Milk fortification experience in Chile . Eva Hertrampf MD. MSc.

1. Milk fortification experience in Chile. Eva Hertrampf MD. MSc. Laboratory of Micronutrients, Institute of Nutrition and Food Technology (INTA) University of Chile. Santiago, Chile.

2. Chile Inhabitants 15,000,000 Per capita GDP US$ 4, 800 Literacy rate : 96% Urban population: 84.9% Life expectancy : 75.2 years Infant mortality 2000: 9.8/ 1.000 Infant malnutrition > 1% Average births per woman = 1.4% Births in Maternity = 99% Breast fed duration = 6m Mother-Children Program (HPS) covers 70% of population in outpatient clinics. (100% of LSS)

3. Introduction • Nutrition interventions are an important • component of social planning in Chile. • Since the 50´s, the National Supplementary Food Program (NSFP) administered by the Chilean Ministry of Health through primary care health centers, provides free of cost milk based complementary foods to children from birth to 5 years of age.

4. In conjunction with the National Supplementary Food Program, is the monthly health care program, which includes: • - growth and development monitoring, - breast feeding promotion, • - immunizations and • - education in nutrition. • Currently 70% of Chilean children under 5 years of age are receiving this benefit.

5. Since the 80´s, Stekel et al, at INTA demonstrated the efficacy of milk fortified with iron and ascorbic acid in the prevention of IDA in chilean infants. • Only in 1999, Ministry of Health authorities decided to replace the unfortified milk (Leche Purita) for a fortified one (Leche Purita Fortificada). • Previous, to the national implementation bioavailability, stability, and organoleptic studies were performed. A new package was designed and an acceptability field survey was done.

6. Fortifying milk with iron in Chile Fortified milk NSFP: children under 2 years of age. Whole fat powder milk 1975 1980 1985 1990 2000 Efficacy Efficacy Effectiveness Milk fortified with Fe and vit C Milk fortified with only iron Milk fortified with Fe and Vit C Fortified formula for infants

7. 80 70 60 50 40 30 20 10 0 Hb<11 g/dL FEP>100 ug/dL FS>10 ug/L Milk fortified with Fe and vitamin C (non-acidified) Hertrampf et al. Rev Med Chile 1990; 118: 1130-1337 25 Fortified Non fortified 20 15 Percentage (%) 11% Iron absorption (%) 10 5 º 0

8. Since 1999, Chilean National Supplementary Feeding Program delivers free of cost 2 kg/month of a full fat powdered milk to the 70% of infants from birth to 18 months of age. Lactating mothers consume it until their infants are weaned. Fortified with mg/100g Iron (ferrous sulfate) 10 Ascorbic acid 70 Zinc (zinc sulfate) 5 Copper (copper sulfate) 0.5 Shelf life = 6 months in a multilayered packaging with a nitrogen flushing. Aceptability= good,similar to non-fortified milk. Leche Purita Fortificada

9. Iron bioavailability from fortified milk. Design in infants using stable isotopes Day 1 Day 2 Day 28 FM* 3 mg 58Fe Ferrous Ascorbate 4 mg 57Fe Magnetic sector thermal ionization mass spec. Fe isolation by anion exchange chromatography method.

10. Iron absorption from iron fortified milk measured in infants and women 25 20 15.4% 12.0% 15 Iron absorption (%) 10 5 0 Infants Stable isotopes Women Radioactive Isotopes

11. Iron supply from fortified foods delivered through Chilean NSFP. Iron absorption Daily Iron absorbed* (%) consumption mg/day Fortified Milk 15.4 500 ml 0.8 Fortified drink 12.4 500 ml 0.4 Vegetable purée 6.0 100 g 0.3 *Iron requirement : 1.0 mg/day

12. Evaluate effectiveness of the fortified milk on the prevention of • IDA and ID in children under the real conditions of distribution by the National SupplementaryFood Program.

13. Effectiveness study design August 1999 Post-fortification June-July 2000 Pre - fortification June-July 1999 Primary Care Health Clinic Southern Area of Santiago Primary Care Health Clinic Southern Area of Santiago 12-18 months infants covered by the National Supplementary Feeding Program, attending to receive immunizations N=128 12-18 months infants covered by the National Supplementary Feeding Program, attending to receive immunizations N=125 Hemocue FEP Serum ferritin

14. Age (mo) 15.3 NS 15.6 Sex fem. (%) 53.1 NS 45.6 <2.500 g BW (%) 3.9 NS 7.2 <3.000 g BW (%) 18.0 NS 15.0 Fe supplements (%) 22.0 NS 21.0 Breast fed* (ms) 5.0 NS 5.9 Characteristics of infants sudied. Pre- p Post- fortification fortification N=128 N=125 *Human milk as the only source of milk

15. Iron nutrition status of infants Ferritin* Hgb FEP (g/L) µg/dL RBC) µg/L) ( ( Pre-fortification 115 ± 12 131.4 ± 60.7 13.3 n=128 (6.1-29.0) P <0.0001 <0.0001 <0.0001 Post-fortification 125 ± 13 97.9 ± 51.8 15.7 n=125 (7.6-32.5) *Geometric mean and range of 1 SD

16. Effect of fortified milk on hemoglobin distribution 40 1999 pre fort n=128 2000 post fort n=125 30 Infants (%) 20 10 0 9 11 13 15 17 19 Hemoglobin (g/dL)

17. 50 40 30 20 10 0 Effect of fortified milk on anemia prevalence in chilean infants 28.8% Anemic* infants (%) 8.8 % Pre-fort Post-fort *Hgb<11g/dL

18. Effect of fortified milk. 80 67% 70 FEP >100 mg/dL RBC Ferritin <10 mg/L 60 50 Infants (%) 40 32% 28% 30 23% 20 10 0 Pre Post Pre Post

19. Conclusions. • The delivery of a fortified powdered full fat cow´s milk through the National Supplementary Food program in Chile is effective in preventing iron deficiency anemia and iron deficient erythropoyesis in infants between 12 and 18 months of age. There is not a significant impact on iron stores. • .