Fortification strategies to meet micronutrient needs: successes and failures

Critical evaluation of strategies for mineral fortification of staple food crops

Staple food crops, in particular cereal grains, are poor sources of key mineral nutrients. As a result, the world's poorest people, generally those subsisting on a monotonous cereal diet, are also those most vulnerable to mineral deficiency diseases. Various strategies have been proposed to deal with micronutrient deficiencies including the provision of mineral supplements, the fortification of processed food, the biofortification of crop plants at source with mineral-rich fertilizers and the implementation of breeding programs and genetic engineering approaches to generate mineral-rich varieties of staple crops. This review provides a critical comparison of the strategies that have been developed to address deficiencies in five key mineral nutrients-iodine, iron, zinc, calcium and selenium-and discusses the most recent advances in genetic engineering to increase mineral levels and bioavailability in our most important staple food crops.

Bacterial vitamin B2, B11 and B12 overproduction: An overview

Consumers are becoming increasingly health conscious and therefore more discerning in their food choices. The production of fermented food products with elevated levels of B-vitamins increase both their commercial and nutritional value, and eliminate the need for subsequent fortification with these essential vitamins. Such novel products could reduce the incidence of inadequate vitamin intake which is common in many parts of the world, not only in developing countries, but also in many industrialised countries. Moreover, the concept of in situ fortification by bacterial fermentation opens the way for development of food products targeted at specific groups in society such as the elderly and adolescents. This review looks at how vitamin overproduction strategies have been developed, some of which have successfully been tested in animal models. Such innovative strategies could be relatively easily adapted by the food industry to develop novel vitamin-enhanced functional foods with enhanced consumer appeal.

Communication and marketing as climate change-intervention assets a public health perspective

The understanding that global climate change represents a profound threat to the health and well-being of human and nonhuman species worldwide is growing. This article examines the potential of communication and marketing interventions to influence population behavior in ways consistent with climate change prevention and adaptation objectives. Specifically, using a framework based on an ecologic model of public health, the paper examines: (1) the potential of communication and marketing interventions to influence population behaviors of concern, including support for appropriate public policies; (2) potential target audiences for such programs; and (3) the attributes of effective climate change messages. Communication and marketing interventions appear to have considerable potential to promote important population behavior change objectives, but there is an urgent need for additional translational research to effectively harvest this potential to combat climate change.

The effectiveness of mass communication to change public behavior

This article provides an overview of the ways in which mass communication has been used -- or can be used -- to promote beneficial changes in behavior among members of populations. We use an ecological perspective to examine the ways in which mass media interventions can be used to influence public behavior both directly and indirectly. Mass media interventions that seek to influence people directly -- by directly targeting the people burdened by the public health problem of concern and/or the people who influence them -- have a long basis in public health history, and recent reviews have clarified our expectations about what can be expected from such approaches. Mass media interventions that seek to influence people indirectly -- by creating beneficial changes in the places (or environments) in which people live and work -- have equal if not greater potential to promote beneficial changes in population health behaviors, but these are currently less explored options. To have the greatest possible beneficial influence on public behavior with the public health resources available, we recommend that public health program planners assess their opportunities to use media to target both people and places in a manner that complements and extends other investments being made in population health enhancement.

Maize meal fortification is associated with improved vitamin A and iron status in adolescents and reduced childhood anaemia in a food aid-dependent refugee population

OBJECTIVE

To assess changes in the Fe and vitamin A status of the population of Nangweshi refugee camp associated with the introduction of maize meal fortification.

DESIGN

Pre- and post-intervention study using a longitudinal cohort.

SETTING

Nangweshi refugee camp, Zambia.

SUBJECTS

Two hundred and twelve adolescents (10-19 years), 157 children (6-59 months) and 118 women (20-49 years) were selected at random by household survey in July 2003 and followed up after 12 months.

RESULTS

Maize grain was milled and fortified in two custom-designed mills installed at a central location in the camp and a daily ration of 400 g per person was distributed twice monthly to households as part of the routine food aid ration. During the intervention period mean Hb increased in children (0.87 g/dl; P < 0.001) and adolescents (0.24 g/dl; P = 0.043) but did not increase in women. Anaemia decreased in children by 23.4% (P < 0.001) but there was no significant change in adolescents or women. Serum transferrin receptor (log10-transformed) decreased by -0.082 microg/ml (P = 0.036) indicating an improvement in the Fe status of adolescents but there was no significant decrease in the prevalence of deficiency (-8.5%; P = 0.079). In adolescents, serum retinol increased by 0.16 micromol/l (P < 0.001) and vitamin A deficiency decreased by 26.1% (P < 0.001).

CONCLUSIONS

The introduction of fortified maize meal led to a decrease in anaemia in children and a decrease in vitamin A deficiency in adolescents. Centralised, camp-level milling and fortification of maize meal is a feasible and pertinent intervention in food aid operations.

Fortified complementary foods with or without alpha-amylase treatment increase hemoglobin but do not reduce breast milk intake of 9-mo-old Zambian infants

BACKGROUND

Malnutrition in late infancy in developing countries may result from poor-quality complementary foods that displace breast milk.

OBJECTIVE

The objective of the study was to assess the effects of fortified complementary blends of different energy densities on growth, hemoglobin concentrations, and breast milk intake of 9-mo-old Zambian infants.

DESIGN

Infants were randomly assigned at 6 mo of age to receive for 3 mo a fortified blend of maize, beans, bambaranuts, and groundnuts [Chilenje Baby Mix (CBM); energy density: 68 kcal/100 g; n = 37] or a similar blend with alpha-amylase (CBMA; energy density: 106 kcal/100 g; n = 44). Cross-sectional data were obtained at 9 mo for a control group of infants (n = 69) not given the diets. Breast milk intake was measured by using the dose-to-the-mother deuterium dilution technique.

RESULTS

No differences in weight or length z scores, all of which were within normal ranges, were seen between groups at 9 mo. Percentage fat mass was significantly (P = 0.01) greater in the infants in both the CBM (23.2 +/- 2.7%) and CBMA (23.4 +/- 2.5%) groups than in the control group (21.6 +/- 2.6%). Hemoglobin concentrations were significantly (P = 0.03) greater in both intervention groups (CBM group: 104 +/- 12 g/L: CBMA group: 103 +/- 12 g/L) than in the control group (98 +/- 14 g/L). Breast milk intake was not significantly (P = 0.87) different between groups (CBM group: 614 +/- 271 g/d; CBMA group: 635 +/- 193 g/d; control group: 653 +/- 221 g/d).

CONCLUSIONS

The study foods improved hemoglobin concentrations without reducing breast milk intake and may be used to improve the nutritional status of infants in developing countries.

Simultaneous Determination of B-Group Vitamins in Enriched Brazilian Dairy Products

In addition to serving as good natural sources of vitamin B(2), milk and milk products are currently being enriched with the vitamins B(1), B(2), B(6), and nicotinamide in Brazil. The objective of this research was to evaluate the levels of enrichment of these products according to their availability in supermarkets in the Campinas (SP, Brazil) region. The separation of the vitamins was carried out on a C 18 column with gradient elution with acetonitrile and aqueous phase. Detection of vitamins was effected in the ultraviolet region and quantification by an external standard. The levels of vitamin B(2) determined in powdered whole milk, skimmed milk powder, and one brand of flavored lactic beverage, were practically double those stated on the packages. The same occurred with vitamins B(6) and PP (nicotinic acid + nicotinamide), when determined in the same lactic beverage and with vitamin B(6), determined in acidified milk. The high levels of vitamin B(2), naturally present in whole milk, and the predominance of the free form, allowed for the determination of this vitamin in non-enriched milk.

Communication and marketing as tools to cultivate the public's health: a proposed "people and places" framework

Background

Communication and marketing are rapidly becoming recognized as core functions, or core competencies, in the field of public health. Although these disciplines have fostered considerable academic inquiry, a coherent sense of precisely how these disciplines can inform the practice of public health has been slower to emerge.

Discussion

In this article we propose a framework – based on contemporary ecological models of health – to explain how communication and marketing can be used to advance public health objectives. The framework identifies the attributes of people (as individuals, as social networks, and as communities or populations) and places that influence health behaviors and health. Communication, i.e., the provision of information, can be used in a variety of ways to foster beneficial change among both people (e.g., activating social support for smoking cessation among peers) and places (e.g., convincing city officials to ban smoking in public venues). Similarly, marketing, i.e., the development, distribution and promotion of products and services, can be used to foster beneficial change among both people (e.g., by making nicotine replacement therapy more accessible and affordable) and places (e.g., by providing city officials with model anti-tobacco legislation that can be adapted for use in their jurisdiction).

Summary

Public health agencies that use their communication and marketing resources effectively to support people in making healthful decisions and to foster health-promoting environments have considerable opportunity to advance the public's health, even within the constraints of their current resource base.

A multimicronutrient-fortified seasoning powder enhances the hemoglobin, zinc, and iodine status of primary school children in North East Thailand: a randomized controlled trial of efficacy

Anemia and co-existing deficiencies of zinc, iron, iodine, and vitamin A occur among children in many developing countries including NE Thailand, probably contributing to impairments in growth, immune competence, and cognition. Sustainable strategies are urgently required to combat these deficiencies. We assessed the efficacy of a micronutrient-fortified seasoning powder served with a school lunch on reducing anemia and improving the micronutrient status of rural NE Thai children. Children (n = 569) aged 5.5-13.4y from 10 schools were randomly assigned to receive a seasoning powder either unfortified or fortified with zinc (5 mg), iron (5 mg), vitamin A (270 microg), and iodine (50 microg) (per serving) and incorporated into a school lunch prepared centrally and delivered 5 d/wk for 31 wk. Teachers monitored school lunch consumption. Baseline and final micronutrient status, hemoglobinopathies, and infection or inflammation were assessed from blood and urine samples. For the primary outcome, anemia (based on hemoglobin), no intervention effect was apparent (odds ratio: 1.02 95% CI: 0.69, 1.51) after adjustment for design strata. The odds of zinc (based on serum zinc) and urinary iodine deficiency in the fortified group were 0.63 (0.42, 0.94) and 0.52 (0.38, 0.71) times those in the unfortified group, respectively. Fortification had no effect on serum retinol (0.61: 0.25,1.51), ferritin (1.12: 0.43, 2.96), or mean red cell volume (1.16: 0.82, 1.64). Therefore, a micronutrient-fortified seasoning powder is a promising vehicle for improving zinc, iodine, and hemoglobin status, and its potential for incorporation into lunch programs in day care centers and schools in NE Thailand warrants investigation.

Public health aspects of food fortification: a question of balance

Micronutrient malnutrition is widespread throughout the world, with important health and economic consequences. Tools to address this situation include food fortification, supplementation and dietary diversification, each having different and complementary roles. Fortification (mandatory and voluntary) has been practised over several decades in Western countries as well as in developing countries. Iodised salt was introduced in the USA in 1924 to reduce severe I deficiency. In 1938 voluntary enrichment of flours and breads with niacin and Fe was initiated to reduce the incidence of pellagra and Fe-deficiency anaemia respectively. Micronutrient intakes in European countries appear to be generally adequate for most nutrients. However, a number of population subgroups are at higher risk of suboptimal intakes (below the lower reference nutrient intake) for some micronutrients, e.g. folate, Fe, Zn and Ca in children, adolescents and young women. Dietary surveys indicate that fortified foods play a role in mitigating such risks for several important nutrients. The number of foods suited to fortification are considerably limited by several factors, including technological properties (notably moisture, pH and O2 permeability), leading to unacceptable taste and appearance, as well as cost and consumer expectations. In countries in which voluntary fortification is widely practised micronutrient intakes are considerably below tolerable upper intake levels. Concerns about safety are addressed in relation to the potentially increased level or proportion of fortified foods (e.g. following potential EU legislation), for nutrients with relatively low tolerable upper intake levels and where the potential benefit and risks are in different subpopulations (e.g. folic acid). Recent models for assessing these issues are discussed.

The nutritional fortification of cereals

The low micronutrient content of cereals requires the fortification of food and biofortification of plants. Many laboratories are currently pursuing biofortification using breeding and genetic modification, but progress is challenged by technical hurdles and our understanding of physiological processes. Recent studies have largely been confined to the improvement of levels of iron, zinc, some vitamins and a variety of essential amino acids. Progress has been made in the accumulation of iron, zinc, and vitamins A and E in genetically modified plants. For future success in this area, many more studies will be required on the physiology of ion uptake and on the transport of vitamin precursors.

Rickets

Rickets, once thought vanquished, is reappearing. In some less developed countries it hardly went away. This seminar reviews the effects of genes, stage of development, and environment on clinical expression of the disease. Rickets can be secondary to disorders of the gut, pancreas, liver, kidney, or metabolism; however, it is mostly due to nutrient deficiency and we concentrate on this form. Although calcium deficiency contributes in communities where little cows' milk is consumed, deficiency of vitamin D is the main cause. There are three major problems: the promotion of exclusive breastfeeding for long periods without vitamin D supplementation, particularly for babies whose mothers are vitamin D deficient; reduced opportunities for production of the vitamin in the skin because of female modesty and fear of skin cancer; and the high prevalence of rickets in immigrant groups in more temperate regions. A safety net of extra dietary vitamin D should be re-emphasised, not only for children but also for pregnant women. The reason why many immigrant children in temperate zones have vitamin D deficiency is unclear. We speculate that in addition to differences in genetic factors, sun exposure, and skin pigmentation, iron deficiency may affect vitamin D handling in the skin or gut or its intermediary metabolism.

Nutrient adequacy and Mediterranean Diet in Spanish school children and adolescents

OBJECTIVE

To evaluate dietary habits and nutritional status of Spanish school children and adolescents, and their relationship with the Mediterranean Diet.

DESIGN

Cross-sectional study by face-to-face interview.

SETTING

Free living children and adolescents of all Spanish regions.

SUBJECTS

A random sample of 3166 people aged 6-24 y.

METHODS

Home interviews conducted by a team of 43 dietitians included 24-h recalls (a second 24-h recall in 25% of the sample) and a short frequency questionnaire to determine the quality of the Mediterranean Diet (KIDMED).

RESULTS

The participation rate was 68%. In general, the adequacy of the Mediterranean Diet rose with increased mean intakes of the majority of vitamins and minerals and decreased percentages of inadequate intakes (&<2/3 of the RNI) for calcium, magnesium, vitamin B(6) and C in both sexes, and iron and vitamin A only in females.

CONCLUSIONS

This study demonstrates that the Mediterranean Diet contributes to nutritional quality, and also shows concomitant risks as the Mediterranean Diet deteriorates.