Time to fortify the world's processed cereals

May 28 2007

Fortifying cereals with a different type of iron supplement reduces anaemia, iron-deficiency anaemia and general iron deficiency children in developing countries, and boosts three major iron status indicators, conclude authors of an Article published in this week's edition of The Lancet.

Sodium Iron EDTA (NaFeEDTA) was found to be much more effective than electrolytic iron, despite the electrolytic form being the most frequently used iron supplement in flour.

Pauline Andang’o, Kenya Medical Research Institute, Centre for Public Health Research, Nairobi, Kenya and Netherlands-based colleagues studied 516 children aged three to eight years from four schools in Marafa, Kenya, some 10% of whom were suffering from anaemia.

Anaemia is defined as a shortage of red blood cells and/or haemoglobin (the oxygen-carrying iron complex) in the blood – one cause of which is iron deficiency.

The authors say: “Fortification of staple cereal flours could be a cost-effective, sustainable way to improve iron status in developing countries.”

The children in the study were divided into four groups and each given the same amount of porridge daily, five times a week. The placebo group had porridge made with unfortified whole maize flour. For the other three groups the porridge was fortified with either high-dose NaFeEDTA (56mg/kg), low-dose NaFeEDTA (28mg/kg) or electrolytic iron (56mg/kg).

The researchers found that, compared to the placebo group, the prevalence of iron-deficiency anaemia dropped by 89% for the high-dose NaFeEDTA group, and by 48% for the low-dose NaFeEDTA group, but there was no evidence for any reduction in the electrolytic iron group.

High-dose NaFeEDTA fortified flour also improved three major iron status indicators in the children taking flour fortified with it – haemoglobin and plasma ferritin concentrations, and amounts of plasma soluble transferrin receptor. Low-dose NaFeEDTA also improved these iron status indicators but to a lesser extent. Electrolytic iron had little effect on these indicators.

Iron can bind to substances that occur naturally in cereals, which in turn prevents the iron being absorbed in the intestines. But the EDTA molecule works by preventing the iron and cereal binding, thus allowing the iron to be absorbed. The authors caution that more work must be done to determine the safe dosage of EDTA – which can in theory induce zinc deficiency, although there is some evidence it can actually improve the absorption of dietary zinc.

The authors conclude: “With continuous iron interventions, iron stores increase rapidly and after two to three years reach plateau values that depend on the absorbable iron that is supplied. Thus we think that continued intervention beyond five months would eventually have led to an even greater discrepancy between the treatment effects associated with NaFeEDTA and electrolytic iron.

“Consumption of whole maize flour fortified with high-dose NaFeEDTA reduced iron deficiency anaemia, iron deficiency, and anaemia in Kenyan children.”

In an accompanying comment, Dr Ted Greiner, a senior nutritionist from the international non-profit health organisation PATH, Washington DC, USA, says: “Governments that mandate fortification will, if they develop capacity for assessment and monitoring, be able to ensure that the right nutrients are added to and maintained in key foods. Food fortification is one of the most sustainable and cost-effective methods available to improve public health.

“These findings turn the tide: it is time to fortify the world’s processed cereals.”