Taylor TE, Ward SA, Wirima JJ, Edwards G. Effect of Plasmodium falciparum malaria infection on the plasma concentration of alpha 1-acid glycoprotein and the binding of quinine in Malawian children. Br J Clin Pharmacol 1991;32:31721. Filteau SM, Morris SS, Abbott RA, Tomkins AM, Kirkwood BR, Arthur P, Ross DA, Gyapong JO, Raynes JG. Influence of morbidity on serum retinol of children in a community-based study in northern Ghana. Am J Clin Nutr 1993;58:1927. Pawlowski ZS, Schad GA, Stott GJ. Hookworm infection and anaemia. Approaches to prevention and control. Geneva: World Health Organizaion, 1991. Bothwell TH. Iron balance and the capacity of regulatory systems to prevent the development of iron deficiency and overload. In: Hallberg L, Asp N-G, eds. Iron nutrition in health and disease. London: John Libbey & Co, 1996. World Health Organization. Guidelines on food fortification with micronutrients. Geneva: WHO, 2006. Zimmermann MB. The potential of encapsulated iron compounds in food fortification: A review. Int J Vitam Nutr Res 2004;74:45361. Zimmermann MB, Wegmueller R, Zeder C, Chaouki N, Rohner F, Saissi M, Torresani T, Hurrell RF. Dual fortification of salt with iodine and micronized ferric pyrophosphate: A randomized, double-blind, controlled trial. Am J Clin Nutr 2004;80:952-9. Sarker SA, Davidsson L, Mahmud H, Walczyk T, Hurrell RF, Gyr N, Fuchs GJ. Helicobacter pylori infection, iron absorption, and gastric acid secretion in Bangladeshi children. Am J Clin Nutr 2004;80:14953. Perez-Exposito AB, Villalpando S, Rivera JA, Griffin IJ, Abrams SA. Ferrous sulfate is more bioavailable among preschoolers than other forms of iron in a milk-based weaning food distributed by PROGRESA, a national program in Mexico. J Nutr 2005;135:649. Moretti D, Zimmermann MB, Wegmuller R, Walczyk T, Zeder C, Hurrell RF. Iron status and food matrix strongly affect the relative bioavailability of ferric pyrophosphate in humans. Am J Clin Nutr 2006;83:6328. Institute of Medicine. Dietary reference intakes for vitamin A, vitamin K, arsenic, boron, chromium, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and zinc. Washington, DC: National Academy Press, 2002. World Health Organization/Centers for Disease Control

4. 5. 6.

7.

8.

9. 10.

11.

12.

13.

14.

15.

16.

17. 18. 19.

Fairweather-Tait S, Hallberg L, Lynch S, Rosado J, Walter T, Whittaker P; SUSTAIN Task Force. The usefulness of elemental iron for cereal flour fortification: A SUSTAIN Task Force report. Sharing United States Technology to Aid in the Improvement of Nutrition. Nutr Rev 2002; 60:391406. Nestel P. Adjusting hemoglobin values in program surveys. Washington DC: International Nutritional Anemia Consultative Group (INACG), 2002. Lynch SR. The impact of iron fortification on nutritional anaemia. Best Pract Res Clin Haematol 2005;18:33346. Asobayire FS, Adou P, Davidsson L, Cook JD, Hurrell RF. Prevalence of iron deficiency with and without concurrent anemia in population groups with high prevalences of malaria and other infections: A study in Cte dIvoire. Am J Clin Nutr 2001;74:77682. Roodenburg AJ, West CE, Beguin Y, Van Dijk JE, Van Eijk HG, Marx JJ, Beynen AC. Indicators of erythrocyte formation and degradation in rats with either vitamin A or iron deficiency. J Nutr Biochem 2000;11:22330. Okano M, Masuda S, Narita H, Masushige S, Kato S, Imagawa S, Sasaki R. Retinoic acid up-regulates erythropoietin production in hepatoma cells and in vitamin A-depleted rats. FEBS Lett 1994;349:22933. Neumcke I, Schneider B, Fandrey J, Pagel H. Effects of pro- and antioxidative compounds on renal production of erythropoietin. Endocrinology 1999;140:6415. Zimmermann MB, Biebinger R, Rohner F, Dib A, Zeder C, Hurrell RF, Chaoki N. Vitamin A supplementation in children with poor vitamin A and iron status increases erythropoietin and hemoglobin concentrations without changing body iron. Am J Clin Nutr 2006;84:5806. Muhilal, Permeisih D, Idjradinata YR, Muherdiyantiningsih, Karyadi D. Vitamin A-fortified monosodium glutamate and health, growth, and survival of children: A controlled field trial. Am J Clin Nutr 1988;48:12716. Suharno D, West CE, Muhilal, Karyadi D, Hautvast JG. Supplementation with vitamin A and iron for nutritional anaemia in pregnant women in West Java, Indonesia. Lancet 1993;342:13258. Bloem MW, Wedel M, van Agtmaal EJ, Speek AJ, Saowakontha S, Schreurs WH. Vitamin A intervention: Short-term effects of a single, oral, massive dose on iron metabolism. Am J Clin Nutr 1990;51:769. Semba RD, Muhilal, West KP, Winget M, Natadisastra G, Scott A, Sommer A. Impact of vitamin A supplementation on hematological indicators of iron metabolism and protein status in children. Nutr Res 1992;12:46978. Powers HJ, Bates CJ, Prentice AM, Lamb WH, Jepson M, Bowman H. The relative effectiveness of iron and iron with riboflavin in correcting a microcytic anaemia in men and children in rural Gambia. Hum Nutr Clin Nutr 1983;37:41325. Powers HJ, Bates CJ, Lamb WH. Haematological response to supplements of iron and riboflavin to pregnant and lactating women in rural Gambia. Hum Nutr Clin Nutr 1985;39:11729. Lee GR. The anemia of chronic disease. Semin Hematol 1983;20:6180. Ganz T. HepcidinA regulator of intestinal iron absorption and iron recycling by macrophages. Best Pract Res Clin Haematol 2005;18:17182. Nemeth E, Tuttle MS, Powelson J, Vaughn MB, Donovan

20.

21.

22.

23.

24.

25. 26.

27. 28. 29.

30.

31.

32.

33.

34.

S594
and Prevention. Assessing the iron status of populations. Geneva: WHO, 2004. Cook JD, Flowers CH, Skikne BS. The quantitative assessment of body iron. Blood 2003;101:335964. Walter T, Olivares M, Hertrampf E. Field trials of food fortification with iron: The experience in Chile. In: Lnnerdal B, ed. Iron metabolism in infants. Boca Raton, Fla, USA: CRC Press, 1990:12755. Walter T, Pino P, Pizarro F, Lozoff B. Prevention of irondeficiency anemia: Comparison of high- and low-iron formulas in term healthy infants after six months of life. J Pediatr 1998;132:63540. Walter T, Dallman PR, Pizarro F, Velozo L, Pea G, Bartholmey SJ, Hertrampf E, Olivares M, Letelier A, Arredondo M. Effectiveness of iron-fortified infant cereal in prevention of iron deficiency anemia. Pediatrics 1993;91:97682. Garby L, Areekul S. Iron supplementation in Thai fishsauce. Ann Trop Med Parasitol 1974;68:46776. Ballot DE, MacPhail AP, Bothwell TH, Gillooly M, Mayet FG. Fortification of curry powder with NaFe(III)EDTA in an iron-deficient population: Report of a controlled iron-fortification trial. Am J Clin Nutr 1989;49:1629. Viteri FE, Alvarez E, Batres R, Torn B, Pineda O, Meji LA, Sylvi J. Fortification of sugar with iron sodium ethylenediaminotetraacetate (FeNaEDTA) improves iron status in semirural Guatemalan populations. Am J Clin Nutr 1995;61:115363. Sivakumar B, Brahmam GN, Madhavan Nair K, Ranganathan S, Vishnuvardhan Rao M, Vijayaraghavan K, Krishnaswamy K. Prospects of fortification of salt with iron and iodine. Br J Nutr 2001;85(suppl 2):S16773. Nestel P, Nalubola R, Sivakaneshan R, Wickramasinghe AR, Atukorala S, Wickramanayake T, The Flour Fortification Trial Team. The use of iron-fortified wheat flour to reduce anemia among the estate population in Sri Lanka. Int J Vitam Nutr Res 2004;74:3551. Zimmermann MB, Zeder C, Chaouki N, Saad A, Torresani T, Hurrell RF. Dual fortification of salt with iodine and microencapsulated iron: A randomized, doubleblind, controlled trial in Moroccan schoolchildren. Am J Clin Nutr 2003;77:42532. Fidler MC, Davidsson L, Walczyk T, Hurrell RF. Iron absorption from fish sauce and soy sauce fortified with sodium iron EDTA. Am J Clin Nutr 2003;78:2748. Thuy PV, Berger J, Davidsson L, Khan NC, Lam NT, Cook JD, Hurrell RF, Khoi HH. Regular consumption of NaFeEDTA-fortified fish sauce improves iron status and reduces the prevalence of anemia in anemic Vietnamese women. Am J Clin Nutr 2003;78:28490. Van Thuy P, Berger J, Nakanishi Y, Khan NC, Lynch S, Dixon P. The use of NaFeEDTA-fortified fish sauce is an effective tool for controlling iron deficiency in women of childbearing age in rural Vietnam. J Nutr 2005;135:2596601. Zimmermann MB, Winichagoon P, Gowachirapant S, Hess SY, Harrington M, Chavasit V, Lynch SR, Hur-

R. F. Hurrell

35. 36.

49. 50. 51.

37.

38.

39. 40.

52.

53. 54. 55.

41.

42.

43.

56. 57. 58.

44.

45. 46.

59.

60.

47.

61.

48.

62.

rell RF. Comparison of the efficacy of wheat-based snacks fortified with ferrous sulfate, electrolytic iron, or hydrogen-reduced elemental iron: Randomized, doubleblind, controlled trial in Thai women. Am J Clin Nutr 2005;82:127682. Hoffpauer DW. Rice enrichment for today. Cereal Foods World 1992;37:7579. Program for Appropriate Technology in Heath (PATH). The research behind ultra rice. Seattle, Wash, USA: PATH, 2005. Moretti D, Zimmermann MB, Muthayya S, Tnankachan P, Lee TC, Kurpad AV, Hurrell RF. Extruded rice fortified with micronized ground ferric pyrophosphate reduces iron deficiency in Indian schoolchildren: A double-blind randomized controlled trial. Am J Clin Nutr 2006;84:8229 Wegmller R, Camara F, Zimmermann MB, Adou P, Hurrell RF. Salt dual-fortified with iodine and micronized ground ferric pyrophosphate affects iron status but not hemoglobin in children in Cte dIvoire. J Nutr 2006;136:181420. Oppenheimer SJ. Iron and its relation to immunity and infectious disease. J Nutr 2001;131(2S-2):616S33S; discussion 633S5S. Gera T, Sachdev HP. Effect of iron supplementation on incidence of infectious illness in children: Systematic review. BMJ 2002;325:1142. Javaid N, Haschke F, Pietschnig B, Schuster E, Huemer C, Shebaz A, Ganesh P, Steffan I, Hurrel R, Secretin MC. Interactions between infections, malnutrition and iron nutritional status in Pakistani infants. A longitudinal study. Acta Paediatr Scand Suppl 1991;374:14150. Mackay HM. Anemia in infancy: Prevalence and prevention. Arch Dis Child 1928;3:11746. Andelman MB, Sered BR. Utilization of dietary iron by term infants. A study of 1,048 infants from a low socioeconomic population. Am J Dis Child 1966;111:4555. Heresi G, Pizarro F, Olivares M, Cayazzo M, Hertrampf E, Walter T, Murphy JR, Stekel A. Effect of supplementation with an iron-fortified milk on incidence of diarrhea and respiratory infection in urban-resident infants. Scand J Infect Dis 1995;27:3859. Power HM, Heese HD, Beatty DW, Hughes J, Dempster WS. Iron fortification of infant milk formula: The effect on iron status and immune function. Ann Trop Paediatr 1991;11:5766. Brunser O, Espinoza J, Araya M, Pacheco I, Cruchet S. Chronic iron intake and diarrhoeal disease in infants. A field study in a less-developed country. Eur J Clin Nutr 1993;47:31726. Hemminki E, Nemet K, Horvath M, Malin M, Schuler D, Hollan S. Impact of iron fortification of milk formulas on infants growth and health. Nutr Res 1995;15:491 503. Singhal A, Morley R, Abbott R, Fairweather-Tait S, Stephenson T, Lucas A. Clinical safety of iron-fortified formulas. Pediatrics 2000;105:E38.