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LACK OF EVIDENCE THAT FORTIFICATION IS EFFECTIVE OR SAFE
- COCHRANE REVIEW (gold standard on health evidence)
Peña-Rosas JP, Mithra P, Unnikrishnan B, Kumar N, De-Regil LM, Nair NS, Garcia-Casal MN, Solon JA. Fortification of rice with vitamins and minerals for addressing micronutrient malnutrition. Cochrane Database of Systematic Reviews 2019, Issue 10. Art. No.: CD009902. DOI: 10.1002/14651858.CD009902.pub2
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009902.pub2/full
Finding: Fortification of rice with iron alone or in combination with other micronutrients may make little or no difference in the risk of having anaemia or presenting iron deficiency and we are uncertain about an increase in mean haemoglobin concentrations in the general population older than 2 years of age. Fortification of rice with iron and other micronutrients such as vitamin A or folic acid may make little or no difference in the risk of having vitamin A deficiency or on the serum folate concentration. There is limited evidence on any adverse effects of rice fortification.
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- Umesh Kapil, Neha Sareen Implementation of Double Fortified Salt in India is based on Low Scientific Evidence Indian Journal of Community Health Vol. 26 No. Supp 2 (2014) http://iapsmupuk.org/journal/index.php/IJCH/article/download/476/476
Finding: We have poor scientific evidence on impact of NIN-Double Fortified Salt in improving Hb levels and preventing IDD.
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- NIN study- Prevalence of Iron Deficiency and its Sociodemographic Patterning in Indian Children and Adolescents: Findings from the Comprehensive National Nutrition Survey 2016–18
https://academic.oup.com/jn/article-abstract/151/8/2422/6287924
Findings: Focusing on increasing iron intake alone, without addressing the multiple environmental constraints related to poverty, may not result in intended benefits.
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Anura V Kurpad, Santu Ghosh, et al., Perspective: When the cure might become the malady: the layering of multiple interventions with mandatory micronutrient fortification of foods in India, The American Journal of Clinical Nutrition, Volume 114, Issue 4, October 2021, Pages 1261–1266, https://doi.org/10.1093/ajcn/nqab245
Findings: The layering of food fortifications by the state, with other forms of in-house fortification or supplementation, is a complex interaction of national and transnational stakeholders with different motivations. The local context-specific balance of harms and benefits, as well as ethics, must override all other considerations.
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- Kulkarni B, Peter R, Ghosh S, Pullakhandam R, Thomas T, Reddy GB, Rajkumar H, Kapil U, Deb S, Johnston R, Agrawal PK, De Wagt A, Kurpad AV, Sachdev HS. Prevalence of Iron Deficiency and its Sociodemographic Patterning in Indian Children and Adolescents: Findings from the Comprehensive National Nutrition Survey 2016-18. J Nutr. 2021 May 28:nxab145. doi: 10.1093/jn/nxab145. PMID: 34049401.
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RISKS OF INCREASED IRON STORES IN BODY- DISLIPIDEMIA, OBESITY, HYPERTENSION, MUCOSAL CELL DAMAGE
- Kim, Young-Eun & Kim, Do-Hoon & Roh, Yong-Kyun & Ju, Sang & Yoon, Yeo-Joon & Nam, Ga & Nam, Hyo-Yun & Choi, Jun-Seok & Lee, Jong-Eun & Sang, Jung-Eun & Han, Kyungdo & Park, Yong-Gyu. (2016). Relationship between Serum Ferritin Levels and Dyslipidemia in Korean Adolescents. PLOS ONE. 11. e0153167. 10.1371/journal.pone.0153167.
Findings: Serum ferritin levels were significantly associated with major dyslipidemia parameters, more prominently in boys than in girls, and this association represents a cardiometabolic risk factor.
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- Sachdev HS, Porwal A, Sarna A, Acharya R, Ramesh S, Kapil U, Kurpad AV. Intraindividual double-burden of anthropometric undernutrition and "metabolic obesity" inIndian children: a paradox that needs action. Eur J Clin Nutr. 2021;75:1205-1217.
https://www.researchsquare.com/article/rs-1136688/v1
Findings: High Serum Ferritin is associated with a significant risk for Non Communicable Diseases in adolescents, and this is dependent on the wealth class, and on co-existing prediabetes. This should be considered when evaluating the benefits and harms of enhancing iron intake in anemia prevention programs.
- Elizabeth K Lund, S Gabrielle Wharf, Susan J Fairweather-Tait, Ian T Johnson, Oral ferrous sulfate supplements increase the free radical–generating capacity of feces from healthy volunteers, The American Journal of Clinical Nutrition, Volume 69, Issue 2, February 1999, Pages 250–255, https://doi.org/10.1093/ajcn/69.2.250
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Findings: Unabsorbed dietary iron may increase free radical production in the colon to a level that could cause mucosal cell damage or increased production of carcinogens.
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- Lee DH, Kang SK, Choi WJ, Kwak KM, Kang D, Lee SH, Lee JH. Association between serum ferritin and hypertension according to the working type in Korean men: the fifth Korean National Health and nutrition examination survey 2010-2012. Ann Occup Environ Med. 2018 Jun 11;30:40. doi: 10.1186/s40557-018-0251-y. PMID: 29942520; PMCID: PMC5996563.
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- Kim YE, Kim DH, Roh YK, Ju SY, Yoon YJ, Nam GE, Nam HY, Choi JS, Lee JE, Sang JE, et al. Relationship between serum ferritin levels and dyslipidemia in Korean adolescents. PLoS One. 2016; 11(4): e0153167.
- Findings: Serum ferritin levels were significantly associated with major dyslipidemia parameters, more prominently in boys than in girls, and this association represents a cardiometabolic risk factor.
- Michael B Zimmermann, Christophe Chassard, Fabian Rohner, Eliézer K N'Goran, Charlemagne Nindjin, Alexandra Dostal, Jürg Utzinger, Hala Ghattas, Christophe Lacroix, Richard F Hurrell, The effects of iron fortification on the gut microbiota in African children: a randomized controlled trial in Côte d'Ivoire, The American Journal of Clinical Nutrition, Volume 92, Issue 6, December 2010, Pages 1406–1415, https://doi.org/10.3945/ajcn.110.004564 https://academic.oup.com/ajcn/article/92/6/1406/4597520
Findings: Anemic African children carry an unfavorable ratio of fecal enterobacteria to bifidobacteria and lactobacilli, which is increased by iron fortification. Thus, iron fortification in this population produces a potentially more pathogenic gut microbiota profile, and this profile is associated with increased gut inflammation.
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- Elizabeth K Lund, S Gabrielle Wharf, Susan J Fairweather-Tait, Ian T Johnson, Oral ferrous sulfate supplements increase the free radical–generating capacity of feces from healthy volunteers, The American Journal of Clinical Nutrition, Volume 69, Issue 2, February 1999, Pages 250–255, https://doi.org/10.1093/ajcn/69.2.250
Findings: Unabsorbed dietary iron may increase free radical production in the colon to a level that could cause mucosal cell damage or increased production of carcinogens
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- Ford, E.S., and Cogswell, M.E. (1999). Diabetes and serum ferritin concentration among U.S. adults. Diabetes Care. 1999; 22:1978–1983.
Findings: Earlier analyses of National Health and Nutrition Examination Survey (NHANES) data showed that the risk of diabetes increased by up to 4-fold when otherwise normal individuals in the highest quintile of serum ferritin concentration were compared to those in the lowest quintile [3].
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- Iron metabolism and type 2 diabetes mellitus: A meta-analysis and systematic review https://onlinelibrary.wiley.com/doi/full/10.1111/jdi.13216
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Jiang L, Wang K, Lo K, Zhong Y, Yang A, Fang X, Akezhuoli H, Song Z, Chen L, An P, et al. Sex-Specific Association of Circulating Ferritin Level and Risk of Type 2 Diabetes: A Dose-Response Meta-Analysis of Prospective Studies. J Clin Endocrinol Metab. 2019;104:4539-4551.
Findings: A meta-analysis of 15 studies showed that greater ferritin levels were associated with a greater risk of type 2 diabetes
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- Iron overload is related to elevated blood glucose levels in obese children and aggravates high glucose-induced endothelial cell dysfunction in vitro
Results and conclusion: Increased ferritin levels are related to impaired glucose tolerance and other metabolic disorders in obese children
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- Meng G, Yang H, Bao X, Zhang Q, Liu L, Wu H, Du H, Xia Y, Shi H, Guo X, Liu X, Li C, Su Q, Gu Y, Fang L, Yu F, Sun S, Wang X, Zhou M, Jia Q, Guo Q, Song K, Huang G, Wang G, Wu Y, Niu K. Increased serum ferritin levels are independently related to incidence of prediabetes in adult populations. Diabetes Metab. 2017 Apr;43(2):146-153. doi: 10.1016/j.diabet.2016.07.028. Epub 2016 Nov 11. PMID: 27843075.
Results and conclusion: serum ferritin levels were significantly and linearly related to prediabetes in men, whereas U-shaped relationships were observed between baseline and mean serum ferritin and prediabetes in women
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- Elizabeth A. Hughes, Jeetesh V. Patel, Zosia Bredow, Paramjit S. Gill, Julia Chackathayil, Elif S. Agaoglu, Paul Flinders, Rebecca Mirrielees, "Ferritin as a Risk Factor for Glucose Intolerance amongst Men and Women Originating from the Indian Subcontinent", International Journal of Endocrinology, vol. 2015, Article ID 924387, 6pages, 2015. https://doi.org/10.1155/2015/924387
Results and conclusion: Ferritin levels are positively associated with glucose intolerance in our test groups, independent of gender and Indian or UK lifestyle factors.
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COST EFFECTIVE SUPPLEMENTATION INTERVENTIONS TO COMBAT ANAEMIA
Improving bioavailability of iron in Indian diets through food-based approaches for the control of iron deficiency anaemia
https://www.fao.org/3/y8346m/y8346m06.pdf
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- Delivering sprinkles Plus through the Integrated Child Development Services (ICDS) to reduce anemia in pre-school children in India https://pubmed.ncbi.nlm.nih.gov/23723079/
Results and conclusion: A significant reduction in anemia (50 % to 33 % in boys; p-value <.000; 47.4 % to 34.2 % in girls) was following MNP supplementation. Integration of a flexibly administered MNP supplementation into the ICDS is effective in reducing and treating anemia in children 6 mo to 6 y age.
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Weekly iron folic acid supplementation(wifs)
https://nhm.gov.in/index1.php?lang=1&level=3&sublinkid=1024&lid=388
The Ministry of Health and Family Welfare has launched the Weekly Iron and Folic Acid Supplementation (WIFS) Programme to meet the challenge of high prevalence and incidence of anaemia amongst adolescent girls and boys. The programme has been rolled out in all States/UTs. The programme covers 11.2 crore beneficiaries including 8.4 crore in-school and 2.8 crore out of school beneficiaries.
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Assessment of Weekly Iron-Folic Acid Supplementation with and without Health Education on Anemia in Adolescent Girls: A Comparative Study
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STATE LED HOLISTIC APPROACH TO COMBAT ANAEMIA
In Chhattisgarh :Chief Minister’s Suposhan Abhiyan was started from 02 October 2019 with public cooperation and public participation in the entire state to address malnutrition and anaemia for children of the age group of 0-6 and women aged 15 to 49 years. Subjects have been put on a wholesome nutrient-rich diet. Their meals include sprouted grains, soyabean and peanuts for protein, eggs for B12, jaggery, green vegetables, fruits, and pickles for iron deficiency, and so on.
Success stories by govt shared here: https://cmchhattisgarh.cgstate.gov.in/Suposhan-Abhiyaan
MILLETS AS AN APPROACH TO COMBAT ANEMIA
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Acceptance and Impact of Millet-Based Mid-Day Meal on the Nutritional Status of Adolescent School Going Children in a Peri Urban Region of Karnataka State in India
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6770931/
Conclusion: The study demonstrated three important pieces of evidence: (1) that the introduction of millet-based meals in school feeding programs can significantly improve the nutritional outcome of school going children compared to fortified rice-based meals; (2) that these meals can be enjoyed by the children; (3) that it can be cost effective if millets are given government pricing support as equally as rice.
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KITCHEN GARDENS AS A COST EFFECTIVE SOLUTION TO ANAEMIA
Correlation of Organic Nutrition Kitchen Garden, Awareness of Consumption of Vegetables and Nutritional Deficiencies Anemia
Results and Conclusion: Chichewada group, where participants received deworming with Albendazole 1 tablet at the start of study + motivation for developing Organic Kitchen Garden and awareness about diet and anemia, showed maximum elevation of Hb within three months and this was maintained when the 1 year second follow up was done. The Hb levels of this group were higher than the group that took iron folic acid supplementation.
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IRON KADHAIs AND ANAEMIA
Cooking In Iron Kadhai’s : A Movement Of Women’s Collectives In Jharkhand To Combat Anaemia
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Food prepared in iron cooking pots as an intervention for reducing iron deficiency anaemia in developing countries: a systematic review
https://pubmed.ncbi.nlm.nih.gov/12859709/
Conclusion: The introduction of iron pots or improving their use in communities in developing countries for the preparation of food maybe a promising innovative intervention for reducing iron deficiency and iron deficiency anaemia. Further research is required to monitor the use and effectiveness of this intervention.
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OTHER FOODS WITH POTENTIAL TO ADDRESS IRON DEIFICIENCY ANAEMIA
Guava with an institutional supplementary meal improves iron status of preschoolers: a cluster-randomized controlled trial
Roy Choudhury D, Nair Krishnapillai M, Nagalla B, Vijaya Kankipati R, Ghosh S, Buwade J, Fernandez-Rao S. Guava with an institutional supplementary meal improves iron status of preschoolers: a cluster-randomized controlled trial. Ann N Y Acad Sci. 2021 May;1492(1):82-95. doi: 10.1111/nyas.14556. Epub 2020 Dec 31. PMID: 33385184.
Results and Conclusion: Diversifying a cereal/pulse–based meal with guava increased meal vitamin C content, thereby reducing iron deficiency (ID) and acute respiratory infection related morbidity. This approach represents a valid and scalable strategy to address iron deficiency among young children.
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There exist 68 indigenous varieties of rice with very high (20 - 300 ppm) iron content (Deb et al. 2015; Sen Gupta et al. 2017).
Sen Gupta, S, A. Baksi, P. Roy, D. Deb and T. Pradeep 2017. Unusual accumulation of silver in the aleurone layer of an Indian rice (Oryza sativa) landrace and sustainable extraction of the metal. ACS Sustainable Chemistry and Engineering 5(9): 8310-8315.
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