Dispelling myths about universal iron fortification

Published on Sep 09, 2022 05:43 PM IST

The article has been authored by Dr Tulika Seth, professor of haematology, All India Institute of Medical Sciences (AIIMS), New Delhi.

According to research done by Indian researchers, like Dr Dipty Jain, many children with sickle cell disease have an iron deficiency as well.(Twitter/AndyVermaut)
According to research done by Indian researchers, like Dr Dipty Jain, many children with sickle cell disease have an iron deficiency as well.(Twitter/AndyVermaut)
ByHindustan Times

There has been much discussion lately around food fortification as a strategy and intervention to address micronutrient deficiencies among affected populations. This piece offers a perspective on the health impact and effectiveness of fortification of food with iron, which is a critical element for addressing anemia.

Anemia caused by iron deficiency is widespread globally. The condition leads to health problems like fatigue, weakness, a higher risk of infections, forgetfulness, lack of concentration, and even heart failure in case of severe anemia. It primarily impacts children and women. It also has an inter-generational impact as it creates a vicious cycle of iron deficiency and health problems as it is passed on from anemic mothers to their babies.

In this scenario, food fortification with iron has emerged as a scientific, widely accepted, and viable public health measure to combat widespread iron deficiency. Many countries are using diverse measures for fortification through bread, salt, rice and flour.

Concerns raised over the so-called adverse health impacts of food fortification have been researched and investigated extensively. These in-depth evaluations of food fortification have established that besides some alterations in taste in the food after the fortification with iron, there are no negative health impacts even among people who have existing health conditions.

Let’s look at some of the concerns and research findings that have addressed these. In many cases, iron-fortified food has advantages over traditional iron medicines.

Diarrhea and other gastrointestinal problems can occur with the use of iron-containing medicines. An investigation by Gera T, Sachdev HS et al. in 2012 found that oral iron supplements/medicines caused an 11% increase in diarrhoea in children in developing countries, but with iron-fortified food, there was a near absence of diarrhoea. This is because the amount of iron added to fortified foods is lower, making it closer to the physiological condition.

Iron medicines in the form of capsules or injections at the time of infection are usually not recommended as there is a small possibility that the iron may be used by bacteria for their growth or that malaria infection may become more severe due to high levels of non -transferrin bound iron (NTBI) in the blood from iron medicines.

Normally, in the presence of an infection or inflammation, the body produces a hormone called hepcidin, which reduces the absorption of iron from the intestines. Hepcidin also affects an iron transporter in the body called ferroportin, which stops the passage of iron from the intestine into the blood reducing recycling of iron in the body. This is a natural switch that decreases iron absorption and makes the food fortification less effective during infections and inflammation. Several researchers and doctors have evaluated the effect of food fortification in African countries and other malaria-endemic areas. Evidence in the form of research data has been published in journals like PLOS One and the European Journal of clinical nutrition showing food fortification did not cause any increase in the severity of malaria or other infections.

Patients with thalassemia major have anaemia due to ineffective blood production and they require regular frequent blood transfusions every 2-3 weeks. Patients with these conditions get iron overload through blood transfusions as each unit of packed red blood cells contains 200–250 mg of iron. Such persons should be on iron chelation (removal) medicines and be regularly monitored for their iron overload blood levels. These patients also absorb some iron from their normal food and taking tea along with meals can reduce this absorption of iron from normal food.

Additionally, according to research done by Indian researchers, like Dr Dipty Jain, many children with sickle cell disease have an iron deficiency as well. Though some sickle cell disease patients need blood transfusions, iron overload is rare in sickle cell disease. If the sickle cell patient is on regular blood transfusion, they will also be given iron chelation medicine by their doctor.

Since patients who get regular blood transfusions are not iron deficient, they do not require iron-fortified food. However, the amount of iron in normal food or fortified food is insignificant concerning the high doses of iron received from blood transfusions, and iron chelating medicines can take care of this.

Hence, consumption of iron-fortified foods will not be dangerous or life-threatening as several headlines have tried to alarm the public.

This is scientifically proven as food fortification is unlike iron medicines or injections.

Non-transferring bound iron (NTBI) causes organ damage in patients with thalassemia major, thalassemia intermedia, and some sickle cell disease patients with iron overload patients. There is only a negligible or no NTBI formed on the consumption of iron-fortified foods, even when the foods are fortified with ferrous sulphate. This was found in a randomized control trial; such data is high-quality scientific data and has been published by Brittenham et al in the American journal of clinical nutrition.

Regular check-ups for sickle cell disease and thalassemia patients receiving regular blood transfusions are always performed as the blood transfusions are given in a hospital or other health care centre. They can additionally be advised to drink tea along with any meals that are made from iron-fortified food. Iron monitoring and iron chelation medicines are now being provided free by many state governments. These regular monitoring measures are required for all patients on regular blood transfusion support.

The persons who may have sickle cell trait or thalassemia minor are only carriers, they do not suffer from any disease, and these persons are not at any risk for iron overload and can freely consume iron-fortified foods.

Those patients who are on regular blood transfusion should continue with their iron chelating medicines and get iron levels regularly monitored as advised by the NHM guidelines for hemoglobinopathies. The randomized control trial of iron-fortified food has shown safety and no increase in NTBI. These persons can also consume tea with meals made with fortified rice, to further reduce the possibility of iron absorption. Though it is not necessary.

To sum up, universal iron fortification is safe. Misleading speculations or alarmist messages not based on scientific facts and good quality data should be avoided.

The article has been authored by Dr Tulika Seth, professor of haematology, All India Institute of Medical Sciences (AIIMS), New Delhi.

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