Effectiveness of a large-scale iron fortified milk distribution program on anemia and iron deficiency in low-income young ...
Overview<br />Background Info<br />Preliminary Study<br />Featured Study<br />Supporting follow up study <br />
Iron (Fe)<br />Found in every body cell  (total 5g)<br />Increased with dietary intake<br />Heme (40% absorption)<br />Non...
Hemoglobin & Myoglobin<br /> O2 carrying capacity<br />Immune function<br />Cognitive development<br />Temp regulation<br ...
Adult <br />Women 18 mg/day<br />Men: 8 mg/day<br />Adolescents<br />Girls: 15 mg/ day<br />Boys: 11 mg/day<br />Children ...
Centers for Disease Control<br />
Increased Iron Needs<br />Premature Babies<br /><ul><li>Miss the most important final weeks to build Fe stores</li></ul>In...
only last for about 6 mo</li></ul>Children and Adolescence<br /><ul><li>Rapid growth
Picky eaters</li></ul>Women<br /><ul><li>Menstruation</li></ul>Pregnancy<br /><ul><li>Increased blood volume and needs
Blood loss</li></li></ul><li>Fe Status Indicators<br />Hb Concentration and Hematocrit<br />Cheap and easy<br />Used for s...
Fe Deficiency <br /> Most common nutritional deficiency around the world.<br />Children under age 5 are one of the most af...
Am J Clin Nutr 2010; 91:431-9<br />What does this mean?<br />“Anemia and Iron Deficiency is associated with adverse effect...
Bioavailability of iron- and copper supplemented milk for Mexican school children<br /><ul><li>Experimented with ways to f...
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</li></ul>Am J of Clin Nutr. ...
Milk Subsidized Program<br />“Liconsa”<br />Started in 1944<br />Distributes whole milk at centers through out the country...
1999 National Nutrition Survey<br />Found that deficiencies were common <br /><ul><li> Fe
vit C
 others
At the time of the study served 5 mil people
4.2 mil aged 1-11 year olds
650, 000 aged 1 – 2 ½ years
Mexican government decided to provide these nutrients in combination with the whole milk</li></ul>Am J of Clin Nutr. 2010;...
Effective?<br />1st Step<br /><ul><li>Completed a Randomized Clinical Trial
Results: Fortifying Milk was effected in improving the Fe status of Toddlers</li></ul>Am J of Clin Nutr. 2010; 91 (2) 431-...
Rationale<br /><ul><li>Did this apply through a Large-Scale Program?
And does improved Fe Status reduce anemia prevalence?</li></ul>Am J Clin Nutr. 2010; 91 (2) 431-439<br />
Design & Subjects<br /><ul><li>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
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Effectiveness of-a-large-scale-iron-fortified-milk-distribution

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  • Just some background info, we’ve learned in every nutrition class pretty much, but I just though it would be good to remind you of the basics. And also, there are some terms that will be important to know when we are discussing the study.Heme= animal sourcesNon- Heme = Plant sources
  • Got this table from the center for disease control. Topic of Preventing Fe DeficiencyA lot of these characteristics apply to the low income class of the Mexican population, and also of other third world countries.
  • Vacant binding sitesLow transferrin saturation means you have a lot of vacant sites where you could bind Fe.Highest in neonates, decreases by age 4 mo, and then increases through childhood and adulthood.Higher after meals
  • When this study was conducted, 27% of Mexican children aged 1-4 yo were anemic 52% were iron deficient at the time of the study
  • -The Mexican government started this program in order to target children who were at risk for nutritional deficiencies. -Supported by a grant from the secretary of social development
  • So the Government thought that if they could fortify the milk with these micronutrients they would be able to prevent nutritional deficiencies in a large part of their population. - This group was part of the lower economic status
  • Still had two more questions….This was the rationale for the featured study today
  • 5 million participants in total- Researchers made a note, wanted to decrease the number of children that wouldn’t get the fortified milk (in fear of deficiencies)
  • Reconstitute milk from dry formOnce in the morning and in afternoon
  • Kcal, Pro, Fat, content all the sameFe &amp; Zn = 5.28 gVit C – 48.0*If you all remember adding vit C to a meal, can help with Fe absorption
  • Felt the this measure would not be reliable for randomized measuresDecided to focus on Serum Soluble Transferrin Receptor because SF fluctuated so much with acute infectionsCollected capillary blood samples and finger pricks
  • Questionnaire was to determine socioeconomic status of household
  • Wanted to determine if there was any problems with the way they randomized the groups and wanted to determine if the groups were truly randomized…..
  • This meant that the two groups were truly randomized, and neither had an advantage over the other from the beginning
  • All three levels of anemiaMild, Mild- moderate, and Moderate anemiaThey set significance at p&gt; .10 so all are significant
  • Estimated Iron Deficiency Prevalence as defined by sTfR over greater than 3.3 ug/L
  • Using fortified milk Indicators of Fe deficiency: SF and high sTfR
  • A lot of times when research is conducted, they take situations out of the field, and move it into a lab, so you have to be careful when recreating the data.But this was able to show, that with the resources that they currently have, they are still able to improve Fe statusOne of the exclusion criteria was if a baby had a Hb of , 90 g/L for ethical reasons they intervened using other methods, so the researchers felt that they might have even seen a more dramatic effect if all population was included in the study.
  • Even though they controlled for the for the confounders found upon statistical calculations, they felt that there would be other confounders when comparing the participants in the study to the rest of the population- Also these indicators vary greatly with infection, inflammation
  • - Adolescent girls had the highest iron-deficient prevelance
  • This shows the break down of the subgroups with highest prevelance of Fe Deficiency.- But even within these groups those who are not Fe-Deficient still have higher Math scores
  • Effectiveness of-a-large-scale-iron-fortified-milk-distribution

    1. 1. Effectiveness of a large-scale iron fortified milk distribution program on anemia and iron deficiency in low-income young children in Mexico<br />Juan A Rivera, Teresa Shamah, Salvador Villalpando, and Eric Monterrubio<br />American Journal of Clinical Nutrition 2010; 91: 431-439<br />
    2. 2. Overview<br />Background Info<br />Preliminary Study<br />Featured Study<br />Supporting follow up study <br />
    3. 3. Iron (Fe)<br />Found in every body cell (total 5g)<br />Increased with dietary intake<br />Heme (40% absorption)<br />Non-heme (2-10% absorption)<br />Increased with Intestinal absorption<br />Decreased with sloughing of intestinal cells, blood loss<br />Wardlaw, F.M., & Hampl J. S. Iron (Fe). In: Perspectives in Nutrition. 7th ed.<br />
    4. 4. Hemoglobin & Myoglobin<br /> O2 carrying capacity<br />Immune function<br />Cognitive development<br />Temp regulation<br />Energy metabolism<br />Work performance<br />Functions of Iron<br />Wardlaw, G.M., & Hampl J.S. Iron (Fe). In: Perspectives in Nutrition. 7th ed.<br />
    5. 5. Adult <br />Women 18 mg/day<br />Men: 8 mg/day<br />Adolescents<br />Girls: 15 mg/ day<br />Boys: 11 mg/day<br />Children <br />7-10 mg/day<br />Infants <br />11 mg/day<br />12 mg/day<br />17mg/day<br />RDA’s Average Intake<br />Centers for Disease Control<br />
    6. 6. Centers for Disease Control<br />
    7. 7. Increased Iron Needs<br />Premature Babies<br /><ul><li>Miss the most important final weeks to build Fe stores</li></ul>Infants<br /><ul><li>Born with Fe stores
    8. 8. only last for about 6 mo</li></ul>Children and Adolescence<br /><ul><li>Rapid growth
    9. 9. Picky eaters</li></ul>Women<br /><ul><li>Menstruation</li></ul>Pregnancy<br /><ul><li>Increased blood volume and needs
    10. 10. Blood loss</li></li></ul><li>Fe Status Indicators<br />Hb Concentration and Hematocrit<br />Cheap and easy<br />Used for screening for deficiency<br />Measures amount of functional Fe<br />Serum Ferritin Concentration<br />Closely related to amount of stored Fe in body<br />More expensive<br />Earliest indicator for depleted Fe stores<br />Transferrin Saturation<br />Measures vacant Fe binding site<br />Changes with infection, age, and time of day<br />Centers for Disease Control<br />
    11. 11. Fe Deficiency <br /> Most common nutritional deficiency around the world.<br />Children under age 5 are one of the most affected age groups<br />Peak prevalence occurs at age 12-23 mo<br />Affects all socioeconomic status<br />30% in lowest group<br />17% in highest<br />Am J Clin Nutr. 2010; 91(2) 431-439<br />
    12. 12. Am J Clin Nutr 2010; 91:431-9<br />What does this mean?<br />“Anemia and Iron Deficiency is associated with adverse effects on neurodevelopment”<br />
    13. 13. Bioavailability of iron- and copper supplemented milk for Mexican school children<br /><ul><li>Experimented with ways to fortify milk with trace minerals
    14. 14. Had to use components that didn’t catalyze off-flavors, peroxidize the lipids, and yet still had good bioavailability
    15. 15. Ferrous/ cupric chloride salt
    16. 16. Ferric/ cupric Lactobionate chelate
    17. 17. Results: Both showed significant increase in Hb
    18. 18. Suggested Milk could be used as a vehicle for Fe or Cu Supplementation
    19. 19. At the time of this study, there were no public health supplementation programs yet in Mexico</li></ul>Am J of Clin Nutr. 1982; 36 (6) 1162-1169<br />
    20. 20. Milk Subsidized Program<br />“Liconsa”<br />Started in 1944<br />Distributes whole milk at centers through out the country<br />Children aged 1-11 years old<br />400 mL of milk/ day<br />Other family members living in poverty<br />2002- started fortifying milk<br />Am J of Clin Nutri. 2010; 91 (2) 431-439.<br />
    21. 21. 1999 National Nutrition Survey<br />Found that deficiencies were common <br /><ul><li> Fe
    22. 22. vit C
    23. 23. others
    24. 24. At the time of the study served 5 mil people
    25. 25. 4.2 mil aged 1-11 year olds
    26. 26. 650, 000 aged 1 – 2 ½ years
    27. 27. Mexican government decided to provide these nutrients in combination with the whole milk</li></ul>Am J of Clin Nutr. 2010; 91 (2) 431-439<br />
    28. 28. Effective?<br />1st Step<br /><ul><li>Completed a Randomized Clinical Trial
    29. 29. Results: Fortifying Milk was effected in improving the Fe status of Toddlers</li></ul>Am J of Clin Nutr. 2010; 91 (2) 431-439<br />
    30. 30. Rationale<br /><ul><li>Did this apply through a Large-Scale Program?
    31. 31. And does improved Fe Status reduce anemia prevalence?</li></ul>Am J Clin Nutr. 2010; 91 (2) 431-439<br />
    32. 32. Design & Subjects<br /><ul><li>Group-Randomized effectiveness trial in children aged 12-30 months
    33. 33. Participants of the Liconsa Program
    34. 34. Selected 12 Milk Distribution Centers
    35. 35. Randomly Assigned:
    36. 36. 5 Non-Fortified Milk
    37. 37. 7 Fortified Milk</li></ul>Am J Clin Nutr. 2010; 91 (2) 431-439.<br />
    38. 38. Milk Contents<br /><ul><li>Distinguished by a ‘color band’ on the package
    39. 39. Unknown to researchers, fieldworkers, personnel and program beneficiaries
    40. 40. Mothers received same instructions to reconstitute
    41. 41. Encouraged to feed 200 ml 2x/day</li></ul>Am J Clin Nutr. 2010; 91 (2) 431-439.<br />
    42. 42. Am J Clin Nutr. 2010; 91(2) 431-439<br />
    43. 43. Collection Methods<br /><ul><li>Weren’t able to get adequate blood samples for 1/3 of the participants like they had hoped.
    44. 44. Primary Indicators
    45. 45. Fe Deficiency- sTfR
    46. 46. Primary Indicator for Anemia-Hb concentration </li></ul>Am J Clin Nutr. 2010; 91 (2) 431-439<br />
    47. 47. Definitions<br /><ul><li>Fe Deficiency: sTfR >3.3 mg/ L
    48. 48. Anemia: Hb <110 g/L
    49. 49. Mild anemia: Hb 100-109.0 g/L
    50. 50. Moderate anemia: Hb 90-99.9 g/L</li></ul>Am J Clin Nutr. 2010; 91 (2) 431-439.<br />
    51. 51. Data Collection: Baseline, 6mo, 12mo<br /><ul><li>Questionnaire: housing characteristics, and possession of household goods
    52. 52. Hb concentration
    53. 53. C-Reactive Protein
    54. 54. Anthropometric Data
    55. 55. Length/ Height and weight</li></ul>Am J Clin Nutr. 2010; 91 (2) 431-439.<br />
    56. 56. Data Collection: Monthly<br /><ul><li>Field worker visited home to ensure compliance
    57. 57. Obtained a food frequency questionnaire</li></ul>Am J Clin Nutr. 2010; 91 (2) 431-439.<br />
    58. 58. Statistical Methods<br /><ul><li>Compared the socioeconomic status of families at baseline between two intervention groups
    59. 59. Adjusted for cluster effects
    60. 60. If something was not normally distributed
    61. 61. Looked at Intervention effects for the 6 and 12 mo age groups
    62. 62. Plausible confounders: sex, ages, socioeconomic status, parent’s schooling, daily milk intake, frequency of respiratory and diarrheal infections.</li></ul>Am J Clin Nutr. 2010; 91(2) 431-439.<br />
    63. 63. Results<br /><ul><li>No statistically significant differences between two baseline groups for:
    64. 64. Anemia
    65. 65. Fe deficiency
    66. 66. Milk intake
    67. 67. Anthropometric data
    68. 68. Socioeconomic status</li></ul>Am J Clin Nutr. 2010; 91 (2) 431-439.<br />
    69. 69. Results: Effect on Anemia<br /><ul><li>Lower prevalence and Larger decline in Fortified Milk group</li></ul>Am J Clin Nutr. 2010; 91 (2) 431-439.<br />
    70. 70. Am J Clin Nutr. 2010; 91 (2) 431-439.<br />
    71. 71. Effect on Iron Status<br /><ul><li>Fortified Milk group had a statistically significant decline in Iron Deficiency prevalence
    72. 72. Differences between 6 and 12 month measurements for both groups were not statistically significant</li></ul>Am J Clin Nutr. 2010; 91 (2) 431-439.<br />
    73. 73. Am J Clin Nutr. 2010; 91 (2) 431-439.<br />
    74. 74. Discussion<br /><ul><li>Determined results “biologically important”
    75. 75. “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”
    76. 76. Decreases mild-moderate anemia by
    77. 77. 36% at 6 mo
    78. 78. 57% at 12 mo
    79. 79. Reduced indicators of Fe deficiency</li></ul>Am J Clin Nutr. 2010; 91 (2) 431-439.<br />
    80. 80. Discussion<br /><ul><li>Used the distribution centers already in place
    81. 81. Could have seen a “floor effect”</li></ul>Am J Clin Nutr. 2010; 91 (2) 431-439.<br />
    82. 82. Limitations<br /><ul><li>Selection bias through changing indicators once study began
    83. 83. Results from iron deficiency should be interpreted with caution
    84. 84. Different subjects in Fortified and Non-Fortified groups
    85. 85. Limited data was published</li></ul>Am J Clin Nutr. 2010; 91 (2) 431-439.<br />
    86. 86. Iron Deficiency and Cognitive Achievement in School- Aged Children and Adolescents in the United States <br />National Health and Nutrition Examination Survey<br /><ul><li>Cross sectional survey for children 6-16 year old (n= 5398)
    87. 87. Determined Iron Deficiency and Anemia using serum ferritin and Hb
    88. 88. Compared the Fe status to their standardized test scores</li></ul>Am Academy of Pediactrics. 2001; 107(6)1381-1386.<br />
    89. 89. Results<br />Used Logistic regression to control for<br /><ul><li>Below average scores
    90. 90. Other confounding factors
    91. 91. Found:
    92. 92. Lower Math scores were associated with lower than normal Fe status
    93. 93. Elevated Risk for lower scores, even if only Fe deficient</li></li></ul><li>Am Academy of Pediatrics. 2001; 107 (6) 1381-1386.<br />
    94. 94. As working professionals……<br /><ul><li>Emphasize the importance of Fe at all ages, but especially those with rapid growth
    95. 95. Heme vs. Non-Heme
    96. 96. Finding the populations that are known to be at risk for deficiency is important
    97. 97. Screen & Intervene</li></li></ul><li>Resources<br />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.<br />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.<br />Mayo Clinic. Iron Deficiency Anemia. [Accessed 9/1/05] Available from: http://www.mayoclinic.com/health/iron-deficiency-anemia/ds00323. <br />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 ClinNutr. 2010; 91(2) 431-439.<br />Wardlaw, G. M., & Hampl J. S. Iron (Fe). In: Perspectives in Nutrition. 7th ed. New York, New York, McGraw Hill. 2007, 428-434.<br />Rivera, R. et al. Bioavailability of iron- and copper- supplemented milk for Mexican school children. Am J ClinNutri. 1982; 36 (6). 1162-1169.<br />

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