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Therapeutic effects of NaFeEDTA-fortified soy sauce in anaemic children in China

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Therapeutic effects of NaFeEDTA-fortified soy sauce in anaemic children in China
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   Asia Pacific J Clin Nutr (2002) 11(2): 123–127  Original Article Therapeutic effects of NaFeEDTA-fortified soy sauce inanaemic children in China Junsheng Huo 1 PhD , Jing Sun 1 BSc , Hong Miao 1 MSc , Bo Yu 1 MSc , Tao Yang 1 BSc , Zhaoping Liu 1 PhD , Chengqian Lu 1 MSc , Junshi Chen 1 PhD , Ding Zhang 2 MSc , Yuzhen Ma 2 BSc , Anxu Wang 2 BSc and Yongli Li 2 BSc 1  Institute of Nutrition and Food Hygiene, Chinese Academy of Preventive Medicine, Beijing, China 2  Henan Center of Disease Control, Zhengzhou, China The therapeutic effects of NaFeEDTA-fortified soy sauce on anaemic students were investigated. Three hundredand four iron-deficient anaemic school children (11–17years) were randomly assigned to three treatmentgroups: control group (consuming non-fortified soy sauce), low-NaFeEDTA group (consuming fortified soysauce, providing 5mg Fe/day) and high-NaFeEDTA group (consuming fortified soy sauce, providing 20mgFe/day). Blood haemoglobin (Hb) levels were determined before and after 1month, 2months and 3months of intervention. In addition, serum iron (SI), serum ferritin (SF), free erythrocytic porphyrin (FEP), total ironbinding capability (TIBC) and transferritin (TF) were measured before and after consumption of soy sauce for3months. The results obtained herein show that the parameters measured were not changed remarkably withinthe 3-month intervention in the control group ( P <0.05). However, increased Hb, SI, SF and TF levels anddecreased TIBC and FEP levels were observed in both the high-NaFeEDTA group ( P <0.01) and the low-NaFeEDTA group ( P <0.05). The effectiveness of iron intervention in the low-NaFeEDTA group and high-NaFeEDTA group had no statistical significance after 3months. It was concluded that nutritional interventionfor anaemic students using NaFeEDTA-fortified soy sauce could play a positive role in the improvement of ironstatus and control of anaemia. Key words: China, food fortification, Henan, iron deficiency anaemia, NaFeEDTA, soy sauce. 123 Introduction Compared with the commonly used iron salt fortificants,NaFeEDTA is characterised by a higher absorption rate inthe human body, less adverse effects on the organoleptic pro-file and intrinsic nature of its food vehicles and less influenceon the bioavailability of other minerals. 1,2 As a result,increasing attention has been focused on the use of NaFeEDTA as a nutrient fortificant. Three major population-based intervention trials, in which NaFeEDTA was used asthe iron fortificant, have been conducted: 1 (i) Garby andAreekul’s 24-month population trial in Thailand in 1974, inwhich fish-sauce was selected as the carrier; 3,4 (ii) Viteri etal. ’s 20-month population trial using sugar as the carrier inan urban community in Guatemala in 1983; 5,6 and (iii) Bal-lot’s 24-month population trial in an urban community inSouth Africa in 1986, in which curry powder was selected asthe carrier. 7,8 These studies showed that administeringNaFeEDTA-fortified foods results in a promising improve-ment in iron deficiency anaemia (IDA) among populations.However, among the three reported trials, only the third trialconducted by Ballot in South Africa was double-blinded.Iron deficiency anaemia is an important and urgent nutri-tional problem, and food fortification is considered an indis-pensable approach eliminating IDA from China. Soy sauce isa popular traditional condiment in China, making it a candi-date for use as a carrier. The studies on soy sauce fortifiedwith ferrous sulphate (FeSO 4 ) conducted by Dai in 1980sprovided convincing results that the consumption of iron-fortified soy sauce improved iron status. 9–10 Unfortunately,the organoleptic profiles of soy sauce fortified with FeSO 4 were not acceptable because of significant precipitation of the FeSO 4 . Our previous study reported that the absorptionrate of iron in NaFeEDTA-fortified soy sauce was up to10.51% in human subjects. It was higher than that of FeSO 4 ,with an absorption rate of 4.73%, suggesting that this forti-fied food may play a significant role in supplementing ironand thereby protecting against IDA. To investigate the effectsof NaFeEDTA-fortified soy sauce on IDA in Chinese popu-lations, a therapeutic trial in juvenile students suffering fromIDA was conducted. The results obtained herein will serve asa basis for conducting further population-based effectiveness Correspondence address: Dr Huo Junsheng, Institute of Nutrition and Food Hygiene, 29 Nanwei Road, Beijing 100050, P. R. China.Tel: +86 10 63034140; Fax: +86 10 63011875Email: jshuo@mail.263.net.cnAccepted 7 September 2001  studies in areas with a high prevalence of IDA usingNaFeEDTA-fortified soy sauce. These studies may offer apractical solution to the problem of IDA in some populations. Materials and methods The trial protocol was reviewed and approved by the ExternalMedical Ethics Committee of the Institute of Nutrition andFood Hygiene, Chinese Academy of Preventive Medicine. Subjects With the assistance of the Henan Provincial Center for Dis-ease Control and Prevention and the Wancheng DistrictCenter for Disease Control and Prevention, Nanyang City,Henan Province, boarding students aged 11–17years werescreened to assess their appropriateness for inclusion as sub- jects in this study. The subjects had similar living standardsand dietary patterns. They were chosen from three middleschools in the Wancheng District, Nanyang City, HenanProvince.Dietary surveys were conducted using a three-day foodweighing and recording method 11 in the cafeterias of theselected schools, followed by calculation of dietary ironintake. In addition, a health survey was carried out thatincluded blood haemoglobin (Hb) concentration, age,nationality, height, weight, medical history, boarding or notand eating in the schools’cafeterias or not.According to the Diagnosis Criteria for Anaemia recom-mended by the World Health Organization, 12 the studentswere diagnosed as anaemic in accordance with the followingcriteria: boys or girls younger than 15years with Hb con-centration<120g/L; girls aged 15years or older with Hbconcentration<120g/L; and boys aged 15years or olderwith Hb concentration<130g/L. All students with anaemiawere randomly assigned to one of the three treatmentgroups: (i) control group, consuming non-fortified soy sauce;(ii) low-NaFeEDTA group, consuming NaFeEDTA-fortifiedsoy sauce containing 1mg Fe/mL; and (iii) high-NaFeEDTAgroup, consuming NaFeEDTA-fortified soy sauce containing4mg Fe/mL. The soy sauce consumed was produced byBeijing Huwang Wadakan ® Food Company using the low-salt solid fermented technique. Study designSoy sauce supplementation. Based on the study protocol, 5mL of soy sauce was admin-istered daily to each subject at lunch in the form of soy saucesoup for a period of 3months. In order to ensure accurateintake, the soup was prepared in the school cafeteria and con-sumed by the subjects under complete supervision from theteachers. At the same time, detailed information on the soysauce consumption of each subject was recorded on a con-sumption sheet. Sample collection. A 10mL sample of intravenous blood was collected fromeach subject before the study and after 3months of soy sauceconsumption. From this sample, 10µL of blood was droppedonto a piece of filter paper for the free erythrocytic porphyrin(FEP) assay. Following centrifugation of blood samples at500g for 20min, serum was separated and stored at –20°Cfor subsequent determination of serum iron (SI), serumferritin (SF) and transferritin (TF) concentrations, and fortotal iron binding capability (TIBC). Blood Hb was mea-sured using fingertip blood taken before the study and after1, 2 and 3months of soy sauce consumption.  Laboratory analyses Haemoglobin concentration was determined by the cyano-methemoglobin assay. 13 Van-Zij solution was purchasedfrom the Institute of Hematology, Chinese Academy of Preventive Medicine. Quality-control serum samples with aknown concentration (127g/L) were provided by the Shang-hai Institute of Clinical Examination. The determination of SI, SF and TF concentrations and TIBC were carried outusing the respective assaying kits (Randox, Crumlin, UK),according to the instructions. FEP concentration was mea-sured by fluorimetry, according to the method previouslydescribed. 14 A FEP standard was purchased from Sigma (St Louis, MO, USA). The STAGE Auto-biochemical Analyser(Nucleus and Electricity Company, Ohio, USA) and SN682Counter (Rihuan Nucleus Instruments, Shanghai, China)were used for the analysis. Results  Diet consumption and iron intake According to the dietary surveys, the average daily ironintakes for the three schools were 17.62, 17.1 and 17.57mg,respectively. Most of the daily iron intake was derived fromcereals and vegetables, showing that the diet consumed is aplant-food-based diet (Table1).  Prevalence of anaemia in the surveyed students Among the 4022 eligible students in the three selected mid-dle schools, 4008 students were available. The prevalence of anaemia diagnosed, based on Hb value, is shown in Table2.Three hundred and four students (155 boys and 149 girls)were diagnosed as anaemic and assigned to one of the threetreatment groups. The incidence for each school was as fol-lows: school 1, 55 boys and 47 girls in the control group(consuming non-fortified soy sauce); school 2, 39 boys and63 girls in the low-NaFeEDTA group (consuming NaFeEDTA-fortified soy sauce containing 1mg Fe/mL); school 3, 61boys and 39 girls in the high-NaFeEDTA group (consumingNaFeEDTA-fortified soy sauce containing 4mg Fe/mL).  Effect of iron-fortified soy sauce on Hb levels in subjects According to Table3, the Hb levels before intervention werenot statistically different between the three groups( P >0.05), indicating the same anaemia profile among thethree groups. Hb levels in the high-NaFeEDTA group weresignificantly higher than those in the control and low-NaFeEDTA groups after 1month of intervention ( P <0.05).Hb levels in the low-NaFeEDTA group and high-NaFeEDTAgroup were significantly increased after 2 and 3months of J Huo, J Sun, H Miao et al .124  Effects of NaFeEDTA in anaemic children125intervention, with significant differences compared withthose in the control group ( P <0.01). Two subjects in thelow-NaFeEDTA group and one subject in the high-NaFeEDTA group were still suffering from anaemia at theend of the study, and other subjects had all recovered fromanaemia. The prevalence of anaemia in the control group,however, was up to 69.5%. The results showed that iron-fortified soy sauce significantly increased Hb levels instudents with anaemia.  Effect of iron-fortified soy sauce on serum iron concentrations in subjects Serum iron concentrations did change significantly after theconsumption of soy sauce by the control group. However, inthe low-NaFeEDTA and high-NaFeEDTA groups, SI con-centrations were increased by 30µg/dL and 24µg/dL,respectively, after 3months of intervention (Table4).  Effect of iron-fortified soy sauce on serum ferritin concentrations in subjects There was no significant change in SF concentration in thecontrol group before or after the consumption of soy sauce(Table4). However, the SF concentrations of both the low-NaFeEDTA group and the high-NaFeEDTA group increasedsignificantly after consuming iron-fortified soy sauce( P <0.01). Furthermore, the SI concentrations in these twoiron intervention groups were significantly higher than in thecontrol group ( P <0.01). Table 1. Daily food consumption and iron intake in surveyed students SchoolCerealsNon-staple foodsCondimentsWheatRiceVegetablesMeat and eggsSalt†Soy sauceSchool 1Weight (g)527.1119.9249.015.311.811.0Iron (mg)14.230.851.280.240.130.89% of total food69.3‡26.71.62.4§% of total iron85.5‡7.31.45.8§School 2Weight (g)502.0101.4260.117.413.212.5Iron (mg)13.550.721.340.280.131.08% of total food66.6‡28.71.92.8§% of total iron83.5‡7.81.67.1§School 3Weight (g)516.5109.2263.317.112.413.0Iron (mg)13.950.781.330.270.121.12% of total food67.2‡28.31.82.7§% of total iron83.8‡7.61.57.1§ †Salt listed here did not include that contributed from soy sauce. Values represent: ‡wheat + rice; §salt + soy sauce. Table 2. Anaemia prevalence in surveyed students in selected schools SchoolsNo. students (11–17years)Anaemia prevalence (%)BoysGirls School 1 84961413.5(Control)School 276663422.6(Low NaFeEDTA)School 360154411.0(High NaFeEDTA) Table 3. Effect of iron-fortified soy sauce on haemoglobin levels in students with anaemia (g/L, Mean±SD) GroupsNo.Before1month after2months after3months afterinterventioninterventioninterventioninterventionControl81116.9±5.5117.9±6.3118.6±5.3118.5±4.7Low NaFeEDTA82115.4±5.1117.2±8.5128.4±7.0 a,bb 135.7±8.5 aa,bb High NaFeEDTA77116.1±5.1124.0±10.6 a,bb 131.6±11.6 aa,bb 140.0±9.5 aa,bb Compared with haemoglobin levels before intervention: a P <0.05; aa P <0.01. Compared with the control group: b P <0.05; bb P <0.01.  J Huo, J Sun, H Miao et al .126  Effect of iron-fortified soy sauce on serum freeerythrocytic porphyrin concentrations in subjects According to the results shown in Table5, the serum FEPconcentration in the control group after the intervention wasnot significantly higher than that before the intervention( P >0.05). However, serum FEP levels decreased by12.13µg/dL and 16.88µg/dL, respectively, in both low-NaFeEDTA and high-NaFeEDTA groups after 3months of intervention.  Effect of iron-fortified soy sauce on total iron binding capability in subjects In both the low-NaFeEDTA and high-NaFeEDTA groups,treatment for 3months significantly decreased the TIBClevels ( P <0.05). In the control group, however, there wereno significant changes in TIBC levels after soy sauce con-sumption compared with that before consumption(Table5).  Effect of iron-fortified soy sauce on serum transferritin concentrations in subjects Table6 shows that TF concentrations in both the low-NaFeEDTA and high-NaFeEDTA groups were decreasedsignificantly compared with that in the control group and thatbefore intervention ( P <0.01). Discussion The present study shows that Hb, SI, SF, FEP, TIBC and TFconcentrations in subjects in the control group were notchanged remarkably after consuming non-fortified soy saucefor 3months. However, all of the above parameters in boththe low-NaFeEDTA group and high-NaFeEDTA group weresignificantly improved after consuming NaFeEDTA-fortifiedsoy sauce. In the low-NaFeEDTA group, consumption of soysauce for 1month did not cause a remarkably increased Hbconcentration. However, this was significantly increasedafter 2 and 3months of intervention. The Hb levels in the twointervened groups did not differ significantly at the end of thestudy, showing that daily supplementation of 5mg Fe asNaFeEDTA in soy sauce can effectively cure IDA within3months. The results also indicate that the daily supplemen-tation of 20mg iron in the form of NaFeEDTA in soy saucecould quickly cure IDA within 2 or 3monthsSoy sauce is a traditional condiment consumed com-monly in all parts of China and used in all types of cookingand cuisines. The average consumption of soy sauce in Chinawas around 12.6g in the early 1990s and it is less varied inthe different regions of China than other potential food carri-ers such as flour, rice, sugar and vinegar. 14 Because of itshigh salt content, the amount of soy sauce used in foodpreparation is self limited. Therefore, the chance of excessiron intake from iron-fortified soy sauce is negligible. Soysauce fortified with NaFeEDTA retained the same features of regular soy sauce in terms of its flavour, colour and precipi-tant when compared with non-fortified soy sauce. This is acritical advantage of using NaFeEDTA over other commonlyused iron compounds (such as FeSO 4 ) as a nutrient fortifi-cant in soy sauce. Table 6. Effect of iron-fortified soy sauce on TF in students with anaemia (mg/dL, Mean±SD) GroupsNo.TF before interventionTF after interventionControl81266.79  ± 55.16259.94  ± 54.25Low NaFeEDTA82264.19  ± 44.69240.94  ± 47.10 aa,bb High NaFeEDTA77269.02  ± 50.50237.76  ± 42.40 aa,bb Compared with TF before intervention: aa P <0.01; Compared with the control group: bb P <0.01. TF, transferritin. Table 5. Effect of iron-fortified soy sauce on FEP and TIBC in students with anaemia (Mean±SD) GroupsNo.FEP (ug/dL)TIBC (ug/dL)Before interventionAfter interventionBefore interventionAfter interventionControl8151.21  ± 24.8057.05  ± 17.750.396  ± 0.0590.390  ± 0.060Low NaFeEDTA8241.71  ± 17.9529.58  ± 12.97 aa,bb 0.416  ± 0.0620.397  ± 0.068 a,b High NaFeEDTA7745.64  ± 20.0228.76  ± 8.31 aa,bb 0.421  ± 0.0590.397  ± 0.068 aa,b Compared with concentration before intervention: a P <0.05; aa P <0.01. Compared with the control group: b P <0.05; bb P <0.01. Table 4. Effect of iron-fortified soy sauce on SI and SF in students with anaemia (Mean±SD) GroupsNo.SI (µg/dL)SF (ng/mL)Before interventionAfter interventionBefore interventionAfter interventionControl8197.69±35.0192.98±30.7648.33±20.2047.13±15.65Low NaFeEDTA8273.11±19.45103.04±25.34 aa,b 43.69±20.7760.88±19.93 aa,bb High NaFeEDTA7780.45±26.18104.17±32.36 a,bb 42.47±16.4458.12±19.99 aa,bb Compared with concentration before intervention: a P <0.05; aa P <0.01. Compared with the control group: b P <0.05; bb P <0.01. SF, serum ferritin; SI,serum iron.  Effects of NaFeEDTA in anaemic children127The present study shows that NaFeEDTA-fortified soysauce is highly effective in treating IDA. It presented evi-dence that this fortified soy sauce could be recommended forpotential wider use in China. Based on the well-establishedprocesses in our Institute, NaFeEDTA made with the samespecifications as products from other foreign companies iscurrently available. NaFeEDTA-fortified soy sauce has beenapproved for manufacture systemically in two big foodindustries by the Chinese Ministry of Health. In addition,NaFeEDTA-fortified soy sauce will be an acceptable condi-ment for the public in that its cost is only 20cents higherthan traditional soy sauce, per serving (500mL). There is apromising future for IDA elimination in China through foodfortification. To obtain further data supporting its effect onIDA and to put it into application sooner, however, it is nec-essary to carry out further studies on NaFeEDTA-fortifiedsoy sauce, including large scale intervention trials in popula-tions with high anaemia prevalence. References 1.Hurrell RF. Preventing iron deficiency through food fortification.Nutr Rev 1997; 55: 210–222.2.Hurrell RF, Ribas R, Davidsson L. Sodium iron EDTA as a foodfortificant: Influence on zinc, calcium and copper metabolism in therat. Br J Nutr 1994; 71: 85–93.3.Garby L, Areekul S. Iron supplementation in Thai fish-sauce. AnnTrop Med Parasitol 1974; 64: 467–476.4.Garby L. Condiments. In: Clydesdale FM, Wiemer KL, eds. IronFortification of Foods. Orlando, FL: Academic Press, 1985; 165–170.5.Viteri FE, Alvares E, Torun B. Prevention of iron deficiency bymeans of iron fortification of sugar. In: Vnderwood BA, ed. Nutri-tion Intervention Strategies in National Development. New York:Academic Press, 1983; 287–314.6.Viteri FE, Garcia-Ibanez R, Torun B. Sodium iron NaFeEDTA asan iron fortification compound in Central America. Am J Clin Nutr1978; 32: 961–971.7.Ballot DE, Macphail AP, Bothwell TH, Gillooly M, Mayet FG.Fortification of curry powder with NaFe (III) EDTA in an iron-deficient population: Report of a controlled iron-fortification trial.Am J Clin Nutr 1989; 49: 162–169.8.Ballot DE, Macphail AP, Bothwell TH, Gillooly M, Mayet FG.Fortification of curry powder with NaFe (III) EDTA in an iron-deficient population: Initial survey of iron status. Am J Clin Nutr1989; 49: 156–161.9.Dai RT. Study on iron fortified soy sauce I. Primary study on FeSO 4 fortified soy sauce. Acta Nutrimenta Sinica 1984; 6: 149–153 (inChinese).10.Dai RT. Study on iron fortified soy sauce II. Absorption of iron for-tified soy sauce in human. Acta Nutrimenta Sinica 1984; 6:231–238 (in Chinese).11.Wang XS, Yin T-A, Liu JP, Wang WG, Yan HC, Gao XL. Methodsfor Evaluation of Nutritional Status in Humans. Tianjin: TianjinScience and Technology Press, 1989; 4–31 (in Chinese).12.Wang XS. Methods for biochemical determinations. In: Wang XS,Yin TA, Liu JP, Wang WG, Yan HC, Gao XL, eds. Methods forEvaluation of Nutritional Status in Humans. Tianjin: Tianjin Sci-ence and Technology Press, 1989; 139–141.13.Chen XC. Applied Nutrition. Beijing: Public Health House, 1984;292–296 (in Chinese).14.Ge KY. The Dietary and Nutritional Status of Chinese Populationin 1990s. National Nutrition Survey, 1992, vol. 1. Beijing: People’sPublic Health House, 1996 (in Chinese).
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