Impact of fiber-fortified food consumption on anthropometric measurements and cardiometabolic outcomes: A systematic review, meta-analyses, and meta-regressions of randomized controlled trials

The consumption of processed and refined food lacking in fiber has led to global prevalence of obesity and cardiometabolic diseases. Fiber-fortification into these foods can yield potential health improvements to reduce disease risk. This meta-analyses aimed to evaluate how fiber-fortified food consumption changes body composition, blood pressure, blood lipid-lipoprotein panel, and glycemic-related markers. Searches were performed from 5 databases, with 31 randomized controlled trial eventually analyzed. Hedges' g values (95% confidence interval [CI]) attained from outcome change values were calculated using random-effects model. Fiber-fortified food significantly reduced body weight (-0.31 [-0.59, -0.03]), fat mass (-0.49 [-0.72, -0.26]), total cholesterol (-0.54 [-0.71, -0.36]), low-density lipoprotein cholesterol (-0.49 [-0.65, -0.33]), triglycerides (-0.24 [-0.36, -0.12]), fasting glucose (-0.30 [-0.49, -0.12]), and HbA1c (-0.44 [-0.74, -0.13]). Subgroup analysis differentiated soluble fiber as significantly reducing triglycerides and insulin while insoluble fiber significantly reduced body weight, BMI, and HbA1c. Greater outcome improvements were observed with solid/semi-solid food state than liquid state. Additionally, fiber fortification of <15 g/day induced more health outcome benefits compared to ≥15 g/day, although meta-regression found a dose-dependent improvement to waist circumference (p-value = 0.036). Findings from this study suggest that consuming food fortified with dietary fiber can improve anthropometric and cardiometabolic outcomes.Supplemental data for this article is available online at https://doi.org/10.1080/10408398.2022.2053658.

Nanoencapsulation of casein-derived peptides within electrospun nanofibres

BACKGROUND

Bioactive peptides derived from milk proteins are recognized as functional foods, but their consumption is limited by undesirable or bitter flavour, poor stability, and low bioavailability. Electrospinning is a versatile process for encapsulation of various bioactive compounds in the form of nanosized fibres, which can circumvent these disadvantages. This study was aimed at the preparation of casein-derived peptides-loaded nanofibres through electrospinning and characterizing them for fortification of milk.

RESULTS

Pullulan at 100, 120, and 140 g kg^-1 concentrations was used for electrospinning of peptides. Scanning electron and atomic force micrographs revealed the formation of clean bead-free peptides-loaded pullulan nanofibres at 120 and 140 g kg^-1 concentrations with mean diameter of 60.45-133.05 nm and encapsulation efficiency of 72.95-86.04%. Fourier transform infrared spectra and X-ray diffractograms revealed the absence of interactions between the functional groups of pullulan and peptides during electrospinning. The zeta potential of the peptides-loaded nanofibres ranged from -15.6 to -24.6 mV, and the hydrodynamic diameter varied from 118.7 to 256.2 nm. The peptides from electrospun nanofibres showed sustained release to the extent of 75.3% after 8 h in gastrointestinal pH conditions. The release kinetics of peptides from nanofibres was best fitted to a Peppas-Sahlin model (R²  = 0.987), and through diffusion and erosion mechanisms. The antioxidant activity of pure peptides and those from nanofibres was comparable. The physico-chemical qualities of milk fortified with encapsulated peptides did not show noticeable difference either.

CONCLUSIONS

From the morphological, ultrastructural, particle size, encapsulation efficiency, release kinetics, and antioxidant activity data, it was inferred that electrospinning could be an effective technique for nanoencapsulation of casein-derived bioactive peptides. These peptides-loaded nanofibres could be used for fortification of milk and milk products. © 2021 Society of Chemical Industry.

Neural tube defect prevalence does not increase after modification of the folic acid fortification program in Chile

BACKGROUND

In 2000, Chile's Ministry of Health mandated fortification of wheat flour with folic acid at a concentration of 2.2 mg/kg to prevent neural tube defects (NTDs), resulting in a 50% reduction in NTD prevalence. Concerns about possible collateral effects of high folic acid intake led, in 2009, to decrease the folic acid fortification to 1.8 mg/kg of flour. Our study evaluated the impact of this modification on the prevalence of NTDs in Santiago.

METHODS

This study measured the prevalence of NTDs in live births and stillbirths born in Santiago. We calculated prevalence ratios (PR) and 95% confidence intervals (CI) between pre-folic acid fortification (1999-2000), post-folic acid fortification (2001-2009), and post-modified folic acid fortification (2010-2015) periods for all NTDs and their specific types. We used chi-square tests to analyze proportions, and a Joinpoint regression to visualize prevalence time trends.

RESULTS

The NTD prevalence for the period 2001-2015 was 8.9 per 10,000 births, which represents a 48% reduction (PR = 0.52; 95% CI = 0.45-0.61; p < .001) from the pre-folic acid fortification period. During 2010-2015, the NTD prevalence was 9.5/10,000 births, which was higher, but not statistically significantly different from 2001 to 2009 prevalence of 8.6/10,000 (PR = 1.11; 95% CI = 0.96-1.30, p = .17).

CONCLUSIONS

Decreasing the concentration of folic acid fortification was not associated with a statistically significant change in the prevalence of NTDs. Mandatory folic acid fortification continues to be a safe and highly effective policy to prevent NTDs. Future studies should evaluate the prevalence of NTDs across Chile and adherence to folic acid fortification mandates.

Ultrasonic Extraction of Bioactive Compounds from Green Soybean Pods and Application in Green Soybean Milk Antioxidants Fortification

Green soybean (Glycine max L.) pods (GSP) are agro-industrial waste from the production of frozen green soybean and milk. These pods contain natural antioxidants and various bioactive compounds that are still underutilized. Polyphenols and flavonoids in GSP were extracted by ultrasound technique and used in the antioxidant fortification of green soybean milk. The ultrasound extraction that yielded the highest total polyphenol content and antioxidant activities was 50% amplitude for 10 min. Response surface methodology was applied to analyze an optimum ultrasonic-assisted extraction (UAE) condition of these variables. The highest desirability was found to be 50% amplitude with an extraction time of 10.5 min. Under these conditions, the experimental total phenolic content, total flavonoid content, and antioxidant activity were well matched with the predicted values (R² > 0.70). Fortification of the GSP extracts (1-3% v/v) in green soybean milk resulted in higher levels of bioactive compounds and antioxidant activity in a dose-dependent manner. Procyanidins were found to be the main polyphenols in dried GSP crude extracts, which were present at a concentration of 0.72 ± 0.01 mg/100 g. The addition of GSP extracts obtained by using an ultrasound technique to green soybean milk increased its bioactive compound content, especially procyanidins, as well as its antioxidant activity.

Preparation of Curcumin Hydrogel Beads for the Development of Functional Kulfi: A Tailoring Delivery System

Curcumin has been demonstrated to have biological activities and its fortification in food products is an important strategy to deliver bioactive ingredients at target sites. However, studies have documented a curcumin low bioavailability and low intake. Hence, combining functional ingredients with food should be needed to prevent widespread nutrient intake shortfalls and associated deficiencies. Thus, curcumin was encapsulated in calcium-alginate and their characteristics as well as in vitro release behavior of curcumin hydrogel beads (CHBs) was studied. Moreover, CHBs were fortified in development of functional Kulfi and their quality characteristics were studied. The encapsulation efficiency was up to 95.04%, indicating that most of the curcumin was entrapped. FTIR shifts in the bands were due to the replacement of sodium ions to the calcium ions. In vitro release (%) for CHBs was found to be 67.15% after 2 h, which increased slightly up to 67.88% after 4 h. The average swelling index of CHBs was found to be 10.21 to 37.92 from 2 to 12 h in PBS (pH 7.40). Control and Kulfi fortified with CHBs showed no significant difference (p > 0.05) in colour (L = 73.03 and 75.88) and the melting rate (0.88 mL/min and 0.63 mL/min), respectively. Standard plate count was reduced in the Kulfi fortified with CHBs (13.77 × 10⁴ CFU/mL) with high sensory score for overall acceptability (8.56) compared to the control (154.70 × 10⁴ CFU/mL). These findings suggested the feasibility of developing CHBs to mask the bitterness, enhance the solubility, and increase the bioavailability in gastrointestinal conditions. Additionally, Kulfi could be a suitable dairy delivery system for curcumin bioactive compounds.

Use of Branded Food Composition Databases for the Exploitation of Food Fortification Practices: A Case Study on Vitamin D in the Slovenian Food Supply

Vitamin D deficiency is a worldwide public health concern, which can be addressed with voluntary or mandatory food fortification. The aim of this study was to determine if branded food composition databases can be used to investigate voluntary fortification practices. A case study was conducted using two nationally representative cross-sectional datasets of branded foods in Slovenia, collected in 2017 and 2020, and yearly sales data. Using food labeling data we investigated prevalence of fortification and average vitamin D content, while nutrient profiling was used to investigate overall nutritional quality of the foods. In both datasets, the highest prevalence of vitamin D fortification was observed in meal replacements (78% in 2017; 100% in 2020) and in margarine, corresponding to high market share. Other food categories commonly fortified with vitamin D are breakfast cereals (5% in 2017; 6% in 2020), yogurts and their imitates (5% in 2017; 4% in 2020), and baby foods (18% in both years). The highest declared average content of vitamin D was observed in margarine and foods for specific dietary use (7-8 μg/100g), followed by breakfast cereals (4 μg/100g), while the average content in other foods was below 2 μg/100g. Only minor differences were observed between 2017 and 2020. Major food-category differences were also observed in comparison of the overall nutritional quality of the fortified foods; higher overall nutritional quality was only observed in fortified margarine. Our study showed that branded food composition databases are extremely useful resources for the investigation and monitoring of fortification practices, particularly if sales data can also be used. In the absence of mandatory or recommended fortification in Slovenia, very few manufacturers decide to add vitamin D, and even when this is the case, such products are commonly niche foods with lower market shares. We observed exceptions in imported foods, which can be subject to fortification policies introduced in other countries.

Childhood and Adolescent Anemia Burden in India: The Way Forward

The burden of anemia in Indian children, based on capillary blood sampling, is believed to be profound and worsening (67.1%) according to the successive National Family Health Surveys (NFHS). This might be an overestimate. The recent Comprehensive National Nutrition Survey of Indian children, that used venous blood sampling, found only less than half (30.7%) the NFHS prevalence, of which only one third was due to iron deficiency (ID). Unfortunately, the apparently worsening NFHS anemia burden estimate has been interpreted as an inadequacy of the present iron supplementation policy. This has led to additional iron supply through mandatory rice fortification. However, the lack of efficacy of iron supplementation appears inevitable, if the true prevalence of iron deficiency anemia is only about 10%. Thus, etiology is a critical consideration when devising appropriate and effective prevention policies. Future policies must focus on precision, thoughtfulness, restraint, and community engagement.

Early versus delayed introduction of human milk fortification in enterally fed preterm infants: A systematic review and meta-analysis

AIM

To assess effects of early versus delayed introduction of human milk fortification in preterm infants.

METHODS

We searched Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PubMed and CINAHL for randomised controlled trials evaluating start time for human milk fortification in preterm infants (March 2020). Two authors assessed trial eligibility and risk of bias, extracted data and assessed evidence certainty.

RESULTS

We identified 1307 publications and included three trials (378 infants). Meta-analysis comparing fortification commencing at an enteral feed volume of ≤40 mL/kg/day versus ≥75 mL/kg/day, showed little to no difference in rates of necrotising enterocolitis (3 trials), sepsis (3 trials), feeding intolerance (2 trials) (low-quality evidence) and infant growth (1 trial, very low-quality evidence).

CONCLUSIONS

Whether early introduction of fortification, at an enteral feed volume of ≤40 mL versus delayed at ≥75 mL/kg/day improves growth or influences adverse feeding outcomes is very uncertain.

Selenium in Wheat from Farming to Food

Selenium (Se) plays an important role in human health. Approximately 80% of the world's population does not consume enough Se recommended by the World Health Organization. Wheat is an important staple food and Se source for most people in the world. This review summarizes literature about Se from 1936 to 2020 to investigate Se in wheat farming soil, wheat, and its derived foods. Se fortification and the recommended Se level in wheat were also discussed. Results showed that Se contents in wheat farming soil, grain, and its derived foods around the world were 3.8-552 μg kg^-1 (mean of 220.99 μg kg^-1), 0-8270 μg kg^-1 (mean of 347.30 μg kg^-1), and 15-2372 μg kg^-1 (mean of 211.86 μg kg^-1), respectively. Adopting suitable agronomic measures could effectively realize Se fortification in wheat. The contents in grain, flour, and its derived foods could be improved from 93.94 to 1181.92 μg kg^-1, from 73.06 to 1007.75 μg kg^-1, and from 86.90 to 587.61 μg kg^-1 on average after leaf Se fertilizer application in the field. There was a significant positive correlation between the Se content in farming soil and grain, and it was extremely the same between the foliar Se fertilizer concentration rate and the grain Se increased rate. The recommended Se fortification level in cultivation of wheat in China, India, and Spain was 18.53-23.96, 2.65-3.37, and 3.93-9.88 g hm^-2, respectively. Milling processing and food type could greatly affect the Se content of wheat-derived food and should be considered seriously to meet people's Se requirement by wheat.

Review of Existing Models to Predict Reductions in Neural Tube Defects Due to Folic Acid Fortification and Model Results Using Data from Cameroon

Several models have been developed to predict the effects of folic acid fortification programs on prevention of neural tube defects (NTDs), but each relies on different assumptions and data inputs. We identified and reviewed 7 models that predict the effects of folic acid intake or status on NTD risk. We applied 4 of these models [the original and a modified version of the Lives Saved Tool (LiST) and models developed by Arth et al. and Wald et al.] to predict the effect of folic acid fortification of wheat flour on reduction of NTDs using national survey data from Cameroon. The estimated percentage of NTDs averted due to fortified wheat flour (5.0 μg folic acid/g flour) varied by predictive model, with a 21-31% reduction in LiST to 83% in Arth's model, and 15% in Wald's model. As the simulated fortification level was increased from 1.0 to 7.0 μg folic acid/g flour, the pattern of change in estimated numbers of NTDs averted differed due to different model assumptions: the number of NTDs averted increased and then reached a plateau in the modified LiST model (as would be expected in real-world conditions), increased sharply in Arth's model, and increased continuously in Wald's model. This wide variation in predicted effects, and implausible results in some cases, undermines the models' utility for users of model outputs. Concurrent collection of dietary and biomarker data, including plasma and RBC folate concentrations, and NTD outcomes, is necessary to validate these models and monitor change in folic acid intake, folate-related biomarkers, and reduced NTD risk due to fortification. In the meantime, models based on erythrocyte folate concentration are recommended, based on biological plausibility and consistency with empirical evidence. Where erythrocyte folate data are unavailable, sensitivity analyses (using several models) could be conducted to examine the range of possible outcomes.

Using Nature to Nurture: Breast Milk Analysis and Fortification to Improve Growth and Neurodevelopmental Outcomes in Preterm Infants

Premature infants are born prior to a critical window of rapid placental nutrient transfer and fetal growth-particularly brain development-that occurs during the third trimester of pregnancy. Subsequently, a large proportion of preterm neonates experience extrauterine growth failure and associated neurodevelopmental impairments. Human milk (maternal or donor breast milk) is the recommended source of enteral nutrition for preterm infants, but requires additional fortification of macronutrient, micronutrient, and energy content to meet the nutritional demands of the preterm infant in attempts at replicating in utero nutrient accretion and growth rates. Traditional standardized fortification practices that add a fixed amount of multicomponent fortifier based on assumed breast milk composition do not take into account the considerable variations in breast milk content or individual neonatal metabolism. Emerging methods of individualized fortification-including targeted and adjusted fortification-show promise in improving postnatal growth and neurodevelopmental outcomes in preterm infants.

Prevalence and Determinants of Vitamin D Deficiency in 9595 Mongolian Schoolchildren: A Cross-Sectional Study

Population-based data relating to vitamin D status of children in Northeast Asia are lacking. We conducted a cross-sectional study to determine the prevalence and determinants of vitamin D deficiency in 9595 schoolchildren aged 6-13 years in Ulaanbaatar (UB), the capital city of Mongolia. Risk factors for vitamin D deficiency were collected by questionnaire, and serum 25-hydroxyvitamin D (25[OH]D) concentrations were measured using an enzyme-linked fluorescent assay, standardized and categorized as deficient (25[OH]D <10 ng/mL) or not. Odds ratios for associations between independent variables and risk of vitamin D deficiency were calculated using multivariate analysis with adjustment for potential confounders. The prevalence of vitamins D deficiency was 40.6% (95% CI 39.7% to 41.6%). It was independently associated with female gender (adjusted odds ratio [aOR] for girls vs. boys 1.23, 95% CI 1.11-1.35), month of sampling (aORs for December-February vs. June-November 5.28 [4.53-6.15], March-May vs. June-November 14.85 [12.46-17.74]), lower levels of parental education (P for trend <0.001), lower frequency of egg consumption (P for trend <0.001), active tuberculosis (aOR 1.40 [1.03-1.94]), household smoking (aOR 1.13 [1.02 to1.25]), and shorter time outdoors (P for trend <0.001). We report a very high prevalence of vitamin D deficiency among Mongolian schoolchildren, which requires addressing as a public health priority.

Technological and nutritional properties of amaranth-fortified yellow cassava pasta

Yellow cassava is an affordable starting material to design a healthy food, having high β-carotene content. White and yellow cassava functional pasta were fortified with 50 g/kg (w/w) amaranth dry leaf powder and analyzed to evaluate the impact of cultivar difference, processing, and addition of amaranth leaf powder on the physicochemical, functional, pasting, antioxidant, and cooking properties of the white and yellow cassava pasta samples. Significant differences were observed among the cassava pasta samples. Leaf powder addition significantly enhanced the dietary fiber (7.6-9.1 g/100 g) and protein (1.41-4.69 g/100 g) contents of formulated cassava pasta. Yellow cassava-amaranth pasta had higher β-carotene (2.07 µg/g), iron (59 mg/kg), and zinc (9 mg/kg) contents than the white cassava-amaranth pasta. The addition of amaranth leaf powder also enhanced the antioxidant capacities of pasta products. Cooking time and gruel solid loss were reduced upon the addition of amaranth leaf powder, which is beneficial to the consumers. Data showed the potential of amaranth-fortified yellow cassava pasta in contributing to a healthy diet in low- and middle-income countries by combining a biofortified crop with leafy vegetables via food-to-food fortification. Practical Application: This work demonstrates the feasibility of a cassava-based pasta fortified with amaranth vegetables as an affordable and nutritious food to benefit micronutrient deficient consumers in countries with high cassava consumption but low vegetable intake. The inclusion of amaranth leaf powder enhanced the developed pasta's nutritional and technological properties, thus presenting a healthy food choice with the potentials for scaling up commercially.

Predicted Shelf-Life, Thermodynamic Study and Antioxidant Capacity of Breadsticks Fortified with Grape Pomace Powders

Grape pomace (GP), is the main winemaking by-product and could represent a valuable functional food ingredient being a source of bioactive compounds, like polyphenols. Polyphenols prevent many non-communicable diseases and could contrast the oxidation reaction in foods. However, the high content in polyunsaturated fatty acid, the described pro-oxidant potential action of some polyphenols and the complex interactions with other components of matrices during food processing must be considered. Indeed, all these factors could promote oxidative reactions and require focused and specific assay. The aims of this study were to evaluate the effects of GP powder (GPP) addition (at 0%, 5% and 10% concentrations) in breadsticks formulations both on the antioxidant activity at room temperature during storage and on the shelf-life by the OXITEST predictive approach. GPP fortification increased the total polyphenols content and the antioxidant activities of breadsticks. FRAP reduced during the first two days of storage at room temperature, TPC increased during the 75 days, while ABTS showed a slight progressive decrease. However, GP negatively influenced OXITEST estimated shelf-life of breadsticks, incrementing the oxidation rate. In conclusion, even if GP fortification of breadsticks could improve the nutritional value of the products, the increased commercial perishability represents a drawback that must be considered.

Nutritional Content and Health Profile of Non-Dairy Plant-Based Yogurt Alternatives

Yogurt is considered a healthy, nutritious food in many cultures. With a significant number of people experiencing dairy intolerance, and support for a more sustainable diet, consumer demand for dairy alternatives has surged. The aim of this study was to conduct a cross-sectional survey of plant-based yogurt alternatives to assess their nutritional content and health profile. A total of 249 non-dairy yogurt alternatives were analyzed from the nutrition label listed on the commercial package. The various yogurt alternatives contained extracts of coconut (n = 79), almonds (n = 62), other nuts or seeds (n = 20), oats (n = 20), legumes (n = 16), and mixed blends (n = 52). At least one-third of the yogurt alternatives had 5 g or more of protein/serving. Only 45% of the yogurt alternatives had calcium levels fortified to at least 10% of daily value (DV), while only about one in five had adequate vitamin D and B12 fortification at the 10% DV level. One-half of the yogurt alternatives had high sugar levels, while 93% were low in sodium. Except for the coconut-based products, the yogurts were not high in fat or saturated fat. The yogurt alternatives were not fortified as frequently or to the same levels as the corresponding non-dairy, plant-based beverages.

Potential of Vitamin D Food Fortification in Prevention of Cancer Deaths-A Modeling Study

Meta-analyses of randomized controlled trials (RCTs) have estimated a 13% reduction of cancer mortality by vitamin D supplementation among older adults. We evaluated if and to what extent similar effects might be expected from vitamin D fortification of foods. We reviewed the literature on RCTs assessing the impact of vitamin D supplementation on cancer mortality, on increases of vitamin D levels by either supplementation or food fortification, and on costs of supplementation or fortification. Then, we derived expected effects on total cancer mortality and related costs and savings from potential implementation of vitamin D food fortification in Germany and compared the results to those for supplementation. In RCTs with vitamin D supplementation in average doses of 820-2000 IU per day, serum concentrations of 25-hydroxy-vitamin D increased by 15-30 nmol/L, respectively. Studies on food fortification found increases by 10-42 nmol/L, thus largely in the range of increases previously demonstrated by supplementation. Fortification is estimated to be considerably less expensive than supplementation. It might be similarly effective as supplementation in reducing cancer mortality and might even achieve such reduction at substantially larger net savings. Although vitamin D overdoses are unlikely in food fortification programs, implementation should be accompanied by a study monitoring the frequency of potentially occurring adverse effects by overdoses, such as hypercalcemia. Future studies on effectiveness of vitamin D supplementation and fortification are warranted.

Nutrient composition of preterm mother's milk and factors that influence nutrient content

BACKGROUND

Breast milk feedings are the optimal feeding choice for premature infants. Clinicians depend on accurate nutrient profiles of the breast milk in order to make informed decisions regarding the need for nutrient supplementation. Existing data for nutrient composition of preterm breast milk are dated and not representative of the current population of women delivering prematurely in the United States.

OBJECTIVES

The purpose of this prospective, longitudinal, single-center observational study was to measure the macronutrient and micronutrient composition of breast milk expressed by mothers, including women who self-identify as black, delivering preterm infants at ≤33 completed weeks of gestation.

METHODS

We collected breast milk samples from mothers of preterm infants admitted to the neonatal intensive care unit at Augusta University Medical Center from January 2019 through November 2019. Mother's milk samples were collected on postpartum days 7, 14, 21, and 28 and analyzed for macronutrients (energy, fat, protein, and carbohydrates) and micronutrients (sodium, potassium, chloride, calcium, phosphorus, magnesium, vitamin D, and zinc).

RESULTS

Thirty-eight mothers, mean age 27 ± 5.1 y and majority black (66%), provided milk for the study. The mean estimated gestational age and birth weight were 28.2 ± 2.8 weeks of gestation and 1098 ± 347 g, respectively, with 42% of mothers in the cohort delivering before week 28 of pregnancy. Differences in protein, sodium, potassium, calcium, phosphorus, and zinc concentrations based on race, day, and milk volume were identified. Dilution effects for protein, sodium, chloride, and vitamin D concentrations over time were identified.

CONCLUSIONS

Our study is among the first to characterize breast milk composition from women who delivered extremely preterm infants and adds to the evidence that race, gestational age, and volume influence the composition of preterm mother's milk. These factors should be considered when designing mother's milk-based feeds for premature infants.

Proposed Nutrient Standards for Plant-Based Beverages Intended as Milk Alternatives

Background: Plant-based beverages (PBB) that are marketed as alternatives to cow milk are gaining in popularity worldwide. Nutrient quality of PBB can be highly variable. Objective: To develop a set of voluntary or mandatory nutrient standards for the PBB product category in order to assist innovation and guide product development and reformulation. Methods: The present goal was to develop standards for PBB energy content, minimum protein content and quality, maximum content for added fat, sugar, and salt, and to suggest fortification levels for selected vitamins and minerals. The standards were based on dietary recommendations and guidelines and current practices of federal agencies in the US. Results: The proposed energy and nutrient content for PBB milk alternatives are maximum 85-100 kcal energy per 100 g; a minimum for 2.2/100 g of high-quality protein, low content of saturated fat (<0.75/100 g) and added sugar (5.3-6.25/100 g) and consistent fortification with calcium, vitamins A, D, B-2, and B-12 at levels comparable to those found in cow milk (1%). Ideally, the protein content ought to be increased (2.8/100 g) and added sugar content reduced even further (2.7-3.1/100 g) for "best of class" products. These proposed standards were applied to the 641 existing PBB products listed in the 2018 version of the USDA Branded Food Products Database (BFPDB). The standards were met by <5% of the PBB on the US market. Conclusion: Often viewed as equivalent to milk in nutritional value, many PBB are often low in protein and are fortified with varying amounts of calcium, and vitamins A and D. Nutrient standards for this category should be adopted by the food industry, by public health regulatory authorities, and by standardization bodies such as the Codex Alimentarius.

Plant-Based Dietary Practices and Socioeconomic Factors That Influence Anemia in India

While rates of malnutrition have declined over the last decade in India due to successful government interventions, the prevalence of anemia remains high. Staple foods provide almost 70% of the daily iron intake. As staple foods are a rich source of phytate, this ingested iron is poorly absorbed. Currently, 59% of children below 3 years of age, 50% of expectant mothers and 53% of women aged 15-19 years are anemic. The most common intervention strategy has been through the use of iron supplements. While the compliance has been low and supplies irregular, such high rates of anemia cannot be explained by iron deficiency alone. This review attempts to fit dietary and cooking practices, field-level diagnostics, cultural beliefs and constraints in implementation of management strategies into a larger picture scenario to offer insights as to why anemia continues to plague India. Since the rural Indian diet is predominantly vegetarian, we also review dietary factors that influence non-heme iron absorption. As a reference point, we also contrast anemia-related trends in India to the U.S.A. Thus, this review is an effort to convey a holistic evaluation while providing approaches to address this public health crisis.

Perspective: When the cure might become the malady: the layering of multiple interventions with mandatory micronutrient fortification of foods in India

When public health programs with single nutrients are perceived to have a poor impact on the target health outcome, the policy response can be to supply more, by layering additional mandatory programs upon the extant programs. However, we argue for extreme caution, because nutrients (like medicines) are beneficial in the right dose, but potentially harmful when ingested in excess. Unnecessary motivations for the reactionary layering of multiple intervention programs emerge from incorrect measurements of the risk of nutrient inadequacy in the population, or incorrect biomarker cutoffs to evaluate the extent of nutrient deficiencies. The financial and social costs of additional layered programs are not trivial when traded off with other vital programs in a resource-poor economy, and when public health ethical dilemmas of autonomy, equity, and stigma are not addressed. An example of this conundrum in India is the perception of stagnancy in the response of the prevalence of anemia to the ongoing pharmacological iron supplementation program. The reaction has been a policy proposal to further increase iron intake through mandatory iron fortification of the rice provided in supplementary feeding programs like the Integrated Child Development Services and the School Mid-Day Meal. This is in addition to the ongoing pharmacological iron supplementation as well as other voluntary iron fortifications, such as those of salt and manufactured food products. However, before supplying more, it is vital to consider why the existing program is apparently not working, along with consideration of the potential for excess intake and related harms. This is relevant globally, particularly for countries contemplating multiple interventions to address micronutrient deficiencies. Supplying more by layering multiple nutrient interventions, instead of doing it right, without thoughtful considerations of social, biological, and ethics frameworks could be counterproductive. The cure, then, might well become the malady.

Effects of Foods Fortified with Zinc, Alone or Cofortified with Multiple Micronutrients, on Health and Functional Outcomes: A Systematic Review and Meta-Analysis

Seventeen per cent of the world's population is estimated to be at risk of inadequate zinc intake, which could in part be addressed by zinc fortification of widely consumed foods. We conducted a review of efficacy and effectiveness studies to ascertain the effect of zinc fortification [postharvest fortification of an industrially produced food or beverage; alone or with multiple micronutrients (MMN)] on a range of health outcomes. Previous reviews have required that the effect of zinc be isolated; because zinc is always cofortified with MMN in existing fortification programs, we did not impose this condition. Outcomes assessed were zinc-related biomarkers (plasma or serum, hair or urine zinc concentrations, comet assay, plasma fatty acid concentrations, and the proportion of and total zinc absorbed in the intestine from the diet), child anthropometry, morbidity, mortality, cognition, plasma or serum iron and copper concentrations, and for observational studies, a change in consumption of the food vehicle. Fifty-nine studies were included in the review; 54 in meta-analyses, totaling 73 comparisons. Zinc fortification with and without MMN increased plasma zinc concentrations (efficacy, n = 27: 4.68 μg/dL; 95% CI: 2.62-6.75; effectiveness, n = 13: 6.28 μg/dL; 95% CI: 5.03-7.77 μg/dL) and reduced the prevalence of zinc deficiency (efficacy, n = 11: OR: 0.76, 95% CI: 0.60-0.96; effectiveness, n = 10: OR: 0.45, 95% CI: 0.31-0.64). There were statistically significant increases in child weight (efficacy, n = 11: 0.43 kg, 95% CI: 0.11-0.75 kg), improvements in short-term auditory memory (efficacy, n = 3: 0.32 point, 95% CI: 0.13-0.50 point), and decreased incidence of diarrhea (efficacy, n = 3: RR: 0.79, 95% CI: 0.68-0.92) and fever (efficacy, n = 2: RR: 0.85, 95% CI: 0.74-0.97). However, these effects cannot be solely attributed to zinc. Our review found that zinc fortification with or without MMN reduced the prevalence of zinc deficiency and may provide health and functional benefits, including a reduced incidence of diarrhea.

Rapid direct analysis of retinyl palmitate (vitamin A) in fortified vegetable oils by HPLC-FLD

Large-scale food fortification of vegetable oils with vitamin A has been implemented successfully for decades in numerous African and Asian countries, contributing demonstrably to reductions in vitamin A deficiency. For these programmes, reliable and validated analytical data are essential to demonstrate compliance with legal standards and fortification levels. Commonly, many analytical laboratories use a saponification method for the quantitative analysis of retinyl palmitate (the mostly used form of vitamin A for fortification) in fortified oils, which implies a multiple-step procedure with long analysis times and the potential risk of analyte loss. The aim of the present study was to develop and validate a direct High-performance Liquid Chromatography (HPLC) method that reduces these sample preparation steps, leading to the cost- and time-efficient quantification of retinyl palmitate in fortified oils. Oil samples are dissolved into the HPLC solvents, then injected directly into a common C₁₈ column, and subsequently detected by a fluorescence detector. The limit of quantification (1.0 mg retinyl palmitate kg^-1) and the working range of 1.0-100 mg retinyl palmitate kg^-1 with a linearity of R² = 0.9989 are appropriate to analyse fortified oil samples. The method also showed adequate precision (RSD between 1.1% and 3.1%) and recoveries (86-103%) at two different concentration levels. The accuracy of the direct HPLC method was additionally proven by the comparison of spiked samples with two external laboratories that used the saponification method. The robustness of the method was confirmed by the analysis of various spiked edible oils. The HPLC column is not deteriorated by the lipid matrix and shows excellent stability and long lifetime. Also, 9-cis-retinyl palmitate formed mainly by light exposure could be detected by this method. The direct HPLC method is a well-suited alternative to the saponification method for the rapid and reliable routine analysis of fortified oil samples.

Acceptability of Vegetable Fortified Ugali in Sub-Saharan Africa

Corn flour-based porridge like dough, ugali, is the staple food of low-income population in sub-Saharan Africa. Lack of vitamin A, carotenoids, and dietary fibers brings about serious health issues to this population. In this study, vegetables including bok choy, broccoli, cabbage, carrot, Chinese onion stalk (C_onion), mushroom, are added during the cooking of ugali, as nutritional supplements. The freeze-dried powder of each vegetable was used for its long storage, stable nutrients, and similar particle size. Sub-Saharan African assessors were trained and sensory evaluated the six different vegetable fortified ugali with the plain, unfortified as the control on five attributes. The plain ugali was indistinguishable with the C_onion stalk fortified in color, with the carrot and C_onion stalk fortified in odor, with all vegetables (except broccoli and mushroom) fortified ugali in taste, with carrot and C_onion stalk fortified in granularity, and with cabbage, carrot, C_onion stalk fortified in viscosity. Preference ranking analysis showed that the C_onion stalk fortified ugali is even more favorably preferred than the plain, unfortified ugali, probably due to the umami components in C_onion that serve as the taste enhancer. This study indicates that Chinese onion stalk is a potential vegetable supplement to population in the sub-Saharan Africa.

Effect of Calcium Compound Type and Dosage on the Properties of Acid Rennet Goat's Milk Gels

The aim of this study was to determine the effect of adding calcium compounds to processed goat's milk, and on the properties of acid rennet goat's milk gels, which are a middle product obtained in the manufacture of acid rennet cheese. The properties of the gels directly affect the quality of acid rennet cheeses. The analysis of raw goat's milk was carried out, then acid rennet gels were produced with the addition of six different calcium compounds (chloride, citrate, bisglycinate, gluconate, lactate, and carbonate). The dynamics of milk fermentation were performed by monitoring the pH value of milk during acidification. The pH, syneresis, color, and texture profile were determined in the formulated acid rennet gels. An organoleptic evaluation was also performed. The study demonstrated that, not only calcium chloride, but also calcium citrate, gluconate, lactate, bisglycinate, and calcium carbonate could be used in the production of goat's milk acid rennet gels, or the middle product in the manufacture of acid rennet curd cheese from goat's milk. Notably, the addition of citrate, bisglycinate, and calcium carbonate in doses of 20 mg Ca 100 g-1 most effectively reduced syneresis compared to the control sample by 4.76% (citrate), 7.85% (bisglycinate), and 10.28% (carbonate). The hardness of the control gels ranged from 2.35 N to 2.99 N. The addition of chloride, citrate, gluconate, lactate, and calcium carbonate to the milk improved the acid rennet gel's hardness. The addition of 20 mg Ca 100 g-1 as gluconate increased the hardness the most (3.61 N). When increasing the calcium dosage in the form of all compounds, there was a tendency to increase the gel's springiness. The addition of chloride, citrate, and bisglycinate to milk did not result in a darkening of the gel's color. The addition of calcium compounds mostly reduced the intensity of goatish taste and odor. Calcium gluconate, in particular, reduced the goatish taste the most, a taste which is not always acceptable by the consumers.

Vitamin D Food Fortification and Biofortification Increases Serum 25-Hydroxyvitamin D Concentrations in Adults and Children: An Updated and Extended Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Low vitamin D status is a global public health issue that vitamin D food fortification and biofortification may help to alleviate.

OBJECTIVES

We investigated the effect of vitamin D food fortification and biofortification on circulating 25-hydroxyvitamin D (25(OH)D) concentrations. We expanded the scope of earlier reviews to include adults and children, to evaluate effects by vitamin D vitamer, and investigate linear and nonlinear dose-response relations.

METHODS

We conducted a systematic review and meta-analysis. We searched CINAHL, MEDLINE, PubMed, Embase, the Cochrane Library, and gray and unpublished literature sites for randomized controlled trials, including people of all ages, with the criteria: absence of illness affecting vitamin D absorption, duration ≥4 wk, equivalent placebo food control, dose quantification, dose ≥5 μg/d, baseline and endpoint or absolute change in 25(OH)D concentrations reported, random allocation, and participant blinding. Quality was assessed using the Jadad Scale.

RESULTS

Data from 34 publications (2398 adults: 1345 intervention, 1053 controls; 1532 children: 970 intervention, 562 controls) were included. Random-effects meta-analysis of all studies combined (mean dose 16.2 μg/d) indicated a pooled treatment effect of 21.2 nmol/L (95% CI: 16.2, 26.2), with a greater effect for studies using cholecalciferol than ergocalciferol. Heterogeneity was high (I2  > 75%). Metaregression analyses for all studies combined suggested positive effect differences for baseline circulating 25(OH)D concentrations <50 nmol/L, dose ≥10 μg/d and a negative effect difference when the intervention arm included a calcium dose ≥500 mg/d greater than the control arm. Dose-response rates were found to be nonlinear (Wald test for nonlinearity P < 0.001). For all studies combined, a threshold occurred at ∼26 nmol/L for a dose of ∼21 μg/d.

CONCLUSIONS

These results support use of vitamin D food fortification to improve circulating 25(OH)D circulations in populations. This work was registered with PROSPERO as CRD42020145497.