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Effectiveness of-a-large-scale-iron-fortified-milk-distribution

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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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