PLACE, TRIAL

ABSTRACT/ SUMMARY 

CAMBODIA 1
UNIVERSITY OF GUELPH, CANADA

CHARLES C, DEWEY C, DANIEL WE, SUMMERLEE AJS (2011).
ANEMIA IN RURAL CAMBODIA: COMMUNITY TRIAL OF A NOVEL SUPPLEMENTATION TECHNIQUE.
EUROPEAN JOURNAL OF PUBLIC HEALTH 21: 43-48.  
https://atrium.lib.uoguelph.ca/xmlui/handle/10214/10490

BACKGROUND
More than 3.5 billion people are affected by iron-deficiency anaemia (IDA). Previous studies have shown that the use of iron pots in daily cooking ameliorates IDA. We report a study on the use of a novel treatment to address IDA in rural women in Cambodia, where the use of iron pots is not common.

METHODS
A community-wide randomized controlled trial was conducted in the village of Preak Ruessei, Kandal Province, Cambodia. Rural women (n = 189) were enrolled and randomly assigned by household to one of three groups: (i) control, (ii) iron treatment with no follow-up and (iii) iron treatment with follow-up visits to provide IDA education. Haemoglobin, serum iron and C-reactive protein concentrations were measured at baseline, 3 and 6 months. A reusable fish-shaped iron ingot was distributed to the two treatment groups and participants were directed to use them daily for cooking. We hypothesized that iron from the ingot would leach iron into food providing an effective iron source.

RESULTS
Blood iron levels were higher in women in the iron fish plus follow-up at 3 months compared with controls, but this was not maintained. At 6 months, haemoglobin and serum iron had fallen in all groups and the proportion of anaemic women had increased.

CONCLUSIONS
This study shows that the iron ingot was effective in the short but not longer-term against IDA. Though a novel treatment option, further research is warranted to determine bioavailability of leached iron and whether or not the surface area is large enough for sufficient iron leaching.

CAMBODIA 2 
UNIVERSITY OF GUELPH, CANADA

CHARLES CV, DEWEY CE, HALL A, HAK C, CHANNARY S, SUMMERLEE AJS (2015).
A RANDOMIZED CONTROL TRIAL USING A FISH-SHAPED IRON INGOT FOR THE AMELIORATION OF IRON DEFICIENCY ANEMIA IN RURAL CAMBODIA.
TROPICAL MEDICINE & SURGERY 3: 3   
http://dx.doi.org/10.4172/2329-9088.1000195

OBJECTIVE
The objectives were to determine whether cooking food with an iron ingot increases the hemoglobin and serum ferritin of women and whether women would use an iron ingot shaped like a fish considered lucky in Cambodian culture.

METHODS
A randomized controlled trial was conducted in three villages in rural Kandal Province, Cambodia. Participants were randomly assigned to the iron ingot, the iron ingot plus nutrition education, or untreated control group. Participants were instructed to use the iron ingot daily by adding it to the cooking pot when preparing soup or boiling drinking water and boiling for at least 10 minutes. Blood samples were taken at baseline and every three months thereafter, over a 12-month trial period.

RESULTS
Overall, a 46% reduction in the prevalence of anemia within the intervention group was noted at the end of the study. Hemoglobin concentrations were greater by 11.8 g/L (95% CI: 9.1, 14.6; P<0.0001) in women in the iron ingot group when compared to controls. Serum ferritin concentrations were 31.0 ng/mL (95% CI: 17.1, 45.0; P<0.0001) greater after 12 months of using the iron ingot when compared to controls. Over 94% of women used the iron ingot at least 3 times per week.

CONCLUSION
The iron ingot shaped as a lucky fish is a very effective, innovative form of homestead food fortification in a country lacking affordable and accessible means of improving iron intake.  

CAMBODIA 3 
UNIVERSITY OF GUELPH, CANADA

RAPPAPORT AI, WHITFIELD KC, CHAPMAN GE, YADA RY, KHEANG KM, LOUISE J SUMMERLEE AJ, ARMSTRONG GR, GREEN TJ (2017).
RANDOMIZED CONTROLLED TRIAL ASSESSING THE EFFICACY OF A REUSABLE FISH-SHAPED INGOT TO INCREASE HEMOGLOBIN CONCENTRATION IN ANEMIC, RURAL CAMBODIAN WOMEN.
AMERICAN JOURNAL OF CLINICAL NUTRITION 106(2): 667-674.   
https://doi.org/10.3945/ajcn.117.152785

BACKGROUND 
Anemia affects 45% of women of childbearing age in Cambodia. Iron supplementation is recommended in populations in which anemia prevalence is high. However, there are issues of cost, distribution, and adherence. A potential alternative is a reusable fish-shaped iron ingot, which, when added to the cooking pot, leaches iron into the fluid in which it is prepared.

OBJECTIVE
We sought to determine whether there was a difference in hemoglobin concentrations in rural Cambodian anemic women (aged 18–49 y) who cooked with the iron ingot or consumed a daily iron supplement compared with a control after 1 y. DESIGN: In Preah Vihear, 340 women with mild or moderate anemia were randomly assigned to 1) an iron-ingot group, 2) an iron-supplement (18 mg/d) group, or 3) a non-placebo control group. A venous blood sample was taken at baseline and at 6 and 12 mo. Blood was analyzed for hemoglobin, serum ferritin, and serum transferrin receptor. Hemoglobin electrophoresis was used to detect structural hemoglobin variants.

RESULTS
Anemia prevalence was 44% with the use of a portable hemoglobinometer during screening. At baseline, prevalence of iron deficiency was 9% on the basis of a low serum ferritin concentration. There was no significant difference in mean hemoglobin concentrations between the iron-ingot group (115 g/L; 95% CI: 113, 118 g/L; P = 0.850) or iron-supplement group (115 g/L; 95% CI: 113, 117 g/L; P = 0.998) compared with the control group (115 g/L; 95% CI: 113, 117 g/L) at 12 mo. Serum ferritin was significantly higher in the iron-supplement group (73 μg/L; 95% CI: 64, 82 μg/L; P = 0.002) than in the control group at 6 mo; however, this significance was not maintained at 12 mo (73 μg/L; 95% CI: 58, 91 μg/L; P = 0.176).

CONCLUSIONS
Neither the iron ingot nor iron supplements increased hemoglobin concentrations in this population at 6 or 12 mo. We do not recommend the use of the fish-shaped iron ingot in Cambodia or in countries where the prevalence of iron deficiency is low and genetic hemoglobin disorders are high. 

CAMBODIA 4
UNIVERSITY OF GUELPH, CANADA

TEOH M, CARLI F, SUMMERLEE L, HAEM D.
FACTORS AFFECTING THE USE OF THE LUCKY IRON FISH AMONG VILLAGERS IN THE KOH RONG ARCHIPELAGO, CAMBODIA AND PERCEPTIONS OF IMPACT. 
JOURNAL OF GLOBAL HEALTH
Revisions required; in progress

BACKGROUND
Iron deficiency anemia remains a significant health problem among the people on the Koh Rong archipelago, Cambodia. There is little adherence to iron supplements, but preliminary studies have shown that community-members might adopt the Lucky Iron Fish to home fortify their meals. OBJECTIVES: (1) To explore the factors that affect use of the Lucky Iron Fish among villagers in the Koh Rong Archipelago; and (2) To study perceptions of the impact of regular use of the Fish on health and well-being.

METHODS
Three-hundred and fifty households in three villages on Krong Preah were provided with the Lucky Iron Fish and given nutrition education and education on the use, hygiene and care of the Fish. The villagers routinely boil water to sterilize it, so they were advised to include the Fish when boiling water to drink each day. Water quality analysis and a 24-hour food collection were completed at 30 households to determine the level of iron available in the usual diet. and to identify any possible contaminants in their water supplies that might confound iron absorption. A further 125 households, were selected to complete a pre/post survey on the acceptability and use of the Fish, perceptions of overall health, changes in diet, barriers to use of the Fish or side-effects of using the Fish)

RESULTS
Average dietary iron intake was ~2.16 mg/day (modal value 2.07 mg/day: range 0.5 – 6 mg iron/day). Factors that facilitated use of the Fish included design, storage and education on care and use of the Fish. At baseline, 71% of the participating women experienced one or more periods of headache per day and 37% of the women reported fainting (defined as losing consciousness and awareness of their surroundings for more than 20 seconds). By endline, after regular use of the Fish, only 59% of the women reported frequent headaches and 26% reported fainting once or more than once per day. The women also reported an increase in their perceptions of energy at endline including ease of: walking to the village shop; climbing stairs to their house; or hill climbing. One hundred and twenty-four of the women reported using the Fish three or more times a day: only one house reported using the Fish less often.

CONCLUSIONS
The high rates of iron deficiency in the islands are likely due to low daily intake of iron. Regular use of the Fish was facilitated by design, education and storage. Villagers reported significant improvements in the frequency of headaches or periods feeling dizzy and that they perceived they had more energy after using the Fish.   

GUATEMALA 1
WASHINGTON STATE UNIVERSITY, USA  

RODRÍGUEZ-VIVALDI AM, BEERMAN K (2018).
TESTING THE EFFICACY OF THE LUCKY IRON FISH® IN REVERSING IRON DEFICIENCY ANEMIA IN RURAL, IMPOVERISHED REGIONS OF GUATEMALA.
JOURNAL OF GLOBAL HEALTH REPORTS 2:E2018014   
https://doi.org/10.29392/joghr.2.e2018014

BACKGROUND
According to the World Health Organization (WHO), the most common nutrient-related cause of anemia is a lack of dietary iron (iron deficiency anemia, IDA). In regions of the world where populations are at greatest risk for IDA, barriers make screening and subsequent treatment challenging. Thus, IDA remains one of the most common, yet treatable, nutrition-related health problems in developing countries. A new approach to IDA remediation, called Lucky Iron Fish® (LIF) (Lucky Iron Fish, Guelph, Canada), overcomes many of these challenges. When placed into a pot of boiling, acidified water for 10 minutes, the LIF releases iron into the cooking water. Subsequently, the food absorbs the iron from the iron-enriched water, increasing the overall iron content of the meal. The purpose of this 52-week longitudinal study, conducted in rural, underserved regions of Guatemala, was to determine whether or not iron status improved after 12 months of using a LIF for meal preparation.

METHODS
Of the 302 people screened for IDA, 145 (48.0%) met the WHO standards for IDA. Heads of households were instructed how to prepare meals using a LIF. Subjects were asked to consume at least one meal/d prepared with a LIF and to return 1 year later to have their iron status retested.

RESULTS
A total of 56 (38.6%) subjects returned after 52 weeks to have their iron status retested. A paired t test showed that mean differences in both hematocrit and hemoglobin values were significantly higher at week 52 (P<0.001 for both) compared to baseline. A total of 45 (80.3%) subjects were no longer anemic at week 52, with a mean difference (follow-up being higher than baseline) in hemoglobin of 1.28 (19.6% improvement) and a mean difference in hematocrit of 3.8 (28.5% improvement).

CONCLUSIONS
The results of this study suggests that regular use of a LIF for meal preparation offers a safe and effective means to reverse IDA in high risk populations that lack the access and financial resources to purchase iron-rich foods or dietary supplements. 

GUATEMALA 2
WASHINGTON STATE UNIVERSITY, USA  

BEERMAN K, RODRÍGUEZ-VIVALDI AM, MCGEEHAN S (TO BE SUBMITTED 2020).
TESTING THE EFFECTIVENESS OF USING THE LUCKY IRON FISH TO ENRICH MEALS PROVIDED IN A SCHOOL-FEEDING PROGRAM IN GUATEMALA.
JOURNAL OF GLOBAL HEALTH REPORTS
https://doi.org/10.29392/001c.75318

BACKGROUND
The Lucky Iron Fish® (LIF) (Lucky Iron Fish, Guelph, Canada) is a culturally sensitive, iron fortificant that can be used in the home. Many children, especially in rural areas in developing countries suffer from iron deficiency and iron deficiency anemia. Some of these children as part of school-feeding programs designed to provide at least one nutritionally adequate meal a day. The purpose of the current was to (a) to develop a process to use LIF in a school kitchen to boost iron in the children’s daily meal and (b) test the efficacy of using iron-enriched meals with the Fish on iron status of the children.

METHODS
A technique was developed to fortify water by boiling a number of Fish in a large cooking pot and then asking children to consume a drink made from the iron-enriched water. Iron status was assessed in capillary blood (Hemocue assessment of hemoglobin in pin-prick blood) at baseline and every month for 6 months.

RESULTS
The results are currently being analyzed and prepared for publication but there was a significant (p < 0.05) improvement in hemoglobin after 6 months among the children. Stratifying the data revealed that the children with the lowest levels of hemoglobin at baseline showed the greatest improvement in hemoglobin levels.  

DOMINICAN REPUBLIC 1
CHILDREN’S HOSPITAL OF PHILADELPHIA, UNIVERSITY OF PENNSYLVANIA, USA 

NAHARA L. SABALLOS, ELIZABETH D. LOWENTHAL, MARIA DUNN, RAMONA CORDERO, INGRID JAPA, ANTONIO MATOS, RYAN M. CLOSE (2018).
ASTMH ABSTRACT IRON INGOTS VS. ENHANCED STANDARD OF CARE WITH ORAL IRON SUPPLEMENTS: ASSESSING TREATMENT EFFICACY AND NON-ADHERENCE AFTER 12-MONTH USE AMONG ANEMIC PRE-SCHOOL AGED CHILDREN IN CONSUELO, DR

ABSTRACT
Iron deficiency and iron-deficiency anemia are major contributors to global pediatric morbidity, particularly among children <5 years of age living in low-resource settings. A retrospective review showed that >50% of young children at our clinic were anemic, despite routine deworming and access to oral iron supplements. Subsequent dietary evaluations revealed poor quality and quantity of dietary iron intake. This prior work highlights a need for evaluation of non-adherence to oral iron and consideration of more sustainable methods of iron supplementation in this setting. We conducted a randomized controlled trial (RCT) among anemic children >1 and <5 years of age randomly assigned to receive an iron ingot to supplement food during cooking (Lucky Iron FishTM [LIF]) or an oral iron supplement (termed enhanced standard of care (eSOC) due to more frequent monitoring and adherence support). Biomarkers related to anemia, iron status, adherence, and barriers to use were assessed at baseline and 3, 6, and 12 months. Enrollment in the RCT is highly acceptable – 100% of the 80 families approached agreed to enroll and 5 withdrew or were lost to follow-up. Twelve-month follow-up is complete for 54 subjects (NLIF=25; NeSOC=29), and follow-up will be complete by September 30, 2018. For the 54 subjects with complete data, hemoglobin (Hb) values improved in both study arms. Median (IQR) baseline Hb was 10.3g/dL (10.0-10.6) and 10.0g/dL (9.55- 10.5) in the LIF and eSOC arm, respectively. At 12 months, median Hb in the LIF arm increased to 11.4g/dL (10.9-11.7) and in the eSOC arm to 11.6g/dL (11.2-12.0). Daily use of the recommended supplement was higher in the LIF group (80.0%) compared with the eSOC group (31.0%). Participants in the eSOC arm also experienced higher rates of vomiting, constipation, dark stool, stomachache, and fatigue, and 69.0% disclosed missing >2 doses per week. Final study analysis will include formal comparisons of biomarkers related to anemia and a more detailed analysis of barriers to use between groups. We hypothesize final analyses to reveal fewer barriers to LIF use due to the incorporation of the iron ingot use in daily cooking practices and fewer side effects. Thus, improvements in iron status may be more sustainable in the LIF arm over time. 

DOMINICAN REPUBLIC 2 
CHILDREN’S HOSPITAL OF PHILADELPHIA, UNIVERSITY OF PENNSYLVANIA, USA 

DATA COLLECTION COMPLETE
On hold due to COVID19; work resuming TBD

BIHAR 1
HARVARD, USA & UNIVERSITY OF GÖTTINGEN, GERMANY   

INDIA DATA COLLECTION COMPLETE
On hold due to COVID19; work resuming TBD

PROVISIONAL SUMMARY OF WORK: Malnutrition and lack of cognitive stimulation are primary risk factors of early childhood development and highly correlated with poverty. Particular children growing up in highly resource constrained environments often fail to reach their developmental potential, which adversely affects socio-economic outcomes later in life. This trial tests at large scale a set of potentially cost-effective tools to improve cognitive, language, socioemotional and motor development of toddlers in rural Bihar, India. We evaluate three interventions with 2000 children aged between 10 and 32 months. The first intervention addresses iron deficiency anemia, a biological risk factor of early development. We distributed a small cast iron ingot shaped like a tulsi leaf, labelled the Lucky Iron Leaf, for iron fortification. By placing the Lucky Iron Leaf in a cooking vessel of boiling water it releases iron into the water and the food. The second intervention addresses cognitive stimulation, a psychosocial risk factor of early development. We conducted four home visits during which dialogic reading was trained and practiced with the primary caregiver and her child. Dialogic reading refers to a method of looking at picture books which emphasizes strategic questioning and feedback in order to encourage children to speak and learn. For daily practice of dialogic reading three picture books were given to the caregiver and her child. Adding on intervention two, the third intervention is a dialogic reading calendar and serves as a reminder and encouragement for daily dialogic reading. We distributed colourful calendars, containing the months of the year, relevant moon periods and religious holidays, and caregivers use stickers to indicate whenever they practiced dialogic reading. The trial follows an individually randomised controlled design. We randomly allocated caregiver-child pairs to one of six groups: (i) Lucky Iron Leaf group, (ii) dialogic reading group without a calendar, (iii) dialogic reading group with a calendar, (vi) Lucky Iron Leaf and dialogic reading group without a calendar, (v) Lucky Iron Leaf and dialogic reading group with a calendar, and (vi) no-intervention group. We expect the iron fortification intervention to reduce iron deficiency anemia and consequently to improve cognitive and motor development. We expect the dialogic reading intervention to show positive effects on the child’s expressive and receptive vocabulary and socioemotional development. Further we expect these effects to be reinforced among the dialogic reading calendar groups.

Note: in the first iteration of this trial, the supply of tomato (used to acidify dahl during cooking) ran out due to the chance in season and the participants stopped using the ingot.  

PUNE 1
SAHARA AALHAD CENTRE, PUNE INDIA & CARLETON UNIVERSITY, CANADA 

HUSSEIN I, FERNANDEZ C, JONES PA (2018).
PILOT STUDIES USING THE LUCKY SHAKTI (IRON) LEAF™ TO PROVIDE AN ADVENTITIOUS SOURCE OF IRON TO HIV-POSITIVE PATIENTS WITHOUT NEGATIVELY AFFECTING VIRAL LOAD OR CD4+ COUNT.
ABSTRACT PRESENTED TO EUROPEAN IRON CLUB 2018 NOVEMBER 2018, MUNICH, GERMANY.

Reduced survival of HIV-positive patients is linked to iron deficiency anemia (IDA) and current HIV treatments magnify the detrimental effects of IDA; for example, anti-retroviral drugs (ARVs) exacerbate iron deficiency. However, providing higher-level iron supplements to counteract IDA can be associated with increased viral load and CD4+ cell counts. Recently, the Lucky Iron Fish® has been shown to alleviate IDA in normal patients and a Lucky Shakti (Iron) Leaf was developed to increase compliance in India where a considerable proportion of the population are vegetarian/vegan. As the ingot consistently releases a low level of bioavailable iron, similar to providing an iron-rich diet, a pilot study was carried out to investigate the possibility that the Lucky Shakti Leaf might improve the iron status of HIV-positive patients without affecting the progression of the disease. Participants (n = 122: 31 men and 91 women) with anemia (Hb 7.4-10.9g/dL) were recruited and randomly assigned (1) regular iron supplements (15mg ferrous sulphate) or (2) Lucky Shakti Leaf plus regular iron supplements. Participants in the Leaf group were provided with instructions on use and care of the Leaf and asked to drink one litre of water boiled for 10 minutes with the Leaf and 2-3 drops of lemon juice every day.
Participants in the control group were asked to drink a litre of water a day, with 2-3 drops of lemon juice only.
The primary outcome was Hb concentration.
Patients were observed by clinicians and any changes in viral load and CD4+ counts monitored. Median baseline Hb was 8.7g/dL (5.5-10.9) and 8.6g/dL (5.4-10.9) in the Leaf and control arm, respectively. One patient was lost from each group during the trial. At endline (six months later), the iron status in the Leaf group significantly (p <0.05) improved over the control group: median Hb in the Leaf arm increased to 11.9g/dL (7.0-11.0) whereas Hb levels were not significantly different from baseline in the control group 8.8g/dL (5.9-10.9). Likewise, there was no significant change in serum ferritin in the control group but a significant (p <0.05) increase in serum ferritin in people using the Leaf. Viral counts remained below detectable levels (96% in the Leaf group; 94% in the control group) and there was no significant difference in CD4+ counts at end-line between the groups and compared with baseline. The data suggest that using the Lucky Shakti Leaf may be helpful in boosting iron levels in HIV-positive patients on ARVs.  

PUNE 2
SAHARA AALHAD CENTRE, PUNE INDIA & CARLETON UNIVERSITY, CANADA 

FERNANDEZ C, HUSSEIN I, SALORE E (2020).
USING THE LUCKY SHAKTI (IRON) LEAF™ TO IMPROVE IRON STATUS OF HIV-POSITIVE PATIENTS IN MARGINAL COMMUNITIES IN INDIA.
Submitted to Global Health Reports

BACKGROUND AND OBJECTIVES
A pilot study demonstrated that HIV-positive participants living in a clinic could use the Lucky Shakti (iron) Leaf to boost iron status (increase in hemoglobin concentrations) without adversely affecting the progression of HIV. Data showed that using the Leaf plus and iron supplement (15mg/day) resulted in higher levels of hemoglobin compared with baseline and controls (iron supplement alone). However, users complained that it was difficult to consume a litre of water enriched with iron by cooking with the Leaf in addition to the large volumes of tea that they normally consume in a day.

METHODOLOGY 
A randomized controlled trial was carried comparing use of the Leaf prepared in water or in tea with changes in hemoglobin in no treatment controls. The objectives of the study were: (1) to expand the study to a larger population of people; (2) to test use of the Leaf on iron status among people living in marginal communities and not receiving a daily iron supplement; and (3) to explore whether preparing the iron-enriched water in black tea resulted in improvements in iron status. RESULTS: Regular use of the Leaf resulted in a significant (p < 0.05) improvement in hemoglobin in the group consuming iron-enriched water (>11g/L) and in the iron-enriched black tea (>9g/L) compared with baseline and with the no treatment controls. No side-effects were noted in either of the treatment groups. Users in the group asked to consume water again complained that drinking an extra litre of water a day was difficult whereas the participants drinking the iron-enriched black did not have concerns.

CONCLUSIONS
Contrary to previous reports, black tea may be appropriate as a vehicle to deliver iron-enriched liquid to people with HIV who have low iron levels. 

PERU
ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI, NEW YORK, USA
HEALTH BRIDGES INTERNATIONAL, PORTLAND, USA
MINISTERIO DE SALUD DE LA REPÚBLICA DEL PERÚ, LIMA, PERU
BAYLOR COLLEGE OF MEDICINE, HOUSTON, USA
ECHO MEDICAL GROUP, BEARSVILLE, USA

RACHEL WHITNEY, WAYNE A. CENTRONE, HOOVER SUPO MAMANI, KAREN FALKENSTEIN, ROBERT S. LEVINE, JADEN HARRIS, MELISSA HAZLITT, CZER ANTHONEY LIM (2021)
IMPACT OF COLLABORATIVE CHILDHOOD ANEMIA INTERVENTION PROGRAM IN PERU
TROPICAL MEDICINE & INTERNATIONAL HEALTH
https://doi.org/10.1111/tmi.13564

OBJECTIVES
To evaluate the impact of a 12‐month multi‐modal public health intervention program for treating and preventing anemia among children aged 6 months to 4 years in an underserved community in Peru.

METHODS
The intervention included nutritional education, use of a Lucky Iron Fish® cooking tool, and dietary supplementation. The primary outcome measure was anemia resolution. Secondary outcomes included absolute changes in hemoglobin, change in knowledge survey scores, and adherence to interventions. Chi‐square and Mann‐Whitney‐U tests were employed to identify associations between anemia and intervention‐related measures. Variables found to be significantly associated in bivariate analysis or of clinical importance were included in a logistic regression model.

RESULTS
Of the 406 children enrolled, 256 (63.1%) completed the program. Of those, 34.0% had anemia at baseline; this decreased to 13.0% over 12 months. The mean hemoglobin for all ages at baseline was 11.3 g/dL (SD 0.9). At 12 months, the mean was 11.9 g/dL (SD 0.8), with a mean increase of 0.5 g/dL (95% CI 0.4‐0.6). Children with anemia at baseline saw an increase of 1.19 g/dL at the 12‐month follow‐up (95% CI 1.12‐1.37). Parents correctly answered 79.0% of knowledge assessment questions at baseline, which increased to 86.6% at 12 months.

CONCLUSIONS
We observed a reduction in the prevalence of mild to moderate anemia among study participants in this vulnerable population and conclude that multi‐modal intervention programs providing nutrition education in conjunction with low‐cost iron supplementation and easy‐to‐use Lucky Iron Fish® cooking tools may reduce and prevent anemia in children.

PLACE, TRIAL

ABSTRACT/ SUMMARY 

LAB TRIAL 1
UNIVERSITY OF GUELPH, CANADA

CHARLES CV, SUMMERLEE AJS, DEWEY CE (2011).
IRON CONTENT OF CAMBODIAN FOODS WHEN PREPARED IN COOKING POTS CONTAINING AN IRON INGOT.
TROPICAL MEDICINE AND INTERNATIONAL HEALTH 16: 1518-1524.
https://doi.org/10.1111/j.1365-3156.2011.02878.x

OBJECTIVES
To investigate the effect of cooking with an iron ingot on the iron content of several water and Cambodian food preparations.

METHODS
Various food and water samples were prepared, in replicate, in glass and aluminium pots with and without an iron ingot. The samples were subjected to iron content analysis using standard ICP-OES procedures.

RESULTS
Prepared with an ingot, the iron content was 76.3 μg iron/g higher in lemon water, 32.6 μg iron/g higher in pork soup and 3.3 μg iron/g higher in fish soup, than in the same foods prepared without an ingot. Acidity of the food samples was positively associated with iron leaching.

CONCLUSIONS
Even when taking into account the low bioavailability of contaminant iron, approximately 75% of the daily iron requirement can be met by consuming 1L of lemon water prepared with an iron ingot. Its use may be a cheap and sustainable means of improving iron intake for those with iron-deficient diets. 

LAB TRIAL 2 
UNIVERSITY OF GUELPH, CANADA

ARMSTRONG GR, DEWEY CE, SUMMERLEE AJS (2017).
IRON RELEASE FROM THE LUCKY IRON FISH™: SAFETY CONSIDERATIONS.
ASIA PACIFIC JOURNAL OF CLINICAL NUTRITION 26: 148-155.
http://dx.doi.org/10.6133%2fapjcn.102015.14

BACKGROUND AND OBJECTIVES
The principal objective was to explore in greater detail safety issues with regard to the use of the Lucky Iron Fish® (fish) as a treatment for iron deficiency and iron deficiency anaemia in women in rural Cambodia.

METHODS AND STUDY DESIGN
Experiments were done to determine: (1) purity of the iron in the fish by mass spectroscopy; (2) release of iron and contaminants released during boiling in water using inductive-ly-coupled plasma optical emission spectroscopy; (3) the impact of cooking time, acidity and number of fish in acidified water and two types of Khmer soups; and (4) drinkability of the water after boiling with different numbers of fish.

RESULTS 
The fish is composed primarily of ferrous iron with less than 12% non-ferrous iron. Contaminants were either not detectable or levels were below the acceptable standards set by the World Health Organization. The length of time boiling the fish and the acidity of the water increased iron release but even with 5 fish boiled for 60 minutes, iron levels only approached levels where side effects are observed. Boiling one fish in water did not affect the perception of colour, smell or taste of the water but boiling in water with two or more fish resulted in the water being unpalatable which further limits the potential for iron toxicity from using the fish.

CONCLUSIONS
The results suggest that the Lucky Iron Fish™ may be a safe treatment for iron deficiency. 

LAB TRIAL 3
GRAND RIVER HOSPITAL, CAMBRIDGE, CANADA 

JOHNSON RL, BOVELL KK, LAHKMA Y (2019).
A CLINICAL ASSESSMENT OF THE BIOAVAILABILITY OF IRON DERIVED FROM THE LUCKY IRON FISH®.
PRESENTED AT THE SECOND INTERNATIONAL CONFERENCE ON BIOVALENCE AND BIOAVAILABILITY, BARCELONA, SPAIN AUGUST 2019.

The Lucky Iron Fish is reported to improve iron status but there are no data on the bioabsorption of iron derived from this source. A set of randomized, controlled trials were completed to determine the bioavailability of iron after consuming water salted with iron from different sources, including the Fish. Thirty-five women (aged 19-35y) were recruited and randomly allocated to three groups: (1) water cooked with the Fish for 10 minutes; (2) water containing 10 mg ferrous sulphate; or (3) no treatment control. After 12h of fasting and no strenuous exercise, the women were asked to drink 1 litre of water. Participants were blinded to the content of the water but aware that they were participating in an iron absorption test. Blood samples were taken at baseline and every 30 minutes for 4 hours to track changes in serum iron. At baseline, serum iron was not statistically significantly (p > 0.05) different among the three groups (5.2 + 0.6 µg/L [Fish]; 4.9 + 0.8 µg/L [sulphate]; & 5.0 + 0.8 µg/L [control]). In both iron-enriched groups, statistically significant (p < 0.05) increases in serum iron occurred, compared with baseline: (12.1 + 2.5 µg/mL [sulfate]; 11.8 + 2.3 µg/L [Fish]). Levels peaked by 90 minutes and waned to baseline over the next 2.5 hours. Serum iron levels in the Fish and sulfate groups were significantly higher (p < 0.01) after baseline compared with levels in the no-treatment controls which did not vary from baseline throughout the trial.

LAB TRIAL 4
UNIVERSITY OF EAST ANGLIA (UK)

RODRIGUEZ-RAMIRO, I, PERFECTOR, A, FAIRWEATHER-TAIT SJ (2017).
DIETARY FACTORS MODULATE IRON UPTAKE IN CACO-2 CELLS FROM AN IRON INGOT USED AS A HOME FORTIFICANT TO PRESENT IRON DEFICIENCY.
NUTRIENTS 9(9): 1005
https://doi.org/10.3390/nu9091005 PMCID: PMC5622765 PMID: 28895913

Iron deficiency is a major public health concern and nutritional approaches are required to reduce its prevalence. The aim of this study was to examine the iron bioavailability of a novel home fortificant, the “Lucky Iron Fish™” (LIF) (www.luckyironfish.com/shop, Guelph, Canada) and the impact of dietary factors and a food matrix on iron uptake from LIF in Caco-2 cells. LIF released a substantial quantity of iron (about 1.2 mM) at pH 2 but this iron was only slightly soluble at pH 7 and not taken up by cells. The addition of ascorbic acid (AA) maintained the solubility of iron released from LIF (LIF-iron) at pH 7 and facilitated iron uptake by the cells in a concentration-dependent manner.
In vitro digestion of LIF-iron in the presence of peas increased iron uptake 10-fold. However, the addition of tannic acid to the digestion reduced the cellular iron uptake 7.5-fold. Additionally, LIF-iron induced an overproduction of reactive oxygen species (ROS), similar to ferrous sulfate, but this effect was counteracted by the addition of AA.
Overall, our data illustrate the major influence of dietary factors on iron solubility and bioavailability from LIF and demonstrate that the addition of AA enhances iron uptake and reduces ROS in the intestinal lumen. 

LAB TRIAL 5
IMP India

ARMSTRONG GR, ASHUTOSH A, SUMMERLEE AJS. (2020)
THE LUCKY SHAKTI (IRON) LEAF ELECTROLYTIC: IRON RELEASE AND SAFETY CONSIDERATIONS FOR USE AS AN ADVENTITIOUS SOURCE OF SUPPLEMENTARY IRON.
Work being prepared for publication Asia Pacific Journal of Clinical Nutrition

BACKGROUND AND OBJECTIVES
Iron deficiency is a global public health problem. The Lucky Iron Fish® has been shown to reduce iron deficiency. The Fish is acceptable to most cultures, but many vegetarians and vegans would prefer not to use a symbol of a Fish. The current work describes developing an iron ingot shaped like the tulsi leaf known and the Lucky Shakti Leaf™ and the tests completed to confirm that it is safe and reliable to use.

METHODS AND STUDY DESIGN
Experiments were done to determine: (1) purity of the iron in the Leaf by mass spectroscopy; (2) release of iron and contaminants released during boiling in water using inductively-coupled plasma optical emission spectroscopy; (3) the impact of cooking time, acidity and number of Leaf in acidified water (using ascorbic acid, lemon juice and acetic acid; and (4) drinkability of the water after boiling with different numbers of Leaf.

RESULTS
The Leaf is made from pure electrolytic iron powder (>99.6% ferrous iron). Contaminants were either not detectable or levels were below the acceptable standards set by the World Health Organization. The length of time boiling the Leaf, the acidity of the water, and the type of acidity affected iron release. Boiling one Leaf in one litre of water for 10 minutes at acid pH released iron into the water: ascorbic acid and lemon juice solutions released ~7mg/L iron at pH5.5 and ~32mg/L iron at pH4.0 In contrast, acetic acid released ~4mg/L at pH5.5 and ~50mg/L at pH4.0 but in taste tests, most users reported that the acetic acid water was unpleasant to drink.

CONCLUSIONS
The results suggest that the Lucky Shakti Leaf releases iron in similar amounts to the Lucky Iron Fish and is a safe treatment for iron deficiency.  

PLACE, TRIAL

ABSTRACT/ SUMMARY 

REVIEW ARTICLE 1

CHARLES CV, SUMMERLEE AJS, DEWEY CE (2012).
ANEMIA IN CAMBODIA: PREVALENCE, ETIOLOGY AND RESEARCH NEEDS.
ASIA PACIFIC JOURNAL OF CLINICAL NUTRITION 21:171-181.
https://www.ncbi.nlm.nih.gov/pubmed/22507602

Anemia is a severe global public health problem with serious consequences for both the human and socio-economic health. This paper presents a situation analysis of the burden of anemia in Cambodia, including a discussion of the country-specific etiology and future research needs. All available literature on the prevalence and etiology of anemia in Cambodia was collected using standard search protocols. Prevalence data was readily identified for pre-school aged children and women of reproductive age, but there is a dearth of information for school-aged children, men and the elderly. Despite progress in nation-wide programming over the past decade, anemia remains a significant public health problem in Cambodia, especially for women and children. Anemia is a multifaceted disease and both nutritional and non-nutritional etiologies were identified, with iron deficiency accounting for the majority of the burden of disease.
The current study highlights the need for a national nutrition survey, including collection of data on the iron status and prevalence of anemia in all population groups. It is impossible to develop effective intervention programs without a clear picture of the burden and cause of disease in the country. 

REVIEW ARTICLE 2

ARMSTRONG GR, SUMMERLEE AJS (2014).
THE ETIOLOGY, TREATMENT AND EFFECTIVE PREVENTION OF IRON DEFICIENCY AND IRON DEFICIENCY ANEMIA IN WOMEN AND YOUNG CHILDREN WORLDWIDE: A REVIEW. JOURNAL OF WOMEN’S HEALTH CARE 4: 213
https://doi.org/10.4172/2167-0420.1000213 doi: 10.4172/2167-0420.1000213

The current review identifies the root causes of the problem, assesses the clinical impact of iron deficiency and iron deficiency anemia with a specific focus on the condition in developing countries, and outlines the potential solutions to address the problem. Iron deficiency, the most common micronutrient deficiency in the world, results from an imbalance in the access and use of iron in the body. Although it is found in the developing and developed world, it predominantly affects women and children especially those living in poverty. The clinical effects of iron deficiency are profound: mild deficiency results in the loss of concentration in children – affecting their performance at school, and reduces work capacity in adults – affecting their ability to work a full week of work; more profound effects can seriously and permanently damage cognitive development and pose serious health issues in pregnancy and child birth. Despite substantial international efforts to address iron deficiency, the levels have continued to rise over the last decade. As we have the technology to solve this problem, the Copenhagen Consensus Centre (which meets every four years) has identified iron deficiency as the principal health challenge facing the world: the health and economic burden falling predominantly on women of reproductive age. 

PLACE, TRIAL

ABSTRACT/ SUMMARY 

PhD THESIS

CHARLES CV (2012).
HAPPY FISH: A NOVEL SUPPLEMENTATION TECHNIQUE TO PREVENT IRON DEFICIENCY ANEMIA IN WOMEN IN RURAL CAMBODIA.
http://hdl.handle.net/10214/5927

Maternal and child undernutrition are a significant problem in the developing world, with serious consequences for human health and socio-economic development. In Cambodia, 55% of children, 43% of women of reproductive age, and 50% of pregnant women are anemic.

Current prevention and control practices rely on supplementation with iron pills or large-scale food fortification, neither of which are affordable or feasible in rural Cambodia. In the study areas, 97% of women did not meet their daily iron requirements. The current research focuses on the design and evaluation of an innovative iron supplementation technique. A culturally acceptable, inexpensive and lightweight iron ingot was designed to resemble a fish species considered lucky in Khmer culture. The ingot, referred to as ‘try sabay’ or ‘happy fish’, was designed to supply iron at a slow, steady rate. Iron leaching was observed in water and soup samples prepared with the iron fish when used concurrently with an acidifier. More than 75% of daily iron requirements can be met with regular use. Its use in the common pot of soup or boiled water provides supplementation to the entire family. The effectiveness of the iron fish was investigated in a randomized community trial involving 310 women in rural Cambodia. Blood samples were taken at baseline and every three months thereafter, over a 12-month trial period. Significant increases in hemoglobin concentrations were observed in women allocated an iron fish when compared to controls throughout the study, with an endline difference of 11.6 g/L. Significant improvements in serum ferritin concentration were observed at 9 months (6.9 ng/mL) and endline (30.8 ng/mL) in women who used an iron fish regularly when compared to the control group.

Overall, use of the iron fish led to a two-fold reduction in the prevalence of anemia. The supplement was used daily by 94% of the households at the end of the trial. The study highlights the acceptability and effectiveness of a fish-shaped iron ingot as a means of improving dietary iron content. It offers a promising, simple solution to iron deficiency anemia if the project can be scaled-up for use throughout the country. 

PhD THESIS

ARMSTRONG GR (2016).
COMMERCIALIZING THE LUCKY IRON FISH™ USING SOCIAL ENTERPRISE: A NOVEL HEALTH INNOVATION FOR IRON DEFICIENCY AND ANEMIA IN CAMBODIA AND BEYOND
http://hdl.handle.net/10214/10490

Research reported in the thesis concerns the process of commercializing a simple health invention, the Lucky Iron Fish™. There are seven distinct components of the research: (1) a study into the dynamics of the release of iron during cooking and demonstration that no other potentially deleterious contaminants that are released at the same time; (2) an assessment of the trace element, mineral and electrolyte content of food and drink consumed over a 24-hour period and ground water content in a province in the northern part of Cambodia (Preah Vihear); (3) an assessment of the prevalence of hemoglobinopathies among participants in a clinical study; (4) a twelve-month, randomized clinical trial comparing the regular use of the fish with taking iron pills (no treatment as a control) on iron status in women; (5) an assessment of the ethical and trust frameworks among groups living and working in Cambodia; (6) a critical assessment of current business models for the development of social enterprise and development of a for-profit, financially and socially sustainable social business to commercialize the Lucky Iron Fish™ ; and (7) the development of an improved version of the fish made from electrolytic iron powder.

Outcomes from the work include: (1) demonstration of consistent and safe release of iron from the fish during cooking; (2) inadequate nutrition among the study population with high intakes of manganese and sodium, which may have serious health implications for children and adults, and low iron that would support the contention that these people are iron deficient; (3) demonstration of very high prevalence of hemoglobinopathies among women (most of whom are carriers) in Preah Vihear – a novel finding that needs further study; (4) midline data on the impact of using the fish; (5) identification of profound differences in trust and ethical frameworks among groups of people in Cambodia and international aid workers; (6) the development of an improved version of the fish releasing known amounts of bioavailable iron; and (7) the incorporation of a for-profit, sustainable social enterprise that could serve as a model for commercialization of other health interventions in developing countries.