Supplementation and Fortification

The serious international problem of iron deficiency has been met with poor success by supplementation and fortification efforts. Both approaches suffer from difficulties in delivery and acceptance. Supplements that readily ionize into the ferrous form, such as ferrous sulfate, ferrous fumerate, or ferrous glu-conate, are highly bioavailable but may cause gastrointestinal discomfort. Iron injections are poorly tolerated and can result in serious infections. Because daily supplementation reduces the physiological efficiency of iron absorption, routine weekly iron supplementation with 60 mg iron has been suggested in developing countries for women of child-bearing age, beginning in adolescence. Menstruating women in more prosperous countries are advised to obtain assessment from a health professional before taking iron supplements in excess of 20 mg daily.

Fortification of staple foods with 3-10 mg iron daily, depending on the needs of the population, is a long-term preventative strategy. In the United States, bread and cereal products are routinely fortified with 20 mg iron per pound (460 g) of flour, and additional fortification at the option of food suppliers is common. However, fortification is difficult when food processing is decentralized, as is common in poor populations. Food fortification carries the additional challenge that the chemical forms of iron most bioavailable also tend to be the most reactive with the food fortified, resulting in adverse changes in flavor, color, and shelf life. Promising approaches include the fortification of food sauces with iron chemically bound with amino acids or with EDTA (sodium iron ethylenediaminetetraacetic acid), which are well absorbed even in the presence of phytic acid. Elemental iron powders, commonly referred to as carbonyl, electrolytic, and reduced forms of iron, are relatively inert in foods and inexpensive, but their bioavailability may be 30-80% less than iron from ferrous sulfate, depending on the dissolution in the gastrointestinal tract. Ferric orthophosphate and ferric pyrophosphate do not adversely affect foods but are poorly bioavailable; however, efforts are under way to enhance their bioavailability by reducing the particle size and encapsulating the particles with various lipids or carbohydrates to prevent agglomeration.

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