Fortification of sugar with iron sodium ethylenediaminotetraacetate (FeNaEDTA) improves status in semirural Guatemalan populations13

Fernando and Jo/ui E Viteri, Svlvi A 32-mo-long, highland control sugar and three two communities, double-blind field community receiving vitamin Aand in the lowlands and study inonly vitaone The 17000. as was in the cornSugar retinyl well acon iron Edmundo Alvarez, Ramiro Batres, Benjamin Tor#{252}n, Oscar Pineda, Luis

iron
A MejIa,

ABSTRACT volving one mm A-fortified sugar-fortified

shown
Guatemala Currently,

to be an adequate
(9), sugar and is being

vehicle
not fortified

for vitamin
impair with iron

A fortification
absorption A in Guate-

in
(10).

it does

FeNaEDIA-

vitamin

Downloaded from ajcn.nutrition.org by guest on November 28, 2012

mala.
Consideration of the fortification of diets rich tion is essential. of this that meals of iron compound to be used in inhibitors of nonheme-iron in iron absorp-

highlands
ness fortified palmitate/kg cepted nutrition pregnant supplements of this munities

of Guatemala,
approach population with was

was
ranged

undertaken
iron and not 15 between 1200

to test
deficiency. and retinol and mg

the effective-

in controlling

1 g FeNaEDIA stable, did The

the nonheme-iron
absorption demonstrated

A nonheme-iron compound becomes part of pool and its absorption is dictated by the iron pool. the the iron We and others sodium (1 1-13) previously in iron ethylenediaminotet-

segregate, impact

by the communities. was estimated women and or treatment

of fortification

at 8, 20, and 32 mo of intervention. All subjects with severe anemia received and were excluded in one from lowland the analysis.

raacetate
typical

(FeNaEDTA)

mixed

at food

fortification
described of iron. the total than when

levels
above

with
is ab-

characteristics

Iron
except

stores
for

in the fortified
women 18-48

communities
y of age

increased Iron
except 1995;61:1

significantly
community

sorbed better than other nonheminic advantage of this compound is that

forms it makes

An added nonheme-

iron pool,
that
in

including

that contributed
2.5 times

by food,
higher

as absorbable
a similar

as

and > 49 y in the control community among KEY adult WORDS field males.

highland
remained Am

community.
unchanged J Clin Nutr

stones
for 153-63.

in the
a rise

FeNaEDTA,

amount of iron as FeSO4 is added. A small pilot trial in the lowlands of Guatemala proved effective in preventing the recurrence of anemia in a semirural population (14). Fortification also South fed the of fish proven Africa doubly nutrients sauce and of curry powder effective in population trials (16). (17). Studies in vitamin sugar fortified demonstrated with FeNaEDTA in Thailand (15) iron-deficient the availability has

Iron,
trial,

vitamin
iron stores,

A, sugar,
Guatemala

FeNaEDTA,

double

fortification,

and
rats of

A and

Introduction Iron deficiency

in the world: severe, nearly it produces

both

is the most
2.5 billion ferropenic

common
people anemia

micronutnient
suffer and diminish from

deficiency
it (1). When with

is associated

poor
serious

health,

increased

risk

of maternal
that

peninatal
human

death,

and

The research objectives of the study being reported were to test the feasibility of the field application of doubly fortified with retinyl palmitate and FeNaEDTA, measure its effectiveness in controlling iron deficiency situations: 1) in highland populations where the almost
I

here sugar and to in two

exclu-

ment

functional impairments and productivity (2-4).

developFrom the Department the Institute Guatemala Mexico; Supported RAMCO kits Nashua, used NH, used Nutritional March 24, and City, of Nutritional of Nutrition Guatemala; American DC. contract study, BASF, trial. Address correspondence of to FE Viteri, California, Berkeley, DepartCA University and AG, AIDITA-C-1341, prepared Hampshire Ludwigshafen, INCAP, and donated Chemical Germany, and PAHO/ the serum and the donated Co (Grace specially Sciences, of Central Kelloggs Health University America Latin and America, of California, Panama (INHealth Berkeley; CAP), Oro,
2

In Central are widespread

populations

iron
chronic areas rare

intake,
(5-7). (5, 6)

America, iron deficiency and fenropenic anemia and severe especially among the lower-income (5, 6). This occurs mostly as a result of insufficient diets that impair iron absorption, multipanity, and
particularly hookworm in many lowland

Quer#{233}taro,

the Pan

Organization/World

Organization, WHO. ferritin Co),

Washington, by USAID in this and in this Co (Houston)

infections,

the nutritional
widespread

Other nutritional deficiencies contribute anemia problem, and hemoglobinopathies

even (6). though vitamin A deficiency

little

to are
is

in children

FeNaEDTA
3 Reprints

not available.

A logical approach to control of iron deficiency and vitamin A deficiency is the fortification with iron and vitamin A of a food that reaches all the population groups at risk and fulfills the accepted criteria for a food vehicle (8). Sugar has been
Am i Cli,z Nuir
1995;61:1153-63.

ment 94720.

of

Sciences, 1994.

Received Accepted for Clinical

for publication Nutrition

November

4, 1994.

Printed

in USA.

1995

American

Society

1153

1154 sive dietary mm sugar. cause of iron infected factor. A status of these deficiency with was hookworm, objective was receiving dietary, which and 2)

VITERI
in lowland the the vitafortified

El

AL
weighing derived

=120 from and coffee

g and (with were

wrapped Sugar-added or without prepared. also

in dry milk)

corn and

husk

leaves;

they

are

populations

aggravated

tamales.)

orange, Each

pineapple, tea (with and fortified

and papaya or without unfortified

A collateral

to evaluate the doubly

juices, milk

populations

on lemon)

food preparation volunteers. At They

were

was consumed least 60% of the

any difference

by a minimum volunteers were

in taste or in any

of eight adult of rural origin. other characThey did were (T and insea

to note

Subjects All
Nutrition

and

methods of the decwho centers level

teristic

of the foods and beverages not know which preparations had Field acceptability for this with study populations in sugar cane two
were

they had consumed. the fortified sugar. sugar. Four communities sites: two 38 possible

procedures were approved by INCAPs (the Institute of Central America and Panama) Committee for of Human and the in the us to take and operational offield of Subjects, oven the according Public management maintaining Health to the of the their Helsinki health usual Guatemalan communities, practices. application FeNaEDTAand retinyl palmitate-fortifled (Ingenio authorities,

offortifled after screening of I 144 production and

involved

chosen 12)
volved

Protection laration allowed that existed of care Feasibility Production sugar. Diego) already
delivering the

and 1756, respectively, were in the lowlands (50 m above populations

production

level),

and

(13

C) with

of

1645
in the

respectively,

in coffee

and 1095, highlands

( 1100
pairs
profiles

were

m above sea level). These semirural matched as closely as possible socioeconomic from the Department after authorities and what several and was It was accept participation characteristics, of Public town leaders required clearly
individual

low-income by location, and Health. and each Their

community and then, by health cooperation

population, of Guatemala San was study of the

team

available discussions in detail and

Downloaded from ajcn.nutrition.org by guest on November 28, 2012

A sugar agreed being

factory

in the lowlands

obtained involved
members

meetings to explain from

with what the

to add FeNaEDTA produced. Addition in a sweeping of refined added was to the sugar by each

to the vitamin of FeNaEDTA

A-fortified sugar was achieved by powder to had 2% meaThe screw

community

all members

last

manually, centrifugation The amount

motion, the yellow sugar, while it still contained each fell into centrifuge drying did were sugar

communities. would their

understood decisions

that the researchnot to participate at any time, and that on the anemia,

humidity.
sured sugar

in a previously delivers). a conveying

or discontinue this decision other hand, for which The study

in the study

cup (adapted
discharged

load

centrifuge

would not carry any detriment. Participants, would benefit by learning whether they had they was would receive treatment. in a double-blind fashion. conducted

that carried and mixed the sugar to its final mixing stage before packaging. This procedure normal flow FeNaEDTA/kg vitamin A/kg of sugar sugar, production. providing sugar site, The goals 130 mg Fe/kg samples were

and further not alter the to add 1 g and 15 mg sequen-

Community

C served as a control, authors of this study. land

but

unknown to everybody but to the first three In the original experimental design, a lowcommunity were to serve as controls to similar showed lowland

sugar.

Twelve

obtained

and a highland

tially at the packaging of five sugar batches determinations Stability conditions. that tion top. and Sugar

covering the production produced for the study. Iron at INCAP (18, of the fortified and packaging 19). sugar were

period of each and vitamin A under no different tropical than

fortified communities. However, after the basal results a large discrepancy in iron nutrition between the two communities (T only community highland than the community latter did and 12) it was decided C as a control because

were made segregation production

to fortify both and to use it was similar to the other

for ordinary in Guatemala.

vitamin A-fortified The sacks were a slight

color as well

sugar for internal consumptwo-layered paper, sewn at the that helped disguise After production, was where transported the field the the to trials

(13) and differed less from community l from community 12, which showed unexpectsituation resulted in the favorable communities that differed in iron but weakened the design control was because cornto be

The sugar had slight added yellow (iron-fortified warehouses situated were
tropical

brownish hue of FeNaEDTA. unfortified) the communities

as

edly severe iron deficiency. This situation of having three fortified nutrition
there

from

severe

to mild,

sugar

near

was no negative lowland control. The single munity had an intermediate iron nutritional status. The supplied communities by us were to the local informed stores that where a new they sugar

to take
Pacific

place. One warehouse Coast of Guatemala,

was in a town 1 10 m above

located on the sea level, and

would

normally

another one was located midway between the test communities in the Guatemalan highlands, 1080 m above sea level. These warehouses were chosen to represent the usual storage facilities used by
merchants in

purchase their sugar, that the price would be the same as ordinary sugar, and that it may or may not have added iron. We requested that all sugar purchases
in the

be made

in these

stores.

these and

communities.

Sugar

bags

were

stacked

as is were and with

To make
and retailers were asked we sold to keep
distributor

the trial as real-life

communities

as possible,
under study sell the sugar They by

all sugar

distributors

usually

samples for iron and vitamin A analysis obtained periodically for up to 1 y, from the upper, middle, lower portions of 10 randomly chosen bags. Acceptability of commonly used food recipes prepared sugar and and included bread and corn fortified sugar. The added FeNaEDTA was detectable
sugars were placed next

done,

to only

supply of sugar

and

were contacted and we produced, which to do so and Each arrangement household. This

to them a record and

at a 15% store

discount. purchases stable

all agreed each

yellowish hue of the only if the fortified

to each other. Several

containing unfortified common in unfortified various preparations, corn starch masa buns

had a very

clientele.

recipes

allowed month. clients were

Any
about

us to evaluate complaints the sugar with records surveys. The could

each households or other comments were expected obtained subjects thus also noted. purchases exclusive be estimated

sugar purchases every received from their sugar purchases sugof the food-conbased on individual household consumption by household.

Guatemalan sugar kinds of

diets cookies of

were and various deserts.

prepared cakes,

with kitchen. various

fortified These sweet

Household

at INCAPs

experimental

compared

ar-consumption sumption sugar we provided

by periodic

chuchitos

(Dunyea)-based

kinds, and (Chuchitos

fruit-based are solid

FeNaEDTA-FORTIFIED As fortified
(eight for iron

SUGAR sugar and in the gathered analyzed laboratosugar as percent sugar operations also visited was of in the

IMPROVES children nant These gitudinal 9-17 females numbers

IRON

STATUS 80 males

1155 18 y of age, 63 nonpregand 30 females 45 y of age. of obtaining end of the lon3 y in at the

an extra times content Compliance estimated samples

check in 32 mo) with for each

for sugar from

infiltration samples Blue

of unfortified were reaction and with periodically coded, of the fortified expressed unfontified of field were at INCAPs

y of age,

communities,

18-44
were

y of age,
chosen on 163

all households,

in anticipation subjects

by a Prussian

information

ries. also
positive

the consumption household Households visited

for iron. were

fortified

communities

by the head

(EA)
stores.

and encouraged
Other households out
in

to consume
these control households. of iron

sugar

sold

at the community

each community, assuming a 20% dropout rate per year. The actual initial and final numbers studied and their age and sex distribution are presented in Table 1. In the group 9-17 y old the proportion of girls was near 70% in all communities at all evaluation periods. All subjects lost to follow-up had been
investigated nutritional tinuing in the in the When field in terms conditions study. trial possible, lasted of and with their with regard subjects 32 mo. 2. All set subject up hematological, regard did not to these were The to reasons differ encouraged time schedule from conditions iron, for and not (data to continue and the list those other conconnot

in all the communities

to avoid Effectiveness

singling

Dropouts

the

deficiency
>

tinuing invited and to particall individshown). The of are tices Quality procedures. present

All community
ipate in a fingertip uals with mild-moderate highland were treated lations who 67%, 54%, respectively.

members
basal values (defined

aged
hematocnit

I y were screening,

in the trials.
study procedures presented at INCAP controls Some paper are implemented in Table and were results the in the participating hematological both field paper and procedures not covered to follow. sugar is communities

hematocnit degree communities with FeSO4 volunteered

indicative of anemia beyond a as a hematocnit < 30% in the in the lowland communities) popu62%, and C, screenproportions of the were as follows: T, 12, 13, least in the initial only found

or < 28%

conformed
for

to established

pracmethods.

tablets. The for screening

to standardized of these

Downloaded from ajcn.nutrition.org by guest on November 28, 2012

laboratory in the

and 78% for communities Adult males participated

of another

ing, particularly in community 13 where males were screened, none having been community numbers of 66% of children and women treated anemics in these 94, 12, severely

20% of all adult anemic. In this The were, pregin

Biological effectiveness of FeNaEDTA-fortified expressed in terms of hematological and biochemical

the different age, adaptation 1) Subjects the mean (20). from blood/kg norm For the anemic points sex, and with for each iron body of study, as well of the as by the

results (33),
under 20 g/L

at
esti-

were screened. communities

subjects

respectively, 26, treated subjects, nant ness. each whose tological sample, women From

and 22. In this undernourished the 160 mean

paper
children,

all of these
and of effectivemembers and adult

mated
to the The

iron stores,

based
body

on Cook
size of the

et als method
populations following: concentrations

adapted
study.

were excluded from the remaining nontreated, a sample totaling

estimation nonpregnant children

consisted age, g/L

hemoglobin sex, below

from

community,

men

and that

altitude cutoff,

were a deficit

considered of 0.238

and women

was

chosen
was

randomly
below the

among
-

hernatocnit

eligible individuals 1 SD for the hemaThe nest community, of the had

mg body
derived 70 mL

iron stores/kg

body
content wt.

wt was

assigned.

This
(3.4

figure
mg/g)

was
times

norms for Central America for a total of 318 individuals

(20). in each

of hemoglobin

mean
more

hematocnit
than one

values
subject from

- 1 SD from the the same household in the fecal total ova

same
was

norms.
selected to undergo hematolog-

No
in

the sample. sequential ical, and

The subjects detailed dietary, biochemical

sample were and parasite,

subjects with serum fennitin concentrations < 12 g!L, or with serum fennitin concentrations between 12 and 50 p.gfL and inadequate iron transport, the same index
defined estimated by Cook on the et al (33) basis was applied weight but (kg) iron stores were of body as follows:

2) For nonanemic

studies.

The
community

number
was

of subjects
as follows:

by
115

age

and

sex
1-8

sought
y of

children

in each age, 30

Iron stores

0.952

kg)

index

TABLE Number

1 of subjects involved in the study by sex and age groups Number in Basal 91 19 42 15 55 222 70 are higher than T1 Final 35
332

Number sought each Sex and age groups M and F (1-8 y) y) y) y) community 115 30 63 30 80 318 of expected number age and a proportion
-

examined

by community T, C Final 45 39 29 222 39 174 107 were Basal 103 32 60 30 68 293 92 32 mo older Final 50 46 29 29 35 189 116 at the final

T2 Basal 64
23

Final 27
272

Basal 88 20 50 19 68 245 77 because all subjects

M and F (9-17 F (18-44

20 12 27 127 78 those

30 12 56 185 58 in the basal examination

15 10 27 106 65

F ( 45
M Total Percent
1 2

( 18 y)

Control community. Final numbers in these which 20% moved attrition

sex categories

examination,
3

of the subjects

to a higher

age category.

Assuming

for each of 3 y.

1156
TABLE Schedule 2 of study, by month 0 Community involvement and actualization dietary record recall fecal test for sugar intake (Health of previous ova/parasites iron in sugar and distribution (24, 25) x
x (26-29)

VITERI

El

AL

10

12

14

16

18

20

22

24

26

28

30

32

34

36

38

40

42

x x (21) Post) 2 wk (23) (22) x x x x x x

x

Census
Individual Morbidity Morbidity

x
-

x x x x x x x

x
x x

x
x x

x x x x

xx

-x

x-

-x

x x

x x

x x

x x

Quantitative Qualitative Fortified Evaluation Blood Plasma Plasma

(32)

x x
x

x x
x

production evaluation nutrition (31)

Hematological folate vitamin

of iron (30)

x B-12 iron, x and zinc

x

x x
x

x x
x

x x
x

and urine meeting

copper,

Community

and debriefing

Downloaded from ajcn.nutrition.org by guest on November 28, 2012

Inflammation
>

was recognized
presence occurred were

by a serum

ferritin

concentration

50 pg/L in the port. This situation the

of anemia or defects in iron transonly seven times in this study and discarded.

tests effect

to control for of FeNaEDTA

different (37).

basal

iron

stores

in isolating

the

iron-store values 3) For nonanemic ferritin applied. For

=

subjects
children (4.5

with

adequate
the mo

iron transport
following of age
-

and
formu-

Results
Feasibility offield application

serum las were

concentrations

12 p.gfL, 12-107

Iron stores where

.Lg/L.

x kg)

x (ln SF

ln 12)

The produced
neous, being gression the very mean close was

FeNaEDTA-fortified
( SD) iron contents to the amount aimed also very stable except discoloration

sugar

was very

homoge-

and

ln is the natural logarithm and SF is serum ferritin in For females > 9 y old and males between the ages of 9 16 y 11 mo Iron stores
=

(124.3 18.8 mg/kg) for (130 mg/kg). This for a very slow prothat for conditions stored

preparation

of brownish conditions.

in extreme

(4.98

x (ln SF

ln 12)

was
severe

noticeable

to the eye

after

6 mo
sugar

of storage
is seldom

in the most

In Guatemala,

For males Iron

These

17 y of age

more than the bottom

6-8 mo. No settling of the sacks stored

humid between 15 and

of FeNaEDTA under natural

was noted humidity

or vitamin A to storage condi(temperature between 20%

stores

(6.13
for iron

x kg)
stores,

x (ln SF
based

ln 12)
sex, and body and

tions

in tropical

environments 48 #{176}C, and

algorithms

on age,

weight,
total body

were
iron

formulated
for both

from
sexes

literature
at different

values
ages

of normal
(34-36)

oscillated and 95%).

adapted for body weights so that when applied to the adult male and female populations reported by Cook et al (33) the values could be superimposed in the three conditions dictated by the
blood a smooth indicators transition of the body analysis four of iron between study iron status. These algorithms childrens also values allowed and those normal communities

Acceptability and organoleptic food recipes were excellent with

starch that but puddings was strange and gruels to 88% acquired

properties of commonly the following exceptions:

a slight testers, by pinkish-violet but still not

used conn
hue objec-

of the blackened

tionable.

Light-color
Tea

baked
was

preparations

were
the

slightly
addition

darker,
of Fe-

acceptable.

for adults
dwellers tion of their

of the corresponding
stores.

sex.

Actual
were

body
used

weights
for estima-

of

NaEDTA-fortified iron was added

that remained characteristic

sugar, similar to when the same amount of as FeSO4; however, in contrast with the latter
black color with the addition of lemon, it reverted to its in the case of tea with FeNaEDTA-fontified

Statistical

Statistical analysis Institute, Inc, Cary,

serum ferritin

was NC)

performed with SAS and included means

logarithmic

software (SAS and SDs. For

were

sugar. Light coffee was slightly darkened also, but not objectionably so. The appearance of tea and coffee did not change with the addition of milk. In no case was taste, texture, or smell
altered.

concentrations,

transformations

Field
about control the

acceptability

expressed

as

number

of

complaints
in the There

applied because of their comparisons were made

square, peated parisons conditions, simple using and and paired measurements),

positive skewedness. by various techniques,

i

Between-group including chimodels post hoc for recom-

sugar both from and experimental

households communities

and storekeepers was excellent.

tests

(SAS

linear with

analysis

of variance

Bonferronis covaniance

correction tests for individual analysis including post hoc Tukeys

were eight individual complaints registered in 32 mo from households in community T1 and none from the other communities. These eight households frequently received sugar as
partial payment for work from a neighboring sugar mill. These,

FeNaEDTA-FORTIFIED as were exchange Total community pressed individual sum

munity.

SUGAR asked to

IMPROVES categories.
ries.

IRON The rest

STATUS fluctuated were sugar between two adjacent the

1157 categohouseholds

other their sugar

households sugar purchases during the for

in the that 32 by each mo

same

situation, in the intervention

were stones. household could

available individual of

in each be exof The be com88%,

with

No special the higher

in

attributes or lower the control the

detected among consumption. deficiency preintervention)

as percent of expected sugar consumption sugar with This 104%, purchases the estimate and estimate based 92% expected provided for in

based on repeated estimates and household composition. each demand communities with community for sugar l, the compliance could by values each of also

Effectiveness

of iron basal (or and complete

Table
values tion cohorts (32

4 presents
mo later) by age was

and and age on and both

final sex oc-

of

of various community, having determined assigned.

hematological within information

iron-nutni-

compared 98%,

indicators

it, by

of subjects

12,

13,

and

C,
was

respectively. Another obtained tests eight ance expected 93%, These community persistent indicated sugar one and times figures

casions. Final each subject were included between Despite presented excluded, pre-

the age and sex group Because clearly anemic low hemoglobin the differences concentrations and sex group concentrations all but with two the values makes

to which subjects were not study

of compliance in samples of each as the l, there

fortification sugar-iron sugar tests 72%, sugar

extremely This and

on the number the tests indicated

of positive Overall percent were 12, 13,

qualitative household of positive were and no fortified

in the means.

in this

performed during positive 0% results

households

intake complioven 75%, in

posthemoglobin

insensitive. in community than community

intervention. if all that

expressed

this, all but one age lower hemoglobin the basal finding evaluation and is compatible

12

positive was

T
tion.

in

in the higher

final basal

evaluapreva-

in communities

C, respectively. sugar was a It must be a sample time they of had

This

C and problem that some or more

that infiltration in the lowland households times, indicating

of unfortified communities. failed to provide that at the

lence of severe anemia hemoglobin values were Mean cant) basal final hemoglobin

in community higher in the

12. Also as expected, highland communities. in the majority (statistically signifilower relative mean In both Mean
> 45

Downloaded from ajcn.nutrition.org by guest on November 28, 2012

concentrations

increased
>

of instances,
occurred values mean

but mean
only in the values

changes

in the two

10 g/L groups with

run out of sugar, even though they stones. These cases were considered these estimates are compliance figures sugar purchases. of households had conservative estimated these or more in the same four tests from

bought their sugar from the negative tests. Therefore, and lower continuous tests than communitymonitoring 81%, and of 97%

lowland communities. approached normality. in which groups, females were high however,

instances the hemoglobin of age and examination. within between including and particuthan did the the the

decreased males > Final

significantly 18 y of age, in these

y on initial remained capacity

Despite

difficulties, positive

79%,

values

in communities

l,
only ever. from were

12, and 13, respectively,

two positive in the fortified

and only
communities

18%,

14%,

and 2% had
A total of six positive

normal range. Percent saturation basal and final

of total-iron-binding increased

communities. failed

evaluation

in all instances,

households

to test

These coincided with households the stores and were excluded from the lowland communities. average per capita amounts age and sex groups value is itself the

that made no purchases from the study. They all of sugar consumed in each

community C. Again, the lowland communities, larly community 12, presented lower basal values highland deficient transport fortified communities. In all instances, even lowland community, this biological approached communities normality exhibiting at the a greater end

in the most ironindicator of iron of the study, the response.

The

community by Each individual sumption among

are presented average of tended among

in Table 3. 1 1 sugar conto be lower adult males. surveys. group was

In the lowland

communities

(T

and 12) basal

free

erythroof a

surveys. Sugar consumption children < 4 y of age and higher

cyte protoporphynin (FEP) iron-deficient enythropoiesis.

values were elevated, Again, community improvements communities, the .agfL (> 700

indicative 12 presented in this although

Individual sugar consumption When sugar intake in each

varied in the different survey for each age-sex

greater deficiency. Significant were observed in the fortified instances mained in the lowland elevated abnormally

indicator in five values cells) reafter

divided into highest, intermediate, ries, < 5% of all subjects always gory whereas 50-54% of subjects

and lowest intake categoremained in the same cate-

communities

mean

red blood

fluctuated

between

the three

32 mo of fortification.

TABLE Amount

3 of sugar consumed per person in the study communities based on 1 1 individual measurements Community T1 1, T3 C2 in 36 mo

gld
Total Mean population by age and sex groups y) 35.5 39.5 36.8 were performed 42.5 before the 32 mo of intervention. 32.8 37.7 43.0 43.8 31.2
35.7

37.8

23.5

[246-27l]

37.3

20.6

[36()-412]

34.6

15.7

[338-400]

36.1

16.3 36.2
39.1

[204-239]

M and F (1-17 F (18-44 F ( M (

I
2

y)

45 y) 18 y) Two of the I I surveys Control _f SD; community. number of observations

35.0 40.6

36.4 39.5

per survey

in brackets.

1158
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FeNaEDTA-FORTIFIED
Serum the lowland had depleted The fortified fication. fenritin iron changes values demonstrated including As responded in ferritin two upward) communities. adult with very were the that a large men other positively small proportion indicators, to iron in community compared

SUGAR
of 12, the fortiC with

IMPROVES

IRON

STATUS

I 159

populations, reserves. communities

in community

concentration

E
U)

( one
those

downward and in the fortified

Lu

In summary, with few exceptions, when they were lower to begin with
were clearly demonstrated tons of iron community good at basal evaluation subjects. remarkable status C showed within very after Overall, improvements the little 32 anemic

hemoglobin even though

the mo fortified of of study.

values overall
communities

nose they
of the indica-

0 I-

U)

removal

of the values individual In

z
0

contrast, to note
BI2F CHILDREN
I-lly

change. was of was between

It is important a trend among

that in all the communities there ment in hemoglobin concentration lower however, values were at the beginning There only significant.

for an improvethe groups with Few changes, indication

FIGURE at four T1 (U), community. evaluation evaluations T,

the also

study.

BI2F FEMALES lS-44y

BI2F FEMALES 45 y

SI MALES i8 y

an overall the control

1. Evolution
periods

of individual during Community before after those

iron

stores C (0)

grouped

by age and sex in communities

of regression
comparisons

to the mean,
were made

particularly

in community

13. When
and the

evaluation

32 mo of iron

fortification

(#{149}), and
B, basal after

Downloaded from ajcn.nutrition.org by guest on November 28, 2012

T3 (A). evaluation

is the unfortified 1, evaluation from basal

control after to final 8

fortified highland with similar iron

communities (C and 13) that started the study status, differences in final values favored the on the study. of age lowest Women children the are basal To and in of

intervention; All changes

mo of intervention;

2, evaluation 32 mo of except

20 mo of intervention; indicated by NS.

and F, final

intervention.

latter, particularly for serum ferritin concentrations. Means and SDs of individual iron stores estimated basis also iron and begin small except women values. basal of the presented status the with, children changes iron and above of the indicators age stores community and age consistently had lower and sex and by reflect status age and even in the during They with than sex better four in terms were age. older the groups, in Table observed 4. These in iron

are significant

groups

communities

cation slower
It must

and in general, with time, mean rates of change as iron deficiency disappears and stores become be realized whereas that due that positive iron values hemoglobin stones reflect (> an values. determined to have less be expressed 0) represent iron negative to reduced

become larger. iron in-

behaved

as expected increased iron stores

reserves, cluding Given normal

deficit,

sex groups reproductive

characteristics.

(a

that iron reserves are greatly child would be expected grown adult), they can

by body size iron reserves as a percent of

in community C. Iron stores were higher in older and in adult men, who, in general, exhibited the highest As seen before, the lowland communities had lower iron stores for the same and age and sex groups were, than those of communities, all the groups on average,

than

a fully

the norm for individuals norm for iron reserves

normal from ods). stones, the algorithms circulating published used iron

of the same was estimated

from which iron normal also stones data,

sex and similar by subtracting

total served (explained body iron

size. The the total

derived the Meth-

the highland

to generate under

iron deficient in community significant in the fortified

12. Increments
communities

in iron stores
in all but two age

were
and

to estimate reserves values

By expressing negative

as a percent iron

of the norm, deficiency (<

the effect 0 reserves)

sex groups,

and remained

static

in community

C, except

for the

of age and sex on iron reserves

represent

was controlled

for. As for iron

adult males, who increment did not same iron group stores

increased their iron stores differ (P > 0.07) from that 13. sequential instances changes when and

with time. This registered for the observed in mean was and 32

Figure
programmed:

1 depicts
in

in community the the basal four (before

and are expressed also as percentile units of the norm. Therefore, 100% represents an iron deficit of the same magnitude
-

as total with

the

normally the sample control by

expected community, as

reserves of results and

for even

that by Figure

individual. averages fortified 2 presents

This in the

blood

sampling at 8, 20,

allows

expression populations

as weighted

intervention)

compared the where 100% and negative

mo of intervention. for whom complete

period: 89, 74, 154,

The data include only the cohort information was available in each
and 132 subjects for communities

subjects sampling
T, 12,

a whole.

basal and final results of this mode of expression, reflects the norm, 0% indicates no iron reserves, values reflect iron reserves. iron deficiencies as percents The effect of sugar fortification

13, and C, respectively. In other words, they constitute 70%, 70%, 88%, and 70% ofthe cohort with complete basal and final values in the respective communities. For this reason, the two groups subset groups, of children of subjects, were none for women stores. and magnitude revealing. more of the response The fastest and deficient groups to iron highest at the start fortification increments of fortificombined of the groups into a single in community group. In this C showed

of expected normal with FeNaEDTA values positive

as well as the stability Covariance analysis were controlled for changes relation in iron stores to community

of community C are evident. (data not shown) in which basal demonstrated occurred C. The that significant in each fortified fortified communities

a significant
except in iron

change women

in iron

stores

whereas
age

all the significant

fortified
T

of reproductive

in community

community in as a group

and older
ments The shape is particularly occur

in community

13, showed

incre-

were
lute

also
as well

different
results

from

the control
iron including and urinary

community
store values. detailed mineral

in both
data

abso-

as in normalized of this among plasma study, and treated

Other prevalences dietary

on anemia morbidity,

nontreated trace

groups,

among

the

intake,

concentrations,

1160
150

VITERI

El

AL

100
>
Lu

NS

U)
Lu

50
NS4

174NS f

KS MANS

2/s

z
0

a!
I-

-50
ULu

-100 B AGE(y) SEX FIGURE community evaluations F, female; 2. Iron reserves

= 189)

z
0

F 1-8 M+F and deficit

B 9-Il M+F expressed indicated

B 18-44 F as percent

B 45 F norm
127),

B 18 N

B ALL ALL

Downloaded from ajcn.nutrition.org by guest on November 28, 2012

of individual T1
J,

grouped T2

by age and sex and for the total

106),

population
All

(all) from

in the control basal to final M, male;

(0, n
ALL,

and except mean

in the fortified those and SD for

communities the community

(#{149}, n =
intervention;

and T3 (A, F, final

n =

179).

changes

are significant weighted

by NS. B, basal

evaluation

before .t SD.

evaluation

after

32 mo

of intervention;

as a whole.

vitamin studied

A are

nutrition, the object 12, and that

and

parasite

loads publication greater

among (in morbidity

the

subjects

did great

not

differ.

Also, in the of subject

there trial and

were was due

no

instances fortified desertions

in

which sugar. were due

the The to

of another

preparation).

discontinuation majority fecal in economically jects in the the cohort reduces groups Despite

to the

Suffice
ularly

it to state
community

that both to hookworm

the rest

lowland infection
of these

communities, than
variables

and particand similar

household

exhibited

blood

loss

due

did the highland

were

triggered cohort with with complete

migration. basal and data

The reduced number final evaluation, and four periodic differences evaluation

of subalso in between periods.

communities,

in the

evaluations,

all the communities. tion with FeNaEDTA, be detected.

No undesirable effects under the conditions

of sugar fortificaof this trial, could

the probability and within groups this, results

of significant at the different in favor

are clear

of the fortified

population

Discussion
This liminany among where iron-fortification steps to the low-income, iron deficiency study implementation included testing of a field a series trial of pre-

except for hemoglobin concentration. 2) Because iron fortification is primarily

a preventive

rather

than a therapeutic measure for iron deficiency, and for ethical reasons, any individual with moderate or severe anemia (hematocrit was usually personnel. during given
< 30%

conducted

in the in the

highlands therapy as not study were

and and well communities

<

28% other any

in the medical by Health women

lowlands) attention Service pregnant report. hernoglo-

semirural communities in Guatemala, and its consequent anemia are prevalent

a course provided These

of iron subjects, trial,

and

the

32-mo
were

field

trial

itself.
in the

Both
field

highland
trial

and
the

lowland
effec-

as

populations

included

to test

the 32-mo

included individuals

in the present with low

tiveness of sugar under conditions and

ity

fortification with leading to different anemia. All aspects

vitamin degrees of this

A and FeNaEDTA of iron deficiency study were success-

As a consequence

of excluding

ferropenic

bin values, the sensitivity of hemoglobin response to fortification was markedly reduced. In effect, only 20 of a total cohort
of 596 sample in subjects (3.3% had hemoglobin values
<

ful in proving

of execution,
vitamin

the feasibility, organoleptic advantages, simplicand biological effectiveness of FeNaEDTAsugar in controlling iron deficiency

100

gIL

in the basal

prevalence).

Of these,

19 resided

in the lowlands,

and

A-fortified Guatemala.

6 were

children

between

1 and

8 y of age,

and 5 were

adult

semirural

The
could issues

field

trial

was

not

without

problems,

some

of which
Four main

males in community 12. At the final evaluation, 13 subjects had hemoglobin concentrations < 100 g/L (2.2% prevalence). Twelve of these resided in the lowlands and five of them were

weaken or are addressed

invalidate in this

the results regard.

obtained.

children
time could be if there was a

between

1 and 8 y of age.
to this before, Because in the for the lowland other.

Two

adult

males

in corndesign and in could resource iron not

1) The responsible
natural
erentially

reduction in number of subjects with for explaining some of the results

munity 12 belonged 3) As indicated called one serve nutritional for in the two status control lowlands.

group. the original one of The the

experimental in the highlands one and overall great disparity

selection

process situation
analysis

that excluded
subjects in the

from
fortified

follow-up
communities.

pref-

communities,

iron-deficient on extensive

The
based

confounding

can

be rejected

with
and

confidence
socioeco-

communities, time

of the hematological the dropouts which showed

as a control

nomical characteristics of those remaining in the trial,

in comparison with that the populations

effort already invested when the disparity became impractical to seek a third lowland community.

clear made it The fact that

FeNaEDTA-FORTIFIED
the control and community biology showed during a remarkable stability while

SUGAR
in iron the three

IMPROVES
explanations. cation consumed of the improbable

IRON
The sugar
because

STATUS
possibility in this sugar for trial not (data include highlands vitamin and of an effect all other with years shown). who 28% in had the fortified several A deficiency not or subjects
<

1161 of vitamin communities vitamin before in plasma this A fortifiis highly A was trial samples hematocnit lowlands, being and at

nutrition

the 32 mo of study,

fortified communities, including a similar (13), showed a significant improvement makes us confident of the results sugar exclusively near men sugar-cane in these imperfect design. 4) Infiltration nities nities that was (T employed detected and 12), most

highland community in the same indicators even fortified lowland with this

in Guatemala not detect do during results

<

obtained into the

we any

did time These

the

of unfortified almost located of the

commucommuand mills During could practice in the on less were A sold. Based

in the

values

30%

in the

plantations communities.

corresponding to hemoglobin g/L, respectively, at any evaluations or groups of more

in a following

concentrations of the evaluations to the anemic clinics. subjects The are

close to 95 and 90 before the final details of these to be considered it to say that with new eight cases of time were which treated lower than new in

sugar-production receive some was reduced intervention household than expected to encouraged
qualitative

periods (-4 mo of the year) employees sugar at the mills as pay in kind. This when period, sugar-purchase and receiving exchange the but mills did were not sugar this approached fully directly for disappear. those from that early purchasing

at visits severely article severe anemia to the last 12

(in preparation). declined point mo of that

Suffice significantly only nine

cases detected occurred subjects

in

of more in

monitoring, sugar

all the communities the in community in the fortified T

the mills being

intervention,

reinforce basis of

test to detect iron the exchange policy. continued sugar fortified

in sugar was also introduced to The end result was that on the and
>

12, and that communities 13 (7.5% and Recurrences

recurrences among were significantly 4.0%, respectively) despite their in community

in communities community to those similar

and

Downloaded from ajcn.nutrition.org by guest on November 28, 2012

purchases sugar

exchange 50% of the

77% time,
> 90%

of

C (28.9%). in community

12 were having iron of

households consumed 67% of households time.

Despite

consumed

fortified
the results fortification criteria

sugar
of this with of the

and of the

C (27.2%)

these

shortcomings, of sugar by using

study World

demonHealth cutoff a decline lowland 27.3% in

a much greater hookworm infestation and a precarious nutritional status before fortification. The more important results, given the preventive approach the trial, nutrition community munity by
rnunity.

strate

the

effectiveness

FeNaEDTA.

If anemia
Organization hemoglobin in the communities: community in community among

is estimated

are those in these

that reflect populations.

the biological aspects of iron As was evident in Table 4, the by most the iron-deficient other lowland had start with give strong very of the those support of iron similar trial. expected corncorniron The by to the stones

(WHO) corrected values are increased of

-

for altitude (highland by 5 g/L), there was anemia prevalence in both of a basal

12 was consistently all indicators, followed two were by age highland less and deficient in iron sex and groups

prevalence T,

mild-moderate from

The and and

communities at the biology

13.9%

statuses concordance altitude

and - 16.9% 12. This fall children, women

from

a basal

prevalence
occurred and adult

of 41.7%
primarily men in

of results in these indicators

in prevalence

young

> 45 y of age

findings and age

in the estimations

community T, and among all age and sex groups in community 12. There was also a 2.6% decline in anemia prevalence in the highland community (13), from a basal prevalence of 10.2% showed tion to of 8.7%. a final These prevalence in prevalence reductions of 7.6%. 13.9% Community to C also a decline from

relative iron reserves and sex categories. with time of relative expectations. this field as each in some populations is greatly

despite small numbers in some of the Moreover, the sequence of change depicted reserves show shown the clear in Figure in Figure tendency levels and equilibrium to be l the and degree 1 and the iron trial 2 agree of iron

observed characteristics

of fortification

5.2%,
except

a reducfor those

are significant

with biological Results from stores suggesting status among new needs most reached. the to
characteristic

in community 13. The reduction in anemia prevalence in the lowland communities was also significantly greater than that in community C (P < 0.05). Given the sample structure of the
trial, sugar even these among results are with populations as high encouraging FeNaEDTA with overall and support the efficacy nutrition anemia of fortification in improving mild-moderate iron

stabilize of that adult

they age in 32

reach certain and sex group a new This mo. appears by

that appear community, in iron the 13. case This will is The

situations

is approached equilibrium

of communities determined pathological to increase in most groups

of iron

prevalence

as 41.7%.

At final

evaluation

66 subjects
Of these, at the

had hemoglobin

values

below

(requirements plus probably continue This is evident

losses). Iron stones until this equilibrium of community in response in communities 12. are that reserves

the WHO cutoff. bin concentrations Twelve adults:

20 individuals final than at

had lower hemoglothe basal evaluation. eight

> 45

of these were lowland residents and of them two women of reproductive age, one woman men. 13: In two

were y of

implications of this phenomenon fication programs, iron stores and poor diets and large values than desirable environmental iron reserves that will probably health, among losses until and women

to fontiwith

age, and five adult resided in community age, male one adult woman adults, whereas resided

the highland communities, subjects between 9 and sex category, in each age

six 17 y of and and two sex

will take longer to stabilize at lower losses are reduced (deparasitization, birth spacing). The ideal age of bringing to an amount will most in the develof reproductive

in each age and two adult women

category concentrations

We have

in community C. no explanation for the improvement in community C. We could claim efficiency treatment in health of anemia these

prevent iron deficiency not occur under most could

during pregnancy present conditions

in hemoglobin regression to care (under our in all the commuare only possible

the mean and greater control), including the

nities,

oping world. This tive supplementation same time, under iron are overload minuscule. Five

probably be achieved only by prevenof this vulnerable group (8, 39). At the these circumstances the risks of producing of iron-fortification and six cases programs at end evalucases at basal

as a consequence

including

the

control.

However,

1162
ations which with
oratory by

VITERI had estimated iron occurred in children elevated

indicators

El

AL grammes that the present fication clusions and additive sodium tentative and iron that The Committee prepared when used provisionally at the meeting concluded meeting does food not forti-

reserves and deficiency.

>

women

130% of normal, of reproductive without distribution other

all

of age lab-

EDIA problem

(ethylenediaminotetraacetate) in supervised

serum

ferritin of iron

concentrations The

specifications

of cases

a safety programmes are based

age and sex groups and serum ferritin concentrations these The cases suggest an artifact of response magnitudes

the lack of persistence from basal to final of inflammation. in iron stores

of elevated evaluations in during the trial

in iron deficient populations. on exhaustive tests in experimental essentially range show of doses. that Acute EDIA and chronic

These conanimals is a safe food toxicity to those acceptable sugar

humans, over

which a wide

agree with expectations in that community 12 had the greatest response whereas community 13 had the smallest one, in direct proportion covaniance to initial analysis iron not degree of the of iron deficiency. to fortification, for, indicate start of the on iron Results with from difresponse

occurs with doses that used in iron-fortification daily intake (ADI) for fortification even safe The trials
cultural-grade

are completely programs. EDIA is 2.5

out of proportion Currently the mg/kg. This

makes

ferences in basal iron stores were fortification had even, these increased munities, especially tion.
growth.

stores controlled deficient at the effect similarly when they were

that when trial, iron How-

with FeNaEDTA for 9.3-kg infants reported here FeNaEDIA were

at the amounts used in this trial consuming 30 g fortified sugan/d. conducted that were with batches of agniand of bacteniologically

an insignificant

reserves.

and only in the fortified cornwere negative before fortificaincrements in keeping with in iron their reserves physical

chemically Results of

analyzed for heavy these analyses and

metals and other contaminants. the very low consumption

Also,

in the

groups

of children

EDIA
compared complete humans. Given

as a food
with safety these

additive
industrially in the use

in semi-rural
advanced of

Guaternalan
countries

diets
indicate sugar organoleptic

as
the

in the fortified accomplishing populations tional status At the same load. The
trative mality

communities

Downloaded from ajcn.nutrition.org by guest on November 28, 2012

In other
studied:

words,
exactly

sugar
what

fortified
hoped bringing

with
normality

FeNaEDTA
to iron

was
in the nutni-

FeNaEDTA-fortified and because of the

by

it was it when essentially

to accomplish

it was

developments advantages programs,

and maintaining time it posed obtained this

iron needs no danger 13 are mean

were elevated. of iron overillusnorwere

and stability fortification

of FeNaEDTA, its ease in handling its proven efficacy as an iron source A and iron) even under low risk FeNaEDTA other be

in in

results in that

in community community because be

particularly was iron reaching reserves reserves on (33), male

doubly fortified nutritional status conditions, load sidered As in with grams, should samples overload mote. and in iron-deficient an excellent all

sugar (vitamin of populations the extremely populations, choice and monitoring should

to improve iron very unfavorable iron overbe con(41). proof changes monitoring should programs and This

as a whole

of inducing

in the final

evaluation

86% of the norm. The distribution males in this community can mated from Cook body et als size data the smaller

of final iron superimposed men adult

in adult that estifor population age and of adult in sugar (6). The In prevaand at the end

in iron-fortification of compliance established.

fortification status

nutrition-intervention

for adult

adjusted

a systematic

of the Guatemalan

nutritional

of that community. sex group conform males in the US Survey, and iron nutrition among low of the contrast, lence were men overall trial

This suggests that the data to that for iron nutritional National Health and Nutrition

for this status

include serum of adult males (42), though

fernitin determinations in well-defined to prevent any long-term risk of iron at present this effect appears with very re-

Examination normality

that, taking that can be achieved even supports when the iron prevalence

as the norm, complete with FeNaEDTA-fortified of their in that C had were only diet of this the 42% community same

the quality of anemia near community reserves

is poor

Cost-benefit proves extremely

analysis of sugar favorable and even as a national therapeutic suggest

fortification cost projections that after present for developing the

FeNaEDIA for the control years of may of its iron actuof supple-

of iron
mentation

deficiency and

a few costs

normality

population. low norm of the

establishment

program, programs of the

even of anemia, stable.

though

control world

deficiency in some regions ally be reduced (2, 43).

Special mia thanks are given Group Thanks of this Health and

Estimates of percent iron absorption provided by the FeNaEDTA-fortified pliance

munities

from the diet sugar adjusted method including a growth

plus that for corncomcompofecal have

to various (INACG) for and

members their

of the International advice, G Kahn especially for Carpenter cooperation,

their

Aneto Jesus for his and The in al-

Consultative for

can in children losses estimated.

be

obtained iron during The

by

a factorial

in these median stores

Bulux
critical

his technical

help, manuscript.

to Samuel expressed We
study

his continued to the Guateunderstand-

where from

requirements, and

encouragement. review Public patience, malan

especially

are also

to Kenneth for their

for

nent iron been

the 32 rno of fortification, changes iron in iron absorption figures for mean

are deeply
communities

indebted

hookworm,

and Community
of the

authorities with

estimates

to the

members

for different

communities

and age and sex groups

range

from

ing, lowing

decided special made

collaboration San Diego batches these

the

field

personnel. Guatemala)

0.95 to 3.06 rng Fe/d, or 3.5-14.1% within the range of absorption double-isotope Guaternalan
nities,

of total iron intake, values obtained in previously consumed conducted by these sugar are in line with

and are specific, with commuThus,

decided

cooperation us to prepare sugar

of Ingenio

(Escuintla, possible.

of vitamin studies

A and FeNaEDTA-fortified

radioiron diets and in iron estimates. similar without stores

studies to those and

and -unfortified

with

FeNaEDTA-fortified reserves

(11).

the changes absorption

possible

References
1.

World nutrient WHO,

Health 1992. FE. Iron

Organization. 89th

National session In:

strategies of the

for overcoming Board.

microGeneva: con-

Recently a Joint Additives (JECFA) sionally considered

FAO/WHO Expert Committee on Food (40) concluded that FeNaEDTA is provito be safe in food fortification pro-

malnutrition.

Executive hunger.

2.

Viteri

deficiency.

Ending

hidden

A policy

FeNaEDTA-FORTIFIED
ference Child ville,
4.

SUGAR
Task Force for

IMPROVES
dietary mala).
22.

IRON
intake Trop

STATUS
two methods (San Antonio A, Klein J Trop Ia Paz,

I 163
Guate-

on Survival

micronutrient CO. Center NS.

malnutrition. significance Meharry of

Atlanta: 1992:145-84.

The

comparing Geogr Med

and Development, ed. Functional for Nutrition, The Technol deficiencies. Advisory challengc status Committee de Salud evaluation

1965;17:135-45. C, Lechtig surveys. R. UnderreEnviron ed. New morbidity Introduction Inc, 1955. in Haematology. blood. Lewis Academic in blood iron plasma binding Recomin human of the PCV. London: of iron of total In: Br J Haematol SM, Coster Press, JF, 1975: Pediatr 10th

3. Enwonwu
TN: Scrimshaw industry. 5. Viteri iron 6. FE. and

of iron Medical

deficiency. College, to 1990. the

Nashfood

Martorell porting Child

R, Habicht in fortnightly Health AC, John Read

JP, Yarbrough recall CP.

global

malnutrition American Research, de Centro

1976;22:129-34. to parasitology. Wiley for and Sons

Food folate

1993;47:6()-71. of the Central DC: on Medical de los paIses of the population Institute (in Mata U. of Nutrition Nutritional (Anemias population: Health America America Am#{233}rAmerica y Washington, Pan American 1973.

23.

Chandler York:

Hematological

24.

International Committee
mendations 1967; 13(suppl):71-5.

for Standardization

Organization. Panama. ica 7. Viteri America. Centro noam

8. INACG.

haemoglobinometry appraisal

INCAP/OIR/Ministerios Nutritional and Panama.

y

of Central of Central anemias

25.

Chanarin eds. Quality 103-10.

I. Critical control

(Evaluaci#{243}n nutricional Guatemala: (INCAP), 1969

de la poblaci#{243}n de Centro

in haematology.

Panama.) FE,

and Panama

Spanish). in Central en Latiinfection. Nutricionales Arch

26.

Ramsay Clin Chim Ramsay serum. Heller whole Ramco. Co. Herbert activity Anderson vitamin

WNM. Acta WNM. Clin SR, blood. Serum Chim Labbe

The determination 1957;2:214-20. The determination 1957;2:221-6.

or serum. capacity of in

Guzm#{225}n MA, Influence Influencia iron

of hookworm

27.

America. Nutr Combating

de Ia infeccion (in Spanish). deficiency DC: The anemia Nutrition

por uncinaria.) through food Evaluation Washington, F, Gonzalez Nutr iron

Acta Chem

1973;23:33-53 Washington, G, Aguilar with Health vitamin

28.

RF, Nutter

J. A simplified kit.

assay

for porphyrins TX: Ramco

fortification Inc, 1990. of sugar DC: Pan 30. 31.

32. 29.

Clin

1971;l7:525-8. radio-immuno-assay Houston,

technology. 9. Arroyave fortification American 10. Layrisse as a vehicle

1 1. Viteri

Foundation, level.

ferritin

JR. Flores Organization, fortification.

M, Guzm#{225}nMA. 1979.

1974. V. Aseptic in human BB. B,2 SW,

JD,

Downloaded from ajcn.nutrition.org by guest on November 28, 2012

A at the national C, Renzi Am

addition serum.

method J Clin into Pathol J Clin 5K, Cook Serum Pathol

for Lactobacillus l966;19:12-4. method and zinc MG. CA. for Euglena copper Pathol Blood

casei of folate
assay of the

M, Martincz-Torres for iron

M, Velez J Clin

M. Sugar as an studies. fortifiWR, Fe(II-

1976;29:8-18. NaFe-EDTA Absorption

Investigation J Clin ER. Am BG,

FE, GarcIa-Iba#{241}ez R, Tor#{252}n B. Sodium fortification J Clin Am Nutr J Clin AP, RW. FE, Monroe Quebec, Mcd DE, compound 1978;31:961-71. C. Fe(III)EDTA 1977;30:1166-74. TB, Torrance the in Central America.

in serum. Gabrielli conditions. Skikne in the U.S.

l964;17:14-26. levels Estimates Clinical UK: in various of iron 1970;54:570-7. 1986;68:726-31. estimation Blackwell of measureIn: London: L, Oxford, Methods deficiency.

iron Am
12.

Sinha
Cook

pathologic
33.

Layrisse cation. MacPhail Charlton I)EDTA.

M, Martinez-Tones Nutr Bothwell Factors

complex

as iron

Lynch population. RW,

Reusser JD, Finch in man.

sufficiency 34. Bothwell of body Scientific 35. Heinrich ment, Hallberg Academic 36. Saddi Harwerth Press,
37.

13.

DP, Deyman absorption of iron with of

DP, Bezwoda iron from

TB, iron HC. dose

Charlton stores. Intestinal Iron

affecting

metabolism 1979:89-95. iron absorption

Br J Nutr by means WI,

198 l;45:215-27. deficiency NaFeEDTA. Nutrition Am in Thai TH, Gillooly Med fish M, trial. between in Central In: White Congress Assoc, sauce. Mayet Am (5th 1978. Ann FG. J Clin
38.

Publications, relationship,

14. Viteri America PL,

1977, 15.

GarcIa-Iba#{241}ez R. Prevention of sugar eds. fortification Western Nutrition

in man. and A, eds. Iron during deficiency. SAS users

diagnostic HG, Vannotti requirements A, eds. Iron

therapeutic

applications.

Hemisphere in transition.

L, Harwerth Press, HG, R, Schapira 1970:183-98. Analysis NC: SAS FE. A guide

Canada).

1970:213-96. G. Iron Vanotti growth. In: Hallberg Academic statistics. anemias 5th and London: guide:

Garby Trop Ballot

L, Areekul Parasitol MacPhail of curry report Rodriguez fortified vitamina

S. Iron AP, powder

supplementation Bothwell with

1974;68:467-76. NaFe(III)EDTA iron-fortification in an iron-deficient

16.

Fortification population: Nutr I 7. Pineda iron in sugar nes entre tato

18.

Statistical ed. Cary, Viteri iron tion.

System Institute for

Institute. Inc,

of a controlled A, Viteri in both with retinyl A y hierro de ambos

1985. control Unit of nutritional World Health Organiza-

1980;49:162-9. 0, FE. Interactions nutrients. palmitate nutrientes Guatemala and Panama Cook Iron JD, vitamin of both en ambos fortificada Guatemala: CA. A and nutrients in rats deficient Bioavailability and NaFeEDTA. en azucar City, Finch

the global

deficiency. Geneva, when iron

Presented WHO: 1993.

to Nutrition

(Interaccionutrientes. con palmiInstitute 1977:118-22. Measurement Oxford, of UK: of

39.

Viteri iron

FE, Hercberg study). Joint Forty-first Iron EDTA

5, Gal#{225}n P, Guiro Lausanne, FAOIWHO meeting. for food Inc,

A. Absorption

of supplementary daily or weekly (a 1994: Additives INACG, of iron

en ratas deficientes

supplementation report 1993.)

is administered Switzerland: Expert Geneva: fortification. 1993. and clinical 1989;2:363-89.

Biodisponibilidad de retinol TH, iron OH, Chem and Nutrition Bothwell tissue Blackwell 19. Lowry tometer J Biol
20.

collaborative 82-96. 40. 41.

42.

Nestl#{233} Foundation, on Food 1993. DC:

y NaFeEDTA.) America RW, losses. OA. The Publications, Charlton iron

(Annual

of Central

(in Spanish). in man.

WHO-FAO. (JECFA). INACG. The Kaltwasser overload. Levin eds. Oxford HM, Disease

Committee WHO,

metabolism 1979:443-fl.

Washington,

Scientific Bessey to measurements

Nutrition

Foundation, JP, Werner Clin DT,

adaptation

of the Beckman of biological haematological of family

spectrophomaterials.

E. Diagnosis Haematol Mosley 1993:421-5

evaluation

on minute

quantities Normal

Baillieres Pollitt In: Jamison control University

1946;163:633-42. V, Guzm#{225}nMA. population. Z, Lara MY. values and mothers in American Flores Br J Haematol Estimation 1972;23:189-204.

43.

E, Galloway priorities Press,

R, McGuire WH, 1. in developing

J. Micronutrient Measham AR, countries.

deficiency Bobadilla New JL, York:

Viteri Flores

FE, de Tuna M,

disorders.

the Central
21.