JOURNAL OF TROPICAL PEDIATRICS, VOL. 58, NO. 6, 2012 Use of Iron-Fortified Rice Reduces Anemia in Infants by Francisco Plácido Nogueira Arcanjo,1 Paulo Roberto Santos,1 Caio Plácido Costa Arcanjo,2 Olga Maria Silverio Amancio,3 and Josefina Aparecida Pellegrini Braga3 1 Federal University of Ceara, Sobral Unit 2 University of Fortaleza 3 Federal University of Sao Paulo Summary Food fortification is advocated to tackle iron deficiency in anemic populations. Our objective was to Õ evaluate the impact of iron-fortified rice (Ultrarice ) weekly on hemoglobin and anemia levels compared with standard rice (control). This cluster-randomized study deals with infants (10–23 months) from two public child day care centers in Brazil, n ¼ 216, in an 18 week intervention. The intervention group received individual portions of fortified rice (50 g) provided 56.4 mg elemental/Fe. For intervention center: baseline mean hemoglobin was 11.44  1.07 g/dl, and after intervention 11.67  0.96 g/dl, p < 0.029; for control: baseline mean hemoglobin value was 11.35  4.01 g/dl, and after intervention 11.36  2.10 g/dl, p ¼ 0.986. Anemia prevalence for intervention center was 31.25% at baseline, and 18.75% at end of study, p ¼ 0.045; for control 43.50% were anemic at baseline, and 37.1% at the end of study, p ¼ 0.22. Number Needed to Treat was 7. Iron-fortified rice was effective in increasing hemoglobin levels and reducing anemia in infants. Key words: anemia, rice, fortification, iron, infants, hemoglobins. Introduction Iron deficiency anemia (IDA) is considered to be the most prevalent micronutrient malnutrition, global anemia prevalence is estimated at 24.8% or 1.62 billion individuals [1]. Anemia affects approximately 600 million preschoolers and school-aged children increasing morbidity and mortality, growth retardation and impaired motor and cognitive development [2]. Consequences of anemia and iron deficiency (ID) are multiple and serious, affecting not only the health Acknowledgements The author would like to thank the infants and teachers at the day care centers for their participation and cooperation during this clinical trial; Secretariat of Education and Secretariat of Health at the Municipal City Hall—Morrinhos-CE for their support during the project. Funding This project was funded by Santa Casa de Misericórdia de Sobral Hospital—Research Initiative Grant. of individuals, but also the development of societies and countries. One of the most serious consequences of IDA is increased maternal and perinatal mortality. In the child, anemia and ID negatively affect cognitive and physical development. In adults, it results in a reduction of physical capacity and productivity [3]. Data from WHO reveal that 800 000 deaths each year may be attributed to iron deficiency. In terms of healthy life loss, expressed in disability-adjusted life-years (DALYs), anemia through ID results in 25 million DALYs (2.4% of the world total) [4]. Preschool-age children (aged <5 years) are among the most vulnerable for IDA. The prevalence estimate of global anemia for preschool children is 293.1 million cases, or 47.4% of the total population [1]. In Brazil this prevalence is estimated at 54.9%, or 9.9 million preschoolers [1]. One approach to tackle ID is to fortify staple foods with iron. On a large scale, food fortification can be cost-effective and sustainable, and it allows people to get more nutritional value from the food they already eat [5]. A vehicle for iron fortification in Brazil is rice, as it is universally available on all household tables. The objective of this study was to evaluate the impact of iron-fortified rice on hemoglobin and anemia in infants from public day centers. ß The Author [2012]. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com doi:10.1093/tropej/fms021 Advance Access published on 29 May 2012 475 Downloaded from https://academic.oup.com/tropej/article-abstract/58/6/475/1677850 by guest on 24 October 2018 Correspondence: Francisco Plácido Nogueira Arcanjo, Av. Comandante Mauroce´lio Rocha Ponte, 100, Derby, Sobral, CE 62.042-280, Brazil. Fax: þ55 88 3677 8000; E-mail: <placidoarcanjo@yahoo.com.br>. F. P. N. ARCANJO ET AL. Laboratory measurements The primary outcome of the study was hemoglobin values, for which the infants were submitted to two biochemical evaluations—before and after intervention. Finger prick blood samples were used to determine hemoglobin concentrations by means of portable HemoCue B-hemoglobin photometer (Hb301-HemoCue AB, Ängelholm, Sweden) by trained personnel. Anemia was defined as Hb <11.0 g/dl [3]. Participants The study population was comprised of infants from two randomly chosen public child day care centers using a table of random numbers, the first for intervention and the latter as control (clusterrandomization) (Fig. 1). Sample calculation Anemia prevalence in the study population was estimated at 40% [7]. To achieve a reduction in global anemia prevalence from 40% to 30%, with 80% power, two-sided, Type I error of 5%, accounting for 10% losses to follow-up, each group required a minimum of 85 participants [8]. Inclusion and exclusion criteria All infants aged between 10 and 23 months (n ¼ 216) from the randomized day care centers were invited to participate in the study, inclusion was made official by means of written parental consent; infants already taking iron supplements and those whose parents refused participation were excluded from the study. Procedures The fortified rice was used in the school meal at Center A and the standard rice in Center B. Staff at the day care centers were not aware of the different interventions as all rice was provided by the study team. The fortified and standard rice was used to substitute the rice already used in the school meal. This meal was provided weekly (Wednesdays) during 18 weeks. The data collection team was also blinded as regards to the different groups. Ultra Rice grains are made with rice flour and selected micronutrients, which are combined and then extruded through a rice-shaped mold on the same equipment that is used to make pasta. When the Ultra Rice grains are mixed with white rice— typically at a 1:100 blend ratio—the result is nearly identical to unfortified rice in smell, taste and texture. In this intervention Ultra Rice was used at 6%, proportioning an ingestion of 56.4 mg of elemental iron as micronized ferric pyrophosphate (MFPP) per 50 g portion. The rice was prepared based on an individual portion of 50 g/uncooked rice (1 kg of rice per 20 students). This quantity of rice provided a satisfactory weekly amount of elemental iron considering the Dietary Reference Intakes—DRI for this mixed age group (children aged 7–11 months ¼ 11 mgFe/day and 12–23 months ¼ 7 mgFe/day) [6]. Upon enrollment, the infant’s mother completed a questionnaire, which contained questions on: infant’s age, gender, mother’s schooling and family income. This data were used to define the baseline characteristics of the participants (Table 1). 476 Statistical analysis Data were managed and analyzed using Epi Info 2000, version 3.3.2. (Centers for Disease Control and Prevention, Atlanta, GA, USA). Baseline characteristics were chosen to evaluate the two study groups. To compare ratios and means we used, respectively, the chi-squared test and the paired Student’s t-test to assess the difference in hemoglobin within the groups, and unpaired Student’s t-test between the groups before and after intervention, we considered a p < 0.05 as significant. Analyses were by intention to treat. The relative risk to anemia was calculated upon completion of intervention. The chi-squared test was used to compare the ratios between the study groups. The dependent variable (intervention or control) was organized and examined in the form of a dichotomy: (i) fortified rice (intervention) and (ii) standard household rice (control). From this point, using 2  2 contingency tables, the following measures of association were calculated: reduction of absolute risk (RAR), relative risk (RR), reduction of relative risk (RRR) and number needed for treatment (NNT), which in this study translates to the number of infants that had to be submitted to intervention to avoid an unfavorable outcome (anemia). Medical support was available upon request. Infants, who were still anemic after intervention, were referred for individual treatment. This study was approved by the Ethics Committee for Research at State University ‘Vale do Acaraú’ and developed integrally following the ethical principles established by the National Health Council Resolution No. 196/96. Results At baseline, 18 students were excluded (10 from Center A and 8 from Center B) before blood analysis due to refusal to participate in the study or already using iron supplements (Fig. 1). Journal of Tropical Pediatrics Vol. 58, No. 6 Downloaded from https://academic.oup.com/tropej/article-abstract/58/6/475/1677850 by guest on 24 October 2018 Materials and Methods The study concerns a cluster-randomized, placebo-controlled double-blind trial to compare iron-fortified rice with standard rice, conducted in the City of Morrinhos—Ceará, northeast of Brazil between August and December 2010. It was executed as part of a series of randomized controlled trails, to analyze the effectiveness of fortified rice in young populations conducted in different cities in the northeast of Brazil. F. P. N. ARCANJO ET AL. Public child day care centers in the city n=4 Cluster-randomization 2 Public day care centers Downloaded from https://academic.oup.com/tropej/article-abstract/58/6/475/1677850 by guest on 24 October 2018 Intervention Control Center B 106 infants assigned to standard household rice Center A 110 infants assigned to fortified rice (Ultrarice®) 10 Excluded 4 refused 6 using iron supplementation 8 Excluded 4 refused 4 using iron supplementation Hb assessment at baseline n=100 Hb assessment at baseline n=98 4 Dropouts 2 left center 1 absentee 1 non-compliant 6 Dropouts 1 left center 4 absentee 1 non-compliant Hb assessment 96 analyzed Hb assessment 92 analyzed FIG 1. Study profile—flow of participants through the trial. For the fortified rice group (Center A), the mean hemoglobin value at baseline was 11.44  1.07 and 11.67  0.96 g/dl, after intervention, p ¼ 0.029. For the standard household rice/control group (Center B), the mean hemoglobin value at baseline Journal of Tropical Pediatrics Vol. 58, No. 6 was 11.35  4.01, and 11.36  2.10 g/dl, after intervention, p ¼ 0.99. Anemia prevalence reduced significantly in Center A, p ¼ 0.045, with no significant reduction in Center B, p ¼ 0.22 (Table 2). During the intervention, there were four dropouts 477 F. P. N. ARCANJO ET AL. favorable (non-anemic) or adverse (anemic) outcome. Adverse outcome was present in 34.8% of control subjects and 18.8% of experimental subjects. The difference, the Reduction of Absolute Risk (RAR), was 16%. The 95% CI for this difference ranges from 3.6% to 28.6%. Number Needed to Treat (NNT) was 7. This means that about one in every seven infants will benefit from the treatment. The 95% CI for the NNT ranges from 3.5 to 28.1. Measurements of efficacy were: Relative Risk (RR) ¼ 0.80 and Relative Risk Reduction (RRR) ¼ 0.20. Discussion Considering micronutrient deficiencies in infants, ID has been pointed out as one of the most important as TABLE 1 Baseline characteristics of study participants, by intervention center Variables Day care Center A fortified rice (n ¼ 100) Day care Center B standard rice (n ¼ 98) p-value 11.44 16.4 (4.77) 60:40 89 91 11.35 15.8 (4.27) 54:44 86 90 0.83 0.37a 0.49 b 0.78b 0.83b Hemoglobin (g/dl) Age in months [mean (SD)] Gender M:F Mother with 8 years of schooling Family income 300 USD M:F, male:female. a Descriptive level of unpaired student’s t-test. b Descriptive level of chi-square. TABLE 2 Effect of fortified rice (UR), compared with control (rice) and comparison of hemoglobin means before and after intervention between centers Variables Center A—intervention (UR) (n ¼ 96) Before Hemoglobin (Hb) (g/dl) SD CI Anemiab (%) 11.44 1.07 11.23–11.66 30(31.25) Center B—control (n ¼ 92) a After p-value Before After p-valuea 11.67 0.96 11.48–11.86 18(18.75) 0.029 11.35 4.01 10.68–12.02 40(43.50) 11.36 2.10 10.69–12.03 32(34.80) 0.986 0.045c Baseline Hemoglobin (Hb) (g/dl) SD CI Anemiab, n (%) 0.22c After intervention d Center A Center B p-value Center A Center B p-valued 11.44 1.07 10.85–12.04 30 (31.25) 11.35 4.01 10.74–11.96 40 (43.50) 0.832 11.67 0.96 11.34–12.00 18 (18.75) 11.36 2.10 11.03–11.69 32 (34.80) 0.192 0.082c 0.013c a Based on paired Student’s t-tests. Anemia defined as Hb concentration <11.0 g/dl. c Descriptive level of chi-square. d Based on unpaired Student’s t-tests. b 478 Journal of Tropical Pediatrics Vol. 58, No. 6 Downloaded from https://academic.oup.com/tropej/article-abstract/58/6/475/1677850 by guest on 24 October 2018 from Center A (two left the center, one absentee, one non-compliant); in Center B there were six dropouts (one left the center, four absentee, one non-compliant) (Fig. 1). Mean hemoglobin values at baseline and after intervention showed no statistical difference between the centers, p ¼ 0.832 and p ¼ 0.192, respectively. At baseline, anemia prevalence in both centers was statistically similar (p ¼ 0.082), but different after intervention, p ¼ 0.013 (Table 2) There was no statistically significant difference, between the centers, in baseline characteristics: infant’s age, gender, mother’s schooling and family income (Table 1). In this study the following indicators were compared: fortified rice vs. standard household rice, for a F. P. N. ARCANJO ET AL. Journal of Tropical Pediatrics Vol. 58, No. 6 and an 80% reduction in anemia prevalence [19]. In the Philippines, different rice fortifications were compared in anemic schoolchildren during 6 months, rice enriched with ferrous sulfate in one group, rice enriched with MFPP in another and a control group with non-fortified rice. There was a statistically significant reduction in anemia levels for both fortified groups [20]. Despite the study significantly increasing hemoglobin levels in the fortified rice group, the mean increase was small. We hypothesize that if the study population had lower hemoglobin levels at baseline the results may have been more expressive. Still, for every seven infants that were enrolled in the intervention one recovered hemoglobin levels to achieve non-anemic status, which represents a positive outcome in an intervention that submitted infants to no discomfort whatsoever. This intention-to-treat intervention conducted at day care centers with both anemic and non-anemic infants, achieved its goal of increasing hemoglobin values, reducing anemia and preventing infants from becoming anemic. The effectiveness of this intervention can be seen in the fact that it was conducted without altering customary eating habits, or the application of any special conditions and circumstances. Thus, we demonstrated that rice is a suitable vehicle to deliver iron to anemic populations, which have rice as a staple in their diet. This provides an excellent method to tackle the problems of ID, possibly benefiting billions of people in the world. References 1. Benoist B, Mclean E, Egli I, et al. (eds). Worldwide Prevalence of Anemia 1993-2005: WHO Global Database on Anemia. Geneva: WHO, 2008. 2. De-Regil LM, Jefferds ME, Sylvetsky AC, Dowswell T. Intermittent iron supplementation for improving nutrition and development in children under 12 years of age. Cochrane Database Syst Rev 2011;12:CD009085. 3. WHO. Iron Deficiency Anaemia: Assessment, Prevention, and Control. A Guide for Programme Managers. Geneva: WHO, 2001. 4. WHO. The World Health Report 2002: Reducing Risks, Promoting Healthy Life. Overview. Geneva: WHO, 2002. 5. Allen L, de Benoist B, Dary O, Hurrell R (eds). Guidelines on Food Fortification with Micronutrients. Geneva/Rome: WHO/Food and Agriculture Organization of the United Nations, 2006. 6. Food and Nutrition Board. Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium and Zinc: A Report of the Panel on Micronutrients Subcommittees on Upper Reference Levels of Nutrients and of Interpretation and Uses of Dietary Reference Intakes, and the Standing Committee on the Scientific Evaluation of Dietary Reference Intakes. Washington, DC: National Academic Press, 2001. 479 Downloaded from https://academic.oup.com/tropej/article-abstract/58/6/475/1677850 by guest on 24 October 2018 it impacts on several aspects later in life [9]. Due to its significance, several studies have been trying to develop the ideal vehicle to address ID. Worldwide, alternative approaches have been used, however for better implementation each approach needs to be intrinsically linked to local feeding habits, cultural habits, locally available foodstuffs and other variables [7, 10–12]. In our study, we evaluated the use of rice as target vehicle, due to its daily presence on any Brazilian table. Our intervention used rice once weekly according to the day care centers’ pre-established menu. The 56.4 mg elemental iron/weekly dosage represented 8 mg daily, chosen according to DRI recommendations [6]. Additionally, other studies have achieved success, with similar dosages in supplementation, increasing hemoglobin values and reducing anemia in different population group [13, 14]. However, as far as the review showed there are no studies available on rice fortified weekly. In our study, we recognize that there may have been iron absorption enhancers involved such as, the rice was always added to meat or poultry and the population studied presented high levels of anemia at baseline (37%) probably associated to low iron stores [15]. During the intervention, there was a slight darkening of 40% of the participants’ feces, which continued notable for 1–2 days. Additionally, 25–30% of the infants presented less consistent feces. However, no complaints from the participants/parents were registered. The absence of anthropometric measurements may be considered as a limitation of the study. Up to now, no other studies have been published with this age range, using MFPP in weekly dosages. Our results were compared with those of other studies using different age ranges with different iron dosages. In a home-based 5 month RCT conducted in Brazil with anemic infants, Beinner et al. [16] using the same iron, daily, compared the use of iron-fortified rice with iron drops and concluded that iron-fortified rice improved iron status at least as well as providing iron drops. Radhika et al. [17] in a double-blind, 8 month, placebo-controlled trial used MFPP in extruded rice kernels mixed in a rice-based meal, improved iron stores without reducing anemia in schoolchildren aged 5–10 years in India, when compared to control. The positive results obtained in our weekly intervention have also been witnessed in other studies using extruded rice grains fortified with MFPP, with different methodologies. In a 7 month RCT, using a rice-based lunch meal fortified with 20 mg/ Fe/daily, Moretti et al. [18] obtained a reduction in ID and anemia in schoolchildren when compared to non-fortified control. In Mexico, a group of women received a daily portion of iron-fortified rice with an estimated 13 mg/Fe/day ingestion, during 6 months, resulting in a significant increase in body iron stores F. P. N. ARCANJO ET AL. 480 15. 16. 17. 18. 19. 20. pre-school children: a randomized, double-blind, placebo-controlled trial. J Trop Pediatr 2011;57:433–8. Moretti D, Zimmermann MB, Wegmüller R, et al. Iron status and food matrix strongly affect the relative bioavailability of ferric pyrophosphate in humans. Am J Clin Nutr 2006;83:632–8. Beinner MA, Velasquez-Meléndez G, Pessoa MC, Greiner T. Iron-fortified rice is as efficacious as supplemental iron drops in infants and young children. J Nutr 2010;140:49–53. Radhika MS, Nair KM, Kumar RH, et al. Micronized ferric pyrophosphate supplied through extruded rice kernels improves body iron stores in children: a double-blind, randomized, placebo-controlled midday meal feeding trial in Indian schoolchildren. Am J Clin Nutr 2011;94:1202–10. Moretti D, Zimmermann MB, Muthayya S, et al. Extruded rice fortified with micronized ground ferric pyrophosphate reduces iron deficiency in Indian schoolchildren: a double-blind randomized controlled trial. Am J Clin Nutr 2006;84:822–9. Hotz C, Porcayo M, Onofre G, et al. Efficacy of iron-fortified Ultra Rice in improving the iron status of women in Mexico. Food Nutr Bull 2008;29:140–9. Angeles-Agdeppa I, Capanzana MV, Barba CV, et al. Efficacy of iron-fortified rice in reducing anemia among schoolchildren in the Philippines. Int J Vitam Nutr Res 2008;78:74–86. Journal of Tropical Pediatrics Vol. 58, No. 6 Downloaded from https://academic.oup.com/tropej/article-abstract/58/6/475/1677850 by guest on 24 October 2018 7. Arcanjo FPN, Pinto VPT, Coelho MR, et al. Anemia reduction in preschool children with the addition of low doses of iron to school meals. J Trop Pediatr 2008;54: 243–7. 8. Lwanga SK, Lemesshow S. Sample Size Determination in Health Studies: A Practical Manual. Geneva: WHO, 1991. 9. Stoltzfus RJ, Mullany L, Black RE. Iron deficiency anaemia. In: Ezzati M, Lopez D, Rodgers A, Murray CJL (eds). Comparative Quantification of Health Risks: Global and Regional Burden of Disease Attributable to Selected Major Risk Factors. Vol. 1. Geneva: WHO, 2004. 10. Dewey KG. Increasing iron intake of children through complementary foods. Food Nutr Bull 2007;28: S595–609. 11. Zlotkin SH, Schauer C, Christofides A, et al. Micronutrient sprinkles to control childhood anaemia. PLoS Med 2005;2:e1. 12. Arcanjo FP, Amancio OM, Braga JA, Pinto VP. Randomized controlled trial of iron-fortified drinking water in preschool children. J Am Coll Nutr 2010;29: 122–9. 13. Palupi L, Schultink W, Achadi E, Gross R. Effective community intervention to improve hemoglobin status in preschoolers receiving once-weekly iron supplementation. Am J Clinical Nutrition 1997;65:1057–61. 14. Arcanjo FP, Arcanjo CC, Amancio OM, et al. Weekly iron supplementation for the prevention of anemia in