Ironed out
Should bread be fortified with iron? With scientists divided on the issue,
Amira El-Noshokaty can't make up her mind
The Egyptian term for bread-winning is bread eating ; and the saying has it that it is hard. Well, the notion seems to be acquiring a humorously literal dimensions with debates surrounding government plans to add mineral supplements to the flour out of which subsidised baladi bread is made, with a view to reducing invariably high anaemia rates -- for one thing. Already approved, a three-year project has brought together the Ministry of Supplies, the World Health Organisation, the National Nutrition Centre and the National Research Centre; the first phase should be implemented on a budget of LE21 million with an additional $3 million from the World Food Programme. The decision to go ahead with the project comes as a shock to the public, who had been hearing as much about the possibility of adverse health effects as about the beneficial consequences of introducing an iron supplement into the staple of their diet; such confusion was complicated further by statements to the effect that, depending on the individual's constitution, iron may prove to be either helpful or potentially fatal. "So I don't know if I should have extra iron," Ashraf Zakaria, taxi driver, declaims, "so how do I find out? Should I go and have a full check-up before I have a bite of bread?"
But for Ashraf Shaalan, head of the Medical Research Department at the National Research Centre (NRC) -- the force behind the project -- possible adverse effects are by and large negligible. "The percentage of iron-deficiency anaemia among Egyptians is extremely high," he says. "Some 40 years ago it was 30- 40 per cent -- and despite medical and awareness interventions, it has stayed the same." Such efforts comprised making supplements like pills available to people. According to Shaalan, people did not take the supplements as regularly as they might have, falling into their usual dietary routine sooner or later. Efforts therefore proved unsustainable, which is how the fortification plans came about: "Folic acid will also be added, among other supplements. Egyptians suffer a folic-acid deficiency six times the international rate." Crucial for pregnant women -- lack of folic acid can hamper the development of body functions in the foetus -- the supplement is water soluble, which makes it safe even for those who might not need it. Iron, on the other hand, you can overdose on -- hence the ongoing media critique of the project. Still, Shaalan is adamant: "the fact remains that iron deficiency affects children's intelligence, learning capacities and concentration. It's the future of a nation that is at stake here." Besides, he went on, a dose of three milligrammes of iron per gramme of flour is hardly cause for concern since even with those who suffer from anaemia the results will only show in the long run. Bread is a regular meal for over 80 per cent of the population -- available to all -- including those unable to afford meat.
The 0.3 per cent iron content is simply to replace what is lost in the process of turning the wheat into flour, Shaalan went on to explain: whole wheat would alter the age-old taste of baladi bread, which is already on the brown side of things. The change would be so pronounced, he says, people, including himself, would stop eating it. For his part Zakaria believes the subsidised bread, at five piastres apiece, is already barely edible, however: too small, only available from 7-9am and altogether less than perfect as it is. "Maybe," he says, "they should improve the quality of this bread to start with. And if using whole wheat serves the same purpose, why waste so much money on a project like this?" Like many others, Zakaria feels the government has chosen the easiest and most lucrative option. It is not just bread, he says: "everything has chemicals in it, and that's why there's always talk of health hazards when it comes to food, whether it's fruit or vegetables." Some 210 million pieces of baladi bread are produced daily, but quality is compromised by changing government edicts and the corruption of bakery owners, some of whom will sell subsidised flour on the black market. A fact that lead the minister of supplies to proclaim such acts as haram (religiously forbidden ) especially during the Holy month of Ramadan; noting that the government spends LE13 billion on subsidised bread annually, while some bakeries would sell the bread as farm animals' food. Adding mineral supplements will not solve any of these problems, and it might even introduce some problems of its own -- with the possibility of side effects looming.
Shaalan insists that, whereas laboratory animals will absorb as much iron as their bodies take in, suffering various diseases as a result, the human system has a "shut-down mechanism" that prevents this from happening. But scientists like Mohamed El-Asmar, biochemistry professor at Ain Shams University's Faculty of Medicine -- also editor-in-chief of the Egyptian Journal of Biochemistry and Molecular Biology -- argue that more research should be conducted before any such plan is implemented: "I am not against it per se, but we consume a lot of bread to begin with. Our problem is that up to 80 per cent of the people lack nutritional awareness. Excess iron will affect every organ in the body. Any iron I take in is carried through the bloodstream to my tissues, where excess amounts may end up being stored -- a big problem." The shut-down mechanism will not always work, where diseases have resulted in an imbalance of the "iron carrier in the intestines" for example. In this case, it will be stored in body issue, eventually resulting in organ failure: "the trick is to be in control of iron intake, taking into account the fact that people eat a lot of bread and may not know about imbalance in the iron carrier. Excess iron could prove disastrous." Still, El-Asmar is not against the concept of bread fortification in general, only the way it is being carried out in this case. "Is there enough research on the ill human being on medication as opposed to the healthy one? Has there been any monitoring of clinical reactions to the iron supplement to determine whether or not there may be adverse side effects? It is just too early in the day."
One such experiment -- admittedly conducted on rats -- actually made the headlines last week, with the information that an iron overdose is undesirable. "The rats had diabetes in the first place," Shaalan counters. "An overdose occurred only when the equivalent of the iron content of 160 pieces of bread was taken in at once. With the average Egyptian eating no more than six pieces a day, surely these results are irrelevant." And there has been research to suggest the supplement is safe. A few years ago, the National Nutrition Centre undertook a one-year pilot project in Fayoum on iron supplements; which lasted for six months only due to funding constrains. Consequently, the planed post researches never came through. Depending more on international researches, along with research in the US -- the results of which were the principal go-ahead signal -- Shaalan cites a more recent, one-month experiment conducted on local orphans through NGOs in which no complications resulted. But El-Asmar remains sceptical: "what works for the US may not work for us. The parasite infections we have here -- bilharzia, for example -- are endless. Has there been research that takes that into account?" Besides the fact that no comprehensive research has been conducted on humans raised for food to which baladi bread is routinely fed -- El-Asmar's main concern is possible side effects. "Why not make this new bread available only to those who need it?"
Yet the government plans to implement the project all across the country within months, with awareness campaigns and monitoring proceeding side by side with the project itself.
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