ALL ABOUT IRON part 2

03.Preventing iron deficiency by a suitable diet and properly absorbed iron

Training for internal use only – Not to be distributed externally

For further information, see the “Infant nutrition” ,“Nutrition basics” and “Breastfeeding” modules

Breastmilk (or infant formula)* remains the staple diet until a child reaches 2 years of age

From 1 to 2 years, 40% of energy needs should be covered by breastmilk (or infant formula)1 As an important source of energy and nutrients, this is the only food which guarantees optimum nutrition for the growth and development of infants and young children.2

* for formula-fed infants

If a baby is not breastfed, there is only one nutritionally suitable alternative: infant formula

*If the infant cannot be breastfed **In addition to the introduction of solid food ***In addition to diversified and balanced solid food

A level of exclusive breastfeeding which is still inadequate in many countries

Exclusive breastfeeding level for infants under 6 months by region1

LOSS OF THE ESSENTIAL CHARACTER OF SPECIFIC FORMULAS – EXAMPLE OF THE CÔTE D'IVOIRE

Ordinary milk has the benefit for mothers of having a very positive image, by the perception of benefits in terms of nutrition, health and even immunity

“It is a suitable milk for my baby’s age and meets their nutritional needs (vitamins, calcium, iron)” 40%

“it ensures my baby’s good physical growth” 31%

“My baby likes the taste” 20%

Questions

Cow’s milk does not cover a child’s iron needs

Cow’s milk does not cover a child’s iron needs

• Iron present in breastmilk is absorbed 10 times better than iron in cow’s milk
• In some infant formulas, iron bioavailability is as much as 20% thanks to a well-absorbed form of iron and the addition of vitamin C

*Minimum value observed in follow-on formulas on the African market

TO FIND OUT MORE

Infant formulas reduce the risk of iron deficiency

2 cohorts created of infants aged 12 months (n = 255), having consumed ordinary milk or infant formula at 9 months Objective: To study the iron status of infants aged 12 months depending on the main type of milk consumed at 9 months Iron status is assessed by the ferritin level which reflects the importance of directly useable iron reserves in the tissue. Level < 12 µg/L ➜ Depletion of iron reserves

Infant formula consumption seems to be a major protective factor against martial deficiency and iron-deficiency anaemia

Growing-up formula: a solution for achieving iron recommendations after 1 year

0.7 mg/d1

40 L

1.2 kg

125 g

500 ml*

910 g

Cow’s milk

Cooked pulses**

Meat product

Growing-up formula

Spinach

*Based on a growing-up formula containing 1mg/100ml of iron **Calculated on the basis of white beans

TO FIND OUT MORE

Clinical study: Efficacy of a growing-up formula for improving the iron status of young children

TO FIND OUT MORE

Results: Growing-up formula maintains the iron status and reduces the prevalence of iron deficiency

To cover iron needs, growing-up formula cannot be replaced by meat or pulses alone1

Growing-up formula should be continued until the child is able to ingest at least 100-150 g of meat products per day, after 3 years1

Diversification and weaning too early

In many countries: exclusive breastfeeding is mainly stopped by the consumption of water, other drinks and food.

Early weaning deprives children of nutrients and breastmilk.

An identical diet to that of an adult and low in well-absorbed iron

Following diversification, too fast a switch to a diet identical to that of an adult1,2

• Principally, cereal-based,, low in animal proteins (meat, poultry, fish), low in vitamin C, with no specific consumption of milk2

Just 44% of children aged 6 to 24 months received iron-rich food within the previous 24 hours according to a survey in 8 French-speaking countries in Africa.3

FOCUS ON BELIEFS ABOUT ANAEMIA

RESULTS OF A SURVEY IN IVORY COAST

RESULTS OF THE AGILE STUDY –SURVEY OF MOTHERS 2

Traditional remedies for the treatment of anaemia1

• Infusions/decoctions of teak or anango leaves
• Coca Cola® + tomato concentrate
• Hibiscus juice

82% think that red meat is low in iron

71% think that pulses are low in iron

26% think that red meat is low in iron

Red remedies such as blood, the “efficacy” of which is “recognised” by mothers1

Inhibitors and activators of iron absorption

The WHO recommends adding fruit and vegetables rich in vitamin Cto the diet, such as citrus fruit, so as to increase iron absorption, in all age groups.18

The addition or avoidance of certain foods in meals can also increase iron absorption.14,19

Avoid

Add

Inhibitors of iron absorption

Inhibitors and activators of iron absorption:

In particular for babies and young children with high iron needs, strategies aiming to meet their iron needs should also include the fortification of foods.19

Tea

Vitamin C

Coffee

WHO, World Health Organisation

SUMMARY – Covering iron needs by a suitable diet and well-absorbed iron

Prioritise well-absorbed iron ➜ Breastmilk, or infant formula if the child is not breastfed, in addition to a balanced diet

Key MESSAGES

• Iron deficiency is prevented by a diet that favours good iron absorption.

• If a child is not breastfed, infant formulas represent a major part of the diet of children, helping cover iron needs and prevent martial deficiency.

• In Africa, unsuitable dietary practices (premature weaning, loss of essentiality of the right milk, change to adult diet too fast) and misconceptions leading to iron deficiency in children already badly affected by infections and inflammation.

04.Interactions between iron and the gut microbiota: improving iron absorption

For further information: see the modules about the microbiota

The virtuous circle of the gut microbiota: it needs to be balanced to ensure key functions

“Barrier” effect helping limit colonisation by pathogenic bacteria1,2

Development and maturing of the immune system2,3

Metabolic activities1

Production of vitamins (K, B12)1

Influences gut-brain communication2,3

Absorption of nutrients including iron2

Questions

The gut microbiota: an essential factor in iron regulation in the body

For further information: see the modules about the microbiota

The gut microbiota: an essential factor in iron regulation in the body

A balanced interaction between the 2 is essential

Strategies:

• Improve iron absorption to limit undesirable effects and the risk of deficiencies

• Protect the gut microbiota

Gut microbiota

BENEFICIAL EFFECT OF A HEALTHY AND BALANCED MICROBIOTA 3

HARMFUL EFFECT OF NON-ABSORBED IRON ON THE COLON1,2

• Pathogenic gram-negative bacteria

• Imbalance in the intestinal microbiota

• inflammation

• Activity of beneficial bacteria

• Improvement in the intestinal absorption of iron

Iron

Iron supplementation: the scientific evidence

In-depth research on iron supplementation in infants, young children and pregnant women shows that:

80% – 86%

88%

56% – 67%

Daily iron supplementation (12.5-15 mg of iron/day) for infants from 6 to 23 months old reduced the risk of iron-deficiency anaemia by 80 to 86%

In children from 2 to 10 years old, daily (5-400 mg/day) or intermittent (7.5-200 mg/week) iron supplementation reduced the risk of iron-deficiency anaemia by 88%

In pregnant women, the administration of 10 to 300 mg/day of iron reduces the risk of iron-deficiency anaemia by 56 to 67%

SIDE EFFECTS OF IRON SUPPLEMENTATION

However, oral iron supplements often cause gastrointestinal side effects such as:

Iron supplementation remains a current strategy for treating and preventing iron deficiency

This can result in a lack of regularity in the oral administration of iron supplements, which can mean that the treatment fails

diarrhoea, constipation and nausea

The consumption of iron supplements can also have a negative impact on the gut microbiome, resulting in the proliferation of pathogenic bacteria such as Escherichia coli or Salmonella spp., and increasing the risk of infection.

Innovative iron supplement preparations with a low incidence of side effects could improve the regularity of treatment.

TO FIND OUT MORE

Iron supplementation causes an imbalance in the gut microbiota

For further information: see the modules about the microbiota

The role of prebiotics in iron deficiency

• Iron supplements and iron-enriched foods used to manage iron deficiency can have harmful effects on the gut microbiota.

• Prebiotics are the substrates used selectively by the host’s microorganisms to modulate the intestinal microbial balance and provide benefits to the host.

• Prebiotics, including galacto-oligosaccharides (GOS) and fructo-oligosaccharides (FOS), increase the bioavailability of iron, increase its absorption by 60% and have a protective effect on the gut microbiota.

Prebiotics

The inclusion of prebiotics in supplementation and fortification strategies could produce more favourable results

The strategies: improve iron absorption and protect the gut microbiota

Improve iron absorption and reduce the dietary iron dose administered

Protect the gut microbiota from the harmful effects of unabsorbed iron

The right form of iron together with vitamin C improves iron absorption

FORMS OF IRON 1,2

• Choose a highly available ferrous compound (ferrous sulphate, ferrous lactate)

• Choose a chelated form (NaFeEDTA*, bisglycinate)

VITAMIN C

• Most often added to boost iron absorption in food (e.g. infant formulas and baby cereals)
• Its “activator” effect together with its reducing and chelating properties➜ Favours iron absorption by forming soluble chelates with iron and preventing its precipitation
• The addition of vitamin C helps increase iron absorption by a factor of 2 to 3
• A vit C:iron molar ratio of 2:1 is recommended for powdered milk

*EDTA: ethylenediaminetetraacetic acid

For further information: see the modules about the microbiota

The (scGOS/lcFOS) (9:1) mixture increases iron absorption by a direct and indirect effect.

* scGOS/lcFOS: short-chain galacto-oligosaccharides and long-chain fructo-oligosaccharides.

The scGOS/lcFOS* (9:1) mixture stimulates the growth of beneficial gut bacteria

Moro et al. 20021

Study of the influence of the supplementation of infant formula with scGOS/lcFOS *(9:1)(prebiotics) on the stimulation of gut bacteria in 90 full-term infants

The scGOS/lcFOS* (9:1) mixture at 0.8 g/100 mL encourages a gut microbiota profile close to that of breastfed infants1

Adapted from Moro et al. 20021

Synergetic effect of vitamin C and scGOS/lcFOS* (9:1) prebiotics

Christides et al. 20181

In vitro study comparing 4 growing-up formulas with or without prebiotics

Adding vitamin C and prebiotics scGOS/lcFOS* (9:1) to an infant formula increases iron absorption1

TO FIND OUT MORE

Impact of scGOS/lcFOS on iron absorption and the gut microbiota: KIF STUDY

Randomised controlled single-blind study

Objective: To compare the effect of the daily administration of a wheat-based instant cereal containing 3.6 mg of ferrous fumarate (FeFum), ascorbic acid (AA) with or without prebiotics scGOS/lcFOS (9:1) (2 doses tested: 7.5 versus 3 g):

• Primary objective: on the fractional absorption of iron before and after a 3-week intervention

Principal investigator: Prof. Zimmermann

• Secondary objective: on the gut microbiome by qPCR, 16S rRNA gene, shotgun sequencing, faecal pH and faecal calprotectin (marker of intestinal inflammation)

Population: 174 Kenyan infants aged 6-11 months Study conducted in late 2019

Exclusion criteria:

• Hb < 70 g/L
• Severe underweight
• Severe emaciation
• Chronic or acute disease
• Regular administration of supplements containing iron over the first 2 months
• Antibiotic treatment during the past month

TO FIND OUT MORE

KIF STUDY – The addition of scGOS/lcFOS improves iron absorption

FROM A WHEAT-BASED CEREAL CONTAINING FERROUS FUMARATE AND ASCORBIC ACID

60% increase in iron absorption between cereal enriched with iron without scGOS/lcFOS and cereals enriched with iron with scGOS/lcFOS, where consumed daily.

scGOS/lcFOS consumption has medium and long term effects on iron absorption (ferrous fumarate) by conditioning a child’s gut

One 3 g dose of scGOS/lcFOS is as effective at improving chronic iron as 7.5 g

Fractional absorption of iron (values not adjusted) from prebiotic doses in groups of 3.0 and 7.5 g (n = 53) from test meals consumed with and without prebiotics before and after daily administration of prebiotics for 3 weeks. Compared using t tests for dependent samples. ***P <0.001, **P <0.005, *P <0.01

TO FIND OUT MORE

KIF STUDY – Effect of intervention on gut microbiota

➜ Protective effect of prebiotics scGOS/lcFOS on dysbiosis not caused by iron

After 3 weeks of consuming iron + 7.5g of prebiotics scGOS/lcFOS:

• Reduction in faecal pH
• Reduction in intestinal inflammation
• Increase in abundance of lactobacillus
• Reduction in abundance of enterobacteria
• Reduction in the total of all pathogens

➜ The effect on the abundance of lactobacillus is also observed with 3g of prebiotics scGOS/lcFOS

Key MESSAGES

• Improving dietary iron absorption (bioavailable form of iron, vitamin C and prebiotics) is an effective strategy for preventing deficiency and reducing the adverse effects of unabsorbed iron on the gut microbiota.

• Prebiotics promote iron absorption and rebalance the gut microbiota.

• Prebiotic-enriched infant formulas are characterised by increased iron absorption and good digestive tolerance. They represent an effective nutritional strategy for formula-fed infants to help prevent iron deficiency.

IMPORTANT NOTICE

The World Health Organisation (WHO) recommends that pregnant women and mothers of infants and young children be particularly well informed about: ​

• the advantages of breastmilk, which is the ideal food for a baby. It is the most suitable milk for the baby's specific needs, and protects from disease,
• the importance of a good diet for the mother to prepare for and then to proceed with breastfeeding,​
• the negative effect of mixed feeding for a baby, by alternating breastfeeding and bottle-feeding, as this can interfere with the production of breastmilk,​
• the difficulty in reversing the decision not to breastfeed,​
• the socio-economic implications that should be taken into consideration when choosing a feeding method. It is important to provide a reminder about the cost of infant formulas and at the same time to detail the quantities to be used depending on the infant’s age.​

If a decision to use infant formula is reached, when mother does not breastfeed, it is important to carefully follow the instructions relating to water quality, the correct method of preparation and medical advice. Incorrect use could put a child’s health at risk.

Training for internal use only – Not to be distributed externally

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