Universidade Federal de São Paulo (UNIFESP) Pediatric DepartmentUniversidade Federal de São Paulo (UNIFESP)UNIFESP, Pediatric DepartmentUNIFESPSciEL

Fisberg, Mauro

Tosatti, Abykeyla Melisse

Revista Brasileira de Hematologia e Hemoterapia

PubMed

Fisberg, Mauro [UNIFESP]

Tosatti, Abykeyla Melisse [UNIFESP]

Repositório Institucional UNIFESP

94                                                                                                                                                Rev Bras Hematol Hemoter. 2011;33(2):90-95The article "Considerations on the food fortification policy in Brazil"(1) published inthis issue of the Revista Brasileira de Hematologia e Hemoterapia (Journal of Hematologyand Hemotherapy) questions whether the mandate to enrich food will or will not worsenthe health of individuals that suffer from iron excess-related conditions. Another aspectquestioned by this article is whether there is, or there is no danger of an iron and folic acidenriched diet triggering irreversible neurological lesions in vitamin B2-deficient individualswho do not present with anemia.An inadequate folate (folic acid) intake results in megaloblastic anemia and neuraltube defects. Neural tube defects are fatal, although preventable if a woman consumesenough folic acid before getting pregnant and at the beginning of pregnancy.Iron deficiency, which mainly results from low bioavailability of iron andinsufficient iron in the diet to meet the individual's nutritional needs, causes anemia;this is a global public health issue affecting populations of all social classes and isone of the major factors related to low weight at birth, cognitive deficits in childrenand maternal mortality.According to World Health Organization (WHO) data, it is estimated that anemiaaffects 1620 million people worldwide, that is, 24.8% of the population. The highestprevalence is among pre-school children (47.4%), followed by pregnant women (41.8%)and childbearing-age woman (30.2%).(2) Neural tube defects, on the other hand, affect morethan 300,000 children a year, globally.(3)Among the strategies advocated by the WHO to control iron deficiency anemia, andrecommended to ensure a balanced, healthy diet, fortification of food is recognized as thebest approach.(4) Additionally this has the best cost effective ratio over medium to longterms.Vellozo & Fisberg(5) believe that the efficacy of preventing anemia using enrichedfood has proven to be adequate in disease-prevention programs in several countries;however, they highlight that most of the studies are local and age groups are restricted,thus limiting the representativeness of the sample.With the aim of increasing the availability of iron and folic acid-enriched foods to theBrazilian population, and thus reducing the prevalence of anemia and neural tube defects inBrazil, the Ministry of Health, as of June 18 2004, made the addition of iron (30% dailyrecommended intake or 4.2 mg/100 g) and folic acid (70% daily recommended intake or150 µg/100g) to maize and wheat flours mandatory.(6)Few studies evaluating the efficacy or the effectiveness of iron-enriched foods havebeen published in Brazil. Some review studies make it clear that there are few data supportingthe hypothesis that increasing iron intake with some fortified foods (mass or targetedfortification) improves iron nutritional status. Therefore, although desired, the efficacy andeffectiveness of iron-enriched foods on the prevalence of anemia in the population is yet tobe shown.Because fortification programs reach all population groups, there is the concern thatindividuals who already consume iron within the recommended amounts and that have fullbody storages may consume more mineral than that recommended in the Dietary ReferenceIntake leading to side effects. There are few publications addressing moderate overloads ofthis mineral in healthy individuals.The maize and wheat flour iron fortification program must monitor the Brazilianpopulation as a whole and not only those groups that are susceptible to iron-deficiencyanemia. Some studies conducted in European countries, in populations without hereditaryhemochromatosis, showed a positive correlation between the high body iron storageand some types of cancer, mainly in individuals aged 45 and above, showing a long-termdeleterious effect of an excessive iron intake. Brazil offers a contrast where, on one hand,there is high prevalence of iron deficiency anemia and, on the other hand, there arepopulation groups that consume large amounts of foods with high iron availability suchas red meat. Nevertheless, we still do not have data on the prevalence of hereditaryhemochromatosis in the Brazilian population. Therefore, it is necessary to screen theEnrichment of iron and folic acid: The real need and the dangers of this initiative1Pediatric Department, UniversidadeFederal de São Paulo – UNIFESP,São Paulo, SP, Brazil2Universidade Federal de São Paulo– UNIFESP, São Paulo, SP, BrazilMauro Fisberg1Abykeyla Melisse Tosatti2Submitted: 4/3/2011Accepted: 4/13/2011Corresponding author:Mauro FisbergCentro de Atendimento e Apoio aoAdolescenteRua Botucatu, nº 715 – Vila ClementinoPhone: 55 11 5576-436004023-062 – São Paulo, SP, Brazil mauro.fisberg@gmail.comwww.rbhh.org or www.scielo.br/rbhhDOI: 10.5581/1516-8484.20110026Scientific CommentsRev Bras Hematol Hemoter. 2011;33(2):90-95                                                                                                                                                95population. Additionally, there are no national data on themodification of iron status and the prevalence of neonatalmalformations after iron and folic acid fortification.Enrichment with folic acid is an incontestableintervention in primary prevention, with the positive impactin the prevention of neural tube defects already proven inseveral countries. This public health intervention is efficaciousand safe. However, as with iron, there are only a few studiesevaluating its efficacy and effectiveness, since the mostprevalent at risk population, under 3-year-old children, benefitmore with the iron in infant formulas.Folic acid may prevent 50%-70% of the neural tubedefects that are not caused by severe congenital defectssuch as malformation of the baby's spinal cord and brain.Women need folic acid before becoming pregnant and in thefirst stages of pregnancy in order to reduce the occurrenceof disabling or fatal congenital defects.(3)Despite the decrease in the numbers of babies bornwith neural tube defects, some research questions whetheror not the overconsumption of folic acid leads to undesirableconsequences such as the development or evolution ofcancer or irreversible neurological lesions in vitamin B12-deficient patients without anemia.The Medical Institutes of the National Science Academyboth in the USA and in Canada, the European Union ScientificCommittee on Food (SCF), and the Supreme Council of PublicHygiene of France concluded that the maximum daily folic acidintake is 1000 micrograms.(7) The level of folic acid added towheat flours (150 µg/100 g) will not likely lead to a folate intakeabove the tolerable levels of 1000 µg per day.A daily intake higher than 1000 micrograms is excessivein the case of medical supplementation but not for theconsumption of enriched foods. There is no evidence of sideeffects from the intake of folic acid through enriched foods atthe levels recommended to prevent damage such as for neuraltube deficiency and in vitamin B12 deficiency without ane-mia. Folate has been associated with protection against sometypes of cancer, but further investigations are necessary toverify whether people who take high supplement doses,present higher risks of developing cancer.Children of between 1 and 9 years old should not ingestmore than 40 mg a day of iron, whereas for those aged 19 to 70years old the intake should not exceed 45 mg of iron a day.Regarding folic acid, children from 1 to 3 years old should notconsume more than 300 mcg a day and for those with agesranging from 19 to 70 years old the maximum is 1000 mcg a day.The conclusion is that the intake of folic acid fromnormal sources, even taking into account "mandatoryfortification", is not associated with severe damage, includingcarcinogenic effects.(8) The same is true for iron. Howeverthere is a need for population studies to identify the prevalenceof iron overload diseases in Brazil.Even with the very few published studies, the efficiencyof fortification to correct, eradicate, or prevent specificdiseases caused by nutrient deficiencies is highly recognized.Nevertheless, there is the need to pursue new, more efficient,and more adequate ways of fortification. This subject stillneeds to be discussed in academic, governmental, andinstitutional settings.References1. Martins JM. Considerations on the food fortification policy inBrazil. Rev Bras Hematol Hemoter. 2011;32(2):158-163.2. Benoist B, McLean E, Egli I, Cosgswell M, editors. Worldwideprevalência de anemia 1993-2005. WHO Global Database sobreAnaemia [Internet]. Genebra: World Health Organization; 2008.[cited 2009 Nov 21]. Available from: http://whqlibdoc.who.int/publications/2008/9789241596657_eng.pdf3. Flour Fortification Initiative. A public-private-civic investment ineach nation. [database on Internet]. Atlanta, Georgia; 2011. [cited2011 Apr 21]. Available from: http://www.sph.emory.edu/wheatflour/DOCS/FFIFolicAcidStatement.pdf4. Davidson L, Nestel P. International Nutritional AnemiaConsultative Group. Efficacy and effectiveness of interventionsto control iron deficiency and iron deficiency anemia [Internet].Washington DC: International Life Sciences Institute; 2004. [cited2010 Dec 15]. Available from: http://www.unsystem.org/scn/Publications/AnnualMeeting/INACG%20efficacy%20and%20effectiveness.pdf5. Vellozo EP, Fisberg M. A contribuição dos alimentos fortificadosna prevenção da anemia ferropriva. Rev Bras Hematol Hemoter.[Internet]. 2010 [cited 2011 Jan 12];32(Suppl 2):140-7.Available from: http://www.scielo.br/pdf/rbhh/v32s2/aop 55010.pdf6. Brasil. Ministério da Saúde. Agencia Nacional de Vigilância Sanitá-ria. Resolução RCD n. 344, de 13 de Dezembro de 2002. Aprova oRegulamento Técnico para a fortificação das farinhas de trigo emilho com ferro e ácido fólico. Diário Oficial da União da RepublicaFederativa do Brasil [Internet]. Brasília (DF); 18 dez 2002. [cited2010 Jul 27]. Available from: http://www.anvisa.gov.br/legis/resol/2002/344_02rdc.htm7. A model for establishing upper levels of intake for nutrients andrelated substances. Report of Joint FAO/WHO TechnicalWorkshop on Nutrient Risk Assessment [Internet]. Geneva: WHO;2-6 may 2005. [cited 2010 Nov 18]. Available from: http://www.who.int/ipcs/methods/nra_final.pdf8. Folic Acid for the Prevention of Neural Tube Defects: U.S. PreventiveServices Task Force Recommendation Statement. Ann Intern Med.2009;150(9)626-31.xxxScientific Comments

Enrichment of iron and folic acid: the real need and the dangers of this initiative

Mauro Fisberg

Abykeyla Melisse Tosatti

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LAReferencia - Red Federada de Repositorios Institucionales de Publicaciones Científicas Latinoamericanas

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Enrichment of iron and folic acid

A contribuição dos alimentos fortificados na prevenção da anemia ferropriva. Rev Bras Hematol Hemoter. [Internet].

A model for establishing upper levels of intake for nutrients and related substances.

Considerations on the food fortification policy in Brazil. Rev Bras Hematol Hemoter.

Flour Fortification Initiative. A public-private-civic investment in each nation. [database on Internet].

Folic Acid for the Prevention of Neural Tube Defects: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2009;150(9)626-31. xxx Scientific Comments

International Nutritional Anemia Consultative Group. Efficacy and effectiveness of interventions to control iron deficiency and iron deficiency anemia [Internet].

Worldwide prevalência de anemia 1993-2005. WHO Global Database sobre Anaemia [Internet]. Genebra: World Health Organization;

http://dx.doi.org/10.5581/1516-8484.20110026

Enrichment of iron and folic acid: the real need and the dangers of this initiative

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