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JOURNAL OF SCIENCE, Hue University, N0 61, 2010

Panomai N, Sanchaisuriya P, Lowirakorn Department of Nutrition, Faculty of Public Health, University of Khonkaen,Thailand Institute of Tropical Medicine, Charite, University Medicine Berlin, Germany One cost-effective strategy for controlling iron deficiency anemia is the fortification of food. Iron salt fortificants such as NaFeEDTA have the potential to be used widely as an iron fortificant . Milk could be a potentially useful food vehicle for iron fortification programs because of the daily free school milk program in Thailand. Objectives: To investigate the feasibility of iron fortified milk (NaFeEDTA) with a 5 mg iron/sachet/day given to a group of primary school children. Design: One hundred and sixty school aged children (86 males and 74 females) were enrolled and divided into 2 groups: Group 1 received fortified milk (FM) and group 2) received non fortified milk (NF). A sachet of milk was served daily for 5 days per week as 200 ml milk containing 5 mg Fe as NaFeEDTA (FM) or not fortified milk (NF) for 3 months. Concentrations of hemoglobin(Hb), serum ferritin (SF), mean corpuscular volume (MCV), and mean corpuscular hemoglobin (MCH), were measured at baseline and after 3 months to determine the developments. Results: There were statistical differences in the changes of hemoglobin concentration (Hb), mean cell volumes (MCV), and mean corpuscular hemoglobin (MCH), between the fortified milk and non fortified milk group at a significance level of p<0.05. Conclusions: Fortification of milk in connection with a free school milk program is feasible and might be used as a preventive measure against iron depletion in areas with a high rate of iron Key Words: Iron, food fortification, iron deficiency anemia, school aged children
1. Introduction
Among micronutrient deficiencies, iron deficiency anemia (IDA) is an important public health issue. According to the World Health Organization (WHO), worldwide, about two billion people are anemic, with the main cause being a deficiency in dietary iron. The progress in controlling IDA over the last few decades, however, is insufficient. This could be due to the fact that in the past, attention had been drawn mainly to iron deficiency anemia estimated on the grounds of the prevalence of hemoglobin concentrations below thresholds, and not to the iron status of population groups as such. In one recent publication, the WHO stated that ‘not all anemic people are iron deficient and iron deficiency may occur without anemia’. A meaningful public health policy geared towards prevention of IDA therefore might include investigation of the importance of other causes of anemia in a given population. As far as iron deficiency is concerned, implementing measures to improve the iron status of population groups and, as early as possible in the life time of people at risk, i.e. for school children could decrease IDA. Thailand is one of the countries facing the problem of IDA. The Ministry of Public Health (MOPH) of the Thai government indicated that the prevalence of IDA increased from 20.5 % in the year 1995 to 26.7 % in 2003. From a National Food and Nutrition Survey conducted in Thailand around the year 2000 it is known that the prevalence of anemia in school-age children (6-14 years of age) amounted to 13.1 % by using hematocrit threshold values as criteria and 26.7 % when using hemoglobin values as criteria. One way to prevent iron deficiency in school children might be iron fortification. Since 1992 the Royal Thai government has maintained a free milk program (200ml/child/day) to preschool children in the communities and public primary schools. This program was used as a vehicle for a fortification trial by the investigators. It is known that iron salts such as ferrous sulphate and fumarate are reasonably well absorbed and are suitable, when storage is not expected to be long term. Compared with the commonly used iron salt fortificants, sodium iron ethylene diamine tetraacetate (NaFeEDTA) has the potential to be used widely as an iron fortificant in future. NaFeEDTA absorption is 2 to 3 times higher than ferrous sulphate. Its structure affords some protection against phytate inhibition of iron absorption. It is about one third as well absorbed as ferrous sulphate, but has the advantages of greater stability and of increasing the absorption of native non-haem iron and zinc in food. Based on these fortunate preconditions, a fortification trial program using NaFeEDTA fortified milk was conducted. The researchers aimed to undertake an assessment of the feasibility of such a program, as well as to try to establish the effectiveness of the program. In addition a short qualitative dietary survey was undertaken to estimate the frequency of food items known to be either promoting or inhibiting iron absorption. 2. Methodology
A district approximately 660 km northeast of Bangkok was selected as a study area. Four schools at the Si Chomphu district, KhonKaen Province; namely the Si Chomphu Kindergarten, Ban Mai Sok Som Kob, Ban Nong Ta Kai and Choom Chon Ban Wang Perm School participated in the project, which was conducted from November 2007 to March 2008. The Si Chomphu district was chosen for the study because of pronounced interest in health - and the school authorities of the district facilitated cooperation with study team. The selection of schools was based on a simple random sampling technique from schools with not less than 120 and not more than 1,500 school children. From the selected schools, out of 1.158 children in the age of 9 to 11 years 160 school children (86 boys and 74 girls) were randomly selected and asked to join the project, and 80 children for each group were allocated either to the group receiving fortified milk (FM) or getting non-fortified milk only (NF). Children participating in the study had no history and symptoms of a serious disease, in particular, they were not suffering from thalassemia or hematolytical disease, Hb concentration of >8 g/dl and serum ferritin of 12 g/l. Permission to conduct the intervention was received from local education authorities and school principals. Informed written consent was obtained from the parent or guardian of each child who accompanied the children on the first day of the survey. De-worming by 15 mg albendazole was provided for all of the students for the elimination of intestinal parasites before starting the intervention. Based on the study protocol, 5 mg of iron in the form of NaFeEDTA milk (200 ml per sachet) was administered daily to each subject of the fortified milk group (FM) at 8.30 AM for a period of 3 months. The intervention group as well as the control group were given milk of the same brand and quantity. The quantity of NaFeEDTA were given to the students following the Joint Expert Committee on Food Additives (JECFA) recommendations. Both the fortified and the non fortified milk were provided by a milk company located within the Khon Kaen province. The concentration of iron added to the fortified milk was 5 mg of iron per 200 ml of milk as NaFeEDTA. Food grade-NaFeEDTA was manufactured and provided by AkzoNobel Chemicals Pte. Ltd., Singapore. The milk was distributed to each child 5 days/week by the teacher, or a staff member of the project. In order to ensure accurate intake, the milk was consumed by the pupils under the complete supervision of the investigator and teachers. At the same time, detailed information about the milk consumption of each child was recorded on a consumption sheet to check the acceptance of the milk by the students. A short qualitative dietary assessment about food items promoting and inhibiting iron absorption was undertaken at the beginning of the study. A 3 ml venous blood sample was taken at the beginning and at the end of the study period for the measurement of hemoglobin concentration (Hb), serum ferritin (SF), Mean Cell Volume (MCV), and Mean Corpuscular Hemoglobin (MCH). Each sample was inserted into EDTA-coated tubes. The tubes were kept cool and transported to the laboratory at the Research Center, Faculty of Associated. Medical Science, and Faculty of Medicine, Khon Kaen University. All of bloods samples were analyzed to determine iron storage (serum ferritin) which was determined by COBAS INTEGRA®800 analyzer, and red blood cell indices (Hb, serum ferritin(SF), MCV, and MCH) by the Sysmex®SF-3000 automated hematology analyzer, Kobe, Japan. Statistical analysis was done by using the STATA program. Percent mean, standard deviation, and median to describe general information were calculated. Students’t-test and Wilcoxon sign rank test were applied to examine the difference changes of hemoglobin (Hb), serum ferritin (SF), mean cell volume (MCV), and mean corpuscular hemoglobin (MCH) over the study period for 3 months. 3. Results
The age of the students was 9.9 + 0.3 and 9.8+0.4 years old for males and females, respectively. The mean of weight for males was 27.7+5.5 kilograms and for females 29.7+8.8 kilograms. The height of males was 129.6 +7.8.5 cm and of females 133.4+9.2 cm. The results derived from boys and girls had been quite similar and no interesting aspect had been discovered by evaluating sexes separately so that in the following the results are given for both sexes combined except for table 2. Part of the results of a qualitative dietary survey is given in Table 1. Frequent intake of protein supporting iron absorption is mainly restricted to poultry and plants while intake of food known to somehow inhibit iron absorption is mainly due to the digestion of egg yolk and soybean products. Table 1. Number and percent of food items being enhancers or inhibitors of iron absorption
consumed 1 to 2 times /week by 160 school children Food items being
Food items being
enhancer of iron
inhibitor of iron
Based on a qualitative food frequency questionnaire of 160 children. Multiple *Enhancer: Food items rich in heme, ascorbic acid, citric acid, or vitamin A ** Inhibitors: Food items rich in phutate, polyphenols (tannin), soy protein, or Before starting the intervention children had been asked how they tolerated drinking milk in the past. The results are shown in Table 2. Most of the males did not complain about side effects after drinking the milk; 28 children (65.1 %) admitted that drinking the milk did not stimulate their appetite, 11 children (25.6 %) complained about flatulence, 5 children vomited (11.6 %) and 4 (9.3 %) boys complained about having diarrhea. Milk did not stimulate appetite for 22 girls, (59.5 %), flatulence and vomiting and diarrhea was rare for the group of girls as well. Table 2. General health, side effects evaluation for boys and girls.
Rating Scale
Response Factor
Table 3 presents the hemoglobin (Hb), mean cell volume (MCV), mean corpuscular hemoglobin (MCH), and serum ferritin (SF) values before and after 3 months of intervention and the differences before and after the study as means and 95% CI. The p-value indicates the statistical significance between the means of the differences between the group of children receiving fortified milk and the controls. Mean values of Hb for the control group decreased and for the intervention group increased. The difference before and after intervention for both groups is statistically significant. The variation of ferritin was not altered by the intervention. Furthermore it also shows the changes of red blood cell indices after 3 months of the study. The results indicate that the intervention statistically altered the difference between before and after the provision of fortified milk of MCV and MCH for the FM group above the NF group. Table 3. Hemoglobin(Hb), mean cell volume(MCV), mean corpuscular hemoglobin, (MCH),
and serum ferritin(SF) changes in school aged children after 3 months of intervention according Parameters
Data are presented as the mean value + SD. The data were analyzed by the *The data were analyzed by the Mann-Whitney U test and presented as the 4. Discussion
The study site is known to be an area with a high prevalence of iron deficiency. Iron deficiency anemia among school children had been assessed on district level at the Khon Kaen province. A School Health Report by the Si Chomphu Hospital, Si Chomphu district, Khon Kaen province found that the prevalence of iron deficiency anemia on the primary school level was as high as 21.3 %. The situation is not reflected by the school children co-operating in this study, because of ethical reasons anemic children could not be included into the control group. So only quite healthy children had been investigated, thus it was not expected that the results will achieve great improvements in the hematological status of the children in the intervention group. Further limitations of financial resources and lack of adequate laboratory facilities prohibited the author from using other indicators of iron status such as transferrin saturation, serum zinc protoporphyrin or the transferrin receptor. Although ferritin values also reacts to infections, which might have happened here. It is supposed that at least the majority of children taking part in this study were prone to iron depletion which is indicated by the fact that a small but significant improvement of the hematological status of the children of the intervention group could be observed. This was indicated by an improvement in the red cell volume (MCV) and red cell hemoglobin concentration (MCH). Food items supporting but also inhibiting iron absorption are balanced in the dietary intake as indicated by the results given in table 1. Other micronutrients besides iron such as vitamin A might contribute to the risk of the children having insufficient hematological status. Thus supplementing the school milk program by NaFeEDTA might be well justified. 5. Conclusion
Obviously the milk is well tolerated by the children as the results given in table 2 indicate. Lactose intolerance is known to be a problem in Thailand but obviously is not a factor important enough to prevent continuation the milk school program since only a few children report occasional intestinal disturbance when drinking milk. The amount of iron in food fortification of other studies usually has been higher than that used in this study. The use of NaFeEDTA-fortified milk in this study was only 5 mg of iron per person per day which is a quite low dose of NaFeEDTA. Supplementation however might be sufficient to maintain an optimal iron store in children with iron depletion. Additional studies however are required to substantiate this. It is supposed that this also holds true for primary school children, at least when exposed to relatively low doses of iron supplementation, but help children who are in a pure state of iron depletion. In conclusion, the result of this study strongly suggests continuing the supplementation of the school milk program with NaFeEDTA. However further investigations of the iron status of school children are recommended. Acknowledgements
This paper is one part of the results of a Ph.D thesis (Public Health, Graduate School, Khon Kaen University, Thailand). To finish the project would not have been possible without the invaluable support and assistance of the directors and teachers of 4 government schools; Choomchon Ban Wang Perm, Nong Ta Kai Pittaya, Ban Mai Sok Som Kob, and Si Chomphu Kindergarten school, Khon Kaen province, Thailand. The study was supported by AkzoNobel Chemical Company, who supplied a research grant and NaFeEDTA fortificants. REFERENCES
1. WHO. (2007); Geneva (electronic version). 2. MOPH. Nutrition situation and trend. Accessed 15 August 2006; Available at: thailand/ch11.htm#TopOfPag. 3. School Health Report. Situation of iron deficiency anemia in school age . 4. FNRI food and nutrition research institute. Accessed 11 February 2006; Available at: 5. Huo J, Sun J, Miao H, Yu B, Yang T, Lui Z, et al. Therapeutic effects of 6. NaFeEDTA fortified soy sauce in anemic children in China. Asia Pacific J Clin Nutr. 7. U.S.Food and drug Administration. Accessed 28 February 2009; Available from:http://www.cfsan.fda. gov/ ~rdb/opa-g152.html. 8. Agarwal KN, Indicators for Assessment of and Iron Deficiency in the Community. Supercourse/lecture/lec24831/article.doc. 9. Kumar P, Clark M., Clinical medicine. 5th ed. U.K; Bath Press Ltd. (2002); 415. 10. Thi Le H, Brouwer ID, Burema J, Nguyen KC, Kok FJ., Efficacy of iron 11. fortification compared to iron supplementation among Vietmamese school children. 12. Andreoli TE., Carpenter CJ., Griggs RC. Loscalzo J., Cecil essentials of medicine. 6th ed. Philadelphia;W.B.Sauders company, 459-460.


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