Effectiveness of a large-scale iron fortified milk distribution program on anemia and iron
deficiency in low-income young children in Mexico
Juan A Rivera, Teresa Shamah, Salvador Villalpando, and Eric Monterrubio
American Journal of Clinical Nutrition 2010; 91: 431-439
Wardlaw, F.M., & Hampl J. S. Iron (Fe). In: Perspectives in Nutrition. 7th ed.
Iron (Fe) Found in every body cell (total 5g)
◦ Increased with dietary intake Heme (40% absorption) Non-heme (2-10% absorption)
◦ Increased with Intestinal absorption
◦ Decreased with sloughing of intestinal cells, blood loss
Wardlaw, G.M., & Hampl J.S. Iron (Fe). In: Perspectives in Nutrition. 7th ed.
Hemoglobin & Myoglobin◦ O2 carrying capacity
Immune function Cognitive development Temp regulation Energy metabolism Work performance
Functions of Iron
Centers for Disease Control
Adult ◦ Women 18 mg/day◦ Men: 8 mg/day
Adolescents◦ Girls: 15 mg/ day◦ Boys: 11 mg/day
Children ◦ 7-10 mg/day
Infants ◦ 11 mg/day
◦ 12 mg/day◦ 17mg/day
RDA’s Average Intake
Centers for Disease Control
Increased Iron Needs Decreased Iron Intake and Absorption
•Rapid growth•Pregnancy•Blood loss
• Heavy menstrual periods
• Frequent blood donation• Some stomach and
intestinal conditions (food sensitivity, hookworms)
•Lack of heme iron sources in the diet (e.g., vegetarian diets) •Low absorption
• Taking antacids beyond the recommended dose or medicine used to treat peptic ulcer disease and acid reflux can reduce the amount of iron absorbed in the stomach.
Increased Iron NeedsPremature Babies Miss the most important final weeks to build Fe
storesInfants Born with Fe stores only last for about 6 moChildren and Adolescence Rapid growth Picky eatersWomen MenstruationPregnancy Increased blood volume and needs Blood loss
Centers for Disease Control
Fe Status Indicators Hb Concentration and Hematocrit
◦ Cheap and easy◦ Used for screening for deficiency◦ Measures amount of functional Fe
Serum Ferritin Concentration◦ Closely related to amount of stored Fe in body◦ More expensive◦ Earliest indicator for depleted Fe stores
Transferrin Saturation◦ Measures vacant Fe binding site◦ Changes with infection, age, and time of day
Am J Clin Nutr. 2010; 91(2) 431-439
Fe Deficiency Most common nutritional deficiency around
the world.
Children under age 5 are one of the most affected age groups◦ Peak prevalence occurs at age 12-23 mo
Affects all socioeconomic status◦ 30% in lowest group◦ 17% in highest
Am J Clin Nutr 2010; 91:431-9
What does this mean?“Anemia and Iron Deficiency
is associated with adverse effects on
neurodevelopment”
Am J of Clin Nutr. 1982; 36 (6) 1162-1169
Bioavailability of iron- and copper supplemented milk for Mexican school children
Experimented with ways to fortify milk with trace minerals
Had to use components that didn’t catalyze off-flavors, peroxidize the lipids, and yet still had good bioavailability Ferrous/ cupric chloride salt Ferric/ cupric Lactobionate chelate
Results: Both showed significant increase in Hb Suggested Milk could be used as a vehicle for Fe or
Cu Supplementation At the time of this study, there were no public
health supplementation programs yet in Mexico
Am J of Clin Nutri. 2010; 91 (2) 431-439.
Milk Subsidized Program“Liconsa” Started in 1944 Distributes whole milk at centers through
out the country Children aged 1-11 years old
◦ 400 mL of milk/ day Other family members living in poverty 2002- started fortifying milk
Am J of Clin Nutr. 2010; 91 (2) 431-439
1999 National Nutrition Survey Found that deficiencies were common o Feo vit Co others
At the time of the study served 5 mil peopleo 4.2 mil aged 1-11 year oldso 650, 000 aged 1 – 2 ½ years
Mexican government decided to provide these nutrients in combination with the whole milk
Am J of Clin Nutr. 2010; 91 (2) 431-439
Effective?1st Step Completed a Randomized Clinical
Trial Results: Fortifying Milk was
effected in improving the Fe status of Toddlers
Am J Clin Nutr. 2010; 91 (2) 431-439
Rationale
Did this apply through a Large-Scale Program?
And does improved Fe Status reduce anemia prevalence?
Am J Clin Nutr. 2010; 91 (2) 431-439.
Design & Subjects
Group-Randomized effectiveness trial in children aged 12-30 months
Participants of the Liconsa Program Selected 12 Milk Distribution
Centers Randomly Assigned:
5 Non-Fortified Milk 7 Fortified Milk
Am J Clin Nutr. 2010; 91 (2) 431-439.
Milk Contents
Distinguished by a ‘color band’ on the package Unknown to researchers,
fieldworkers, personnel and program beneficiaries
Mothers received same instructions to reconstitute
Encouraged to feed 200 ml 2x/day
Am J Clin Nutr. 2010; 91 (2) 431-439
Collection Methods Weren’t able to get adequate blood
samples for 1/3 of the participants like they had hoped.
Primary Indicators Fe Deficiency- sTfR Primary Indicator for Anemia-Hb
concentration
Am J Clin Nutr. 2010; 91 (2) 431-439.
Definitions
Fe Deficiency: sTfR >3.3 mg/ L
Anemia: Hb <110 g/L
Mild anemia: Hb 100-109.0 g/L
Moderate anemia: Hb 90-99.9 g/L
Am J Clin Nutr. 2010; 91 (2) 431-439.
Data Collection: Baseline, 6mo, 12mo Questionnaire: housing
characteristics, and possession of household goods
Hb concentration C-Reactive Protein Anthropometric Data
Length/ Height and weight
Am J Clin Nutr. 2010; 91 (2) 431-439.
Data Collection: Monthly
Field worker visited home to ensure compliance
Obtained a food frequency questionnaire
Am J Clin Nutr. 2010; 91(2) 431-439.
Statistical Methods Compared the socioeconomic status of
families at baseline between two intervention groups
Adjusted for cluster effects If something was not normally
distributed Looked at Intervention effects for the 6
and 12 mo age groups Plausible confounders: sex, ages,
socioeconomic status, parent’s schooling, daily milk intake, frequency of respiratory and diarrheal infections.
Am J Clin Nutr. 2010; 91 (2) 431-439.
Results
No statistically significant differences between two baseline groups for: Anemia Fe deficiency Milk intake Anthropometric data Socioeconomic status
Am J Clin Nutr. 2010; 91 (2) 431-439.
Results: Effect on Anemia
Lower prevalence and Larger decline in Fortified Milk group
Am J Clin Nutr. 2010; 91 (2) 431-439.
Effect on Iron Status
Fortified Milk group had a statistically significant decline in Iron Deficiency prevalence
Differences between 6 and 12 month measurements for both groups were not statistically significant
Am J Clin Nutr. 2010; 91 (2) 431-439.
Discussion Determined results “biologically
important” “at these early ages, iron repletion's process
and hematopoiesis during a critical time for brain and mental development, which may have long lasting effects on behavior, learning and mental performance”
Decreases mild-moderate anemia by 36% at 6 mo 57% at 12 mo
Reduced indicators of Fe deficiency
Am J Clin Nutr. 2010; 91 (2) 431-439.
Discussion
Used the distribution centers already in place Could have seen a “floor effect”
Am J Clin Nutr. 2010; 91 (2) 431-439.
Limitations Selection bias through changing
indicators once study began Results from iron deficiency should
be interpreted with caution Different subjects in Fortified and Non-
Fortified groups Limited data was published
Am Academy of Pediactrics. 2001; 107(6)1381-1386.
Iron Deficiency and Cognitive Achievement in School- Aged Children and Adolescents in the United States
National Health and Nutrition Examination Survey Cross sectional survey for children 6-16 year
old (n= 5398) Determined Iron Deficiency and Anemia
using serum ferritin and Hb Compared the Fe status to their
standardized test scores
Results
Used Logistic regression to control for Below average scores Other confounding factors
Found: Lower Math scores were associated
with lower than normal Fe status Elevated Risk for lower scores, even
if only Fe deficient
As working professionals……
Emphasize the importance of Fe at all ages, but especially those with rapid growth Heme vs. Non-Heme
Finding the populations that are known to be at risk for deficiency is important Screen & Intervene
Resources Center for Disease Control. (1998). Morbidity and Mortality Weekly
Report: Recommendations to Prevent and Control Iron Deficiency in the United States. (Vol 47 No RR-3) Atlanta, GA.
Halterman, J. S. et al. Iron deficiency and cognitive achievement among school-aged children and adolescents in the United States. Journal of the American Academy of Pediatrics. 2001; 107 (6) 1381-1386.
Mayo Clinic. Iron Deficiency Anemia. [Accessed 9/1/05] Available from: http://www.mayoclinic.com/health/iron-deficiency-anemia/ds00323.
Rivera, J.A. et al. Effectiveness of a large-scale iron-fortified milk distribution program on anemia and iron deficiency in low income young children in Mexico. Am J Clin Nutr. 2010; 91(2) 431-439.
Wardlaw, G. M., & Hampl J. S. Iron (Fe). In: Perspectives in Nutrition. 7th ed. New York, New York, McGraw Hill. 2007, 428-434.
Rivera, R. et al. Bioavailability of iron- and copper- supplemented milk for Mexican school children. Am J Clin Nutri. 1982; 36 (6). 1162-1169.