Multi-micronutrient Fortified Rice Improved Vitamin A Status of Cambodian School Children.

Objectives: In rice-consuming countries, multi-micronutrient fortified rice (MMFR) is a promising cost-effective strategy to control micronutrient deficiencies. The FORISCA project evaluated the impact of MMFR distributed through the WFP school meal program (SMP) on micronutrient status, health, and cognition of Cambodian schoolchildren. Here, effects on anemia, iron and vitamin A (VA) status are presented. Methods: The FORISCA-UltraRice+NutriRice study was a cluster-randomized, double-blinded, placebo-controlled trial in 9500 schoolchildren. Sixteen schools participating in WFP-SMP were randomly assigned to receive either MMFR including VA (MMFR+VA), MMFR without VA (MMFRVA), or unfortified rice (placebo) as breakfast distributed 6 days/week for 6 months. Four additional schools not participating in WFP-SMP were randomly selected as control. Twenty-five percent of schoolchildren from grade 1-6 participated in the biochemical study. Hemoglobin (Hb), iron and VA status were measured at baseline, 3 and 6 months. Results: Baseline prevalence of iron deficiency (ID), anemia and (marginal) vitamin A deficiency (VAD) were 51.6%, 15.7% and 8.6% respectively. Hemoglobinopathy (OR 2.5) , VAD (OR 2.1) and total body iron (TBI) were the strongest predictors of anemia (all p<0.01). The intervention had no overall impact on Hb or anemia prevalence. MMFR+VA significantly reduced VAD from 13.5% to 7.1% (p<0.05), whereas VAD increased in the other groups over the intervention (6.1% to 12.7%). Conclusions: Micronutrient deficiencies were prevalent with especially hemoglobinopathy and VAD and to a lesser extent iron status being risk factors for anemia. Fortified rice containing VA significantly improved VA status of schoolchildren. Funded by USDA/FAS, WFP-DSM consortium and IRD.

Rice Fortified with Iron in School Meals Improves Cognitive Performance in Cambodian School Children.

Objectives: Nutritional status can have a large impact on schoolperformance in children, with micronutrient deficiencies affecting cognitive performance and school attendance through increased morbidity. The FORISCA-UltraRice+NutriRice Trial in Cambodia tested impact of multimicronutrient fortified rice (MMFR) through the WFP school meal program (SMP) on micronutrient status, health and cognitive performance. Methods: The FORISCA-UltraRice+NutriRice study was a cluster-randomized, double-blinded, placebo-controlled trial in 9500 schoolchildren. Sixteen schools participating in WFP-SMP were randomly assigned to receive either MMFR including vitamin A (MMFR+VA), MMFR without VA (MMFR-VA) or unfortified rice (placebo) as breakfast distributed 6 days/week for 6 months. Four additional schools not participating in SMP were randomly selected as control group. Cognitive performance (Raven's Colored Matrices, Block Design and Picture completion), and vitamin A and iron status were determined in 25% of the schoolchildren. Results: Cognitive performance was significantly correlated to stunting (P<0.05) and total body iron (TBI) at baseline and endline (P<0.05), but not to vitamin A status. Cognitive performance improved in all children (P<0.001). Children receiving MMFR-VA (iron without vitamin A) had significant higher improvements in Block Design scores as compared to children receiving MMFR+VA (iron plus vitamin A, P<0.001) or control (P=0.022), and tended to be higher than placebo (P=0.09). Conclusions: Iron status, as well as chronic nutritional deprivation (stunting) are both important determinants of cognitive performance in schoolchildren. Improving iron status through fortified SMP can enhance schoolperformance, but interactions with other micronutrients may modify this effect. The optimal dose of micronutrients needs to be established. Funded by USDA/FAS, WFPDSM consortium and IRD.

What is the Right Indicator to Evaluate Impact of Interventions? Examples from a Rice Fortification Trial in Cambodia.

Objectives: Large-scale programs often use proxy indicators for evaluation purposes but little is known on whether use of these indicators might lead to erroneous conclusions regarding impact of programs. In the FORISCA-UltraRice+NutriRice trial in Cambodia, fortified rice was introduced through the WFP schoolmeal program (WFP-SMP). A wide range of impact indicators collected during the study was explored to test the usefulness of 2 proxy indicators (anemia and stunting) for program evaluation. Methods: In a placebo-controlled, double blinded trial, 20 schools (n=9500) were randomly allocated to no SMP (control, 4 schools), normal schoolmeal (placebo, 4 schools) or a schoolmeal with fortified rice (3 different types, 4 schools each). Data on absenteeism and morbidity was available for all schoolchildren, whereas biochemical data (hemoglobin, iron, zinc and vitamin A status), anthropometry, parasite infection and cognitive performance was available for ~25% of children. Results: At baseline, anemia prevalence was significantly lower in non-SMP (9.5% vs 16.6%, P<0.05) and iron status significantly higher in non-SMP schools than in intervention schools (P<0.005). Stunting prevalence was high (41.5%) and not different among the schools. After 6 months of consumption, fortified rice had no overall impact on anemia prevalence or hemoglobin concentrations, but improved micronutrient status and cognitive performance in some intervention groups. Conclusions: Anemia prevalence is a valid indicator to select schools for SMP, but stunting prevalence had little value in this study. Changes in anemia prevalence did not correspond to changes in functional outcomes, showing that program evaluation requires better proxy indicators. Funded by USDA/FAS, WFP-DSM consortium and IRD.

Optimal Iron to Zinc Ratios for Increased Soluble Iron in Fortified Rice.

Objectives: Previous studies evaluating the ability of fortified rice to improve hemoglobin and ferritin concentrations have produced mixed results. The literature indicates that combining iron (Fe) and zinc (Zn) can reduce the effects on iron status expected from iron supplementation alone. Our objective is to examine the relationship between the Fe/Zn molar ratio in fortified rice and improvements in hemoglobin and ferritin concentrations. Methods: Fe/Zn molar ratios of several fortified rice trials were examined in relation to changes in hemoglobin and serum ferritin concentration. The effect of exogenous zinc on iron solubilization of fortified rice was further evaluated using an in vitro assay to test fortified rice blends with known ratios of iron to zinc. Results: Although the fortified rice Fe/Zn ratios ranged from approximately 1 to 50, only in cases where the ratio exceeded 10 was a significant improvement in iron status (hemoglobin and/or ferritin) observed. The in vitro evaluation clearly associated exogenous zinc, in a dose-dependent manner, with inhibition of iron solubilization. Iron solubilized from fortified rice blends increased exponentially as the Fe/Zn ratio increased from 3.5 to 13.0. The plot of soluble iron vs. Fe/Zn further enabled prediction of the iron solubilization expected for any given Fe/Zn ratio. Conclusions: Iron fortification programs have the potential to significantly reduce iron deficiency anemia (IDA) and iron deficiency (ID). This research aimed to establish the relationship between the Fe/Zn molar ratio and health outcomes. Further research is needed to identify the most cost-effective Fe/Zn molar ratio to reduce IDA and/or ID. *Funded by USDA/FAS.

Ultra Rice Technology: Acceptable Micronutrient Losses and Limited Microbial Growth Enable Shelf Life Extension.

Objectives: The objective of this research was to determine if Ultra Rice (UR) fortified grains are shelf stable and suitable for consumption after 24 months (m) of storage and to document micronutrient losses to determine overages that must be included in the initial formulation. A longer shelf life will prevent the unnecessary disposal of fortified grains at 12m, enable fortified rice grains to be blended prior to transport, and increase the likelihood that it will reach vulnerable populations. Methods: UR premix kernels were sampled from a World Vision warehouse in Burundi every 6m over 24 m. The growth of microorganisms was tested in a certified laboratory and compared with the World Food Programme's (WFP) food safety standards for fortified rice: 10,000 /gram for Aerobic colony count, 50 /gram for Bacillus cereus, 0/gram for E. coli, 10 /gram for Coliforms, 100 /gram for Yeasts and moulds, and negative results for Salmonella. Micronutrient losses were calculated between 0 and 24 m, accounting for moisture. Results: Microorganism growth remained at or below the WFP acceptable limits after 24 m of storage. The micronutrient data indicated losses of 0.5% folic acid, 15.0% thiamine, 18.5% iron, and 18.1% zinc after 24 m of storage. Conclusions: The lack of bacterial growth within UR fortified rice suggests it can be safely consumed for at least 24 m following production and the shelf life can be extended to 24 m under similar storage conditions. Micronutrient losses were small and these amounts will be used to calculate overages with greater precision when formulating future micronutrient premix. *Funded by USDA/NIFA.

Treatment of Anemia with Iron-fortified Rice in a School Lunch Program in Burundi.

Objectives: This cluster-randomized trial tested the efficacy of fortified rice for the treatment of anemia in Burundi. Ultra Rice® (UR) premix kernels were manufactured to contain 100% of the recommended nutrient intakes (RNI) for iron, zinc, thiamin, and folic acid for children 7-9 years. The operational feasibility of providing a stable fortified rice product was also assessed in the Burundian context. Methods: Twelve schools were randomly assigned to receive either UR fortified rice or traditional rice for seven months through a school feeding program. Hemoglobin status was evaluated at baseline and follow-up. Data were collected on the organoleptic acceptability of fortified rice, micronutrient stability with the UR technology, and the blend homogeneity of the rice. Results: Anemia was highly prevalent in schools in Muyinga Province. The fortified rice product was considered acceptable to the local community, maintained stable micronutrient levels, and blended homogeneity. Over the course of the study, anemia status and hemoglobin levels improved in both the control and intervention groups. The intervention did not lead to a significantly greater change in hemoglobin level among those children eating fortified rice (β=0.085 g/dl, 95% CI: -0.21-0.38). Conclusions: High prevalence of fever among the children and the high zinc content of the UR formulation are likely responsible for the non-significant improvement in hemoglobin. Anemia interventions in Burundi should implement multiple strategies to eliminate both iron deficiency and infectious causes of anemia. The zinc content of a multiple micronutrient grain should be studied more carefully to maximize iron uptake. *Funded by USDA/NIFA.