Abstract
Iron deficiency anemia (IDA) is a major public health problem in sub-Saharan Africa. The efficacy of iron fortification against IDA is uncertain in malaria-endemic settings. The objective of this study was to evaluate the efficacy of a complementary food (CF) fortified with sodium iron EDTA (NaFeEDTA) plus either ferrous fumarate (FeFum) or ferric pyrophosphate (FePP) to combat IDA in preschool-age children in a highly malaria endemic region. This is a secondary analysis of a 9-month cluster-randomized controlled trial conducted in south-central Côte d’Ivoire. 378 children aged 12–36 months were randomly assigned to no food intervention (n = 125; control group), CF fortified with 2 mg NaFeEDTA plus 3.8 mg FeFum for six days/week (n = 126; FeFum group), and CF fortified with 2 mg NaFeEDTA and 3.8 mg FePP for six days/week (n = 127; FePP group). The outcome measures were hemoglobin (Hb), plasma ferritin (PF), iron deficiency (ID; PF < 30 μg/L), and anemia (Hb < 11.0 g/dL). Data were analyzed with random-effect models and PF was adjusted for inflammation. The prevalence of Plasmodium falciparum infection and inflammation during the study were 44–66%, and 57–76%, respectively. There was a significant time by treatment interaction on IDA (p = 0.028) and a borderline significant time by treatment interaction on ID with or without anemia (p = 0.068). IDA prevalence sharply decreased in the FeFum (32.8% to 1.2%, p < 0.001) and FePP group (23.6% to 3.4%, p < 0.001). However, there was no significant time by treatment interaction on Hb or total anemia. These data indicate that, despite the high endemicity of malaria and elevated inflammation biomarkers (C-reactive protein or α-1-acid-glycoprotein), IDA was markedly reduced by provision of iron fortified CF to preschool-age children for 9 months, with no significant differences between a combination of NaFeEDTA with FeFum or NaFeEDTA with FePP. However, there was no overall effect on anemia, suggesting most of the anemia in this setting is not due to ID. This trial is registered at clinicaltrials.gov (NCT01634945).
Highlights
Iron deficiency (ID) and anemia are considerable public health problems in sub-Saharan Africa [1].For example, in Côte d’Ivoire, 25–75% of the preschool- and school-age children in rural areas are reported to be iron deficient, and about 80% are anemic [2], which can result in irreversible impairments in cognitive performance and motor development [3,4] unless additional iron is provided
C-reactive protein (CRP) concentration in the complementary food (CF)-ferric pyrophosphate (FePP) group compared to the control group (p = 0.009) and the CF-ferrous fumarate (FeFum) group (p = 0.013), the prevalence of inflammation (CRP > 5 mg/L and/or AGP > 1 g/L) did not differ between groups
The main finding of this study is that, despite the high P. falciparum prevalence and elevated inflammation biomarkers in 12- to 36-month-old children, consumption of iron fortified CF for nine months significantly decreased the prevalence of Iron deficiency anemia (IDA)
Summary
Iron deficiency (ID) and anemia are considerable public health problems in sub-Saharan Africa [1].For example, in Côte d’Ivoire, 25–75% of the preschool- and school-age children in rural areas are reported to be iron deficient, and about 80% are anemic [2], which can result in irreversible impairments in cognitive performance and motor development [3,4] unless additional iron is provided. One strategy to provide iron is through iron fortified complementary food (CF). This approach is not without challenges due to a large variation in the bioavailability of commonly used iron fortification compounds, frequent unacceptable sensory changes caused by the water soluble iron compounds of highest bioavailability, and the presence of phytic acid (PA), a potent inhibitor of iron absorption in CF containing cereals or legumes [5]. Ferrous sulfate is less commonly employed as it often causes unacceptable sensory changes in CF [6]. In order to overcome the inhibitory effect of PA on iron absorption, commercially manufactured infant cereals usually contain additional ascorbic acid (AA) at 2:1 molar ratio (AA:Fe), as recommended by the World Health Organization (WHO) [7]
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