Fortification strategies to meet micronutrient needs: successes and failures

Thiamine deficiency disorders in women and children

Thiamine (vitamin B1) is available in common foods such as the outer husk of rice and is necessary for normal cardiovascular, neurological and metabolic processes. Thiamine deficiency is common in many parts of Asia and Africa, affecting up to a third or more of children and women of child-bearing age. The diagnosis is based on clinical suspicion, especially when noting heart failure in infants, encephalopathy in patients of any age, and peripheral neuropathy in older children and adults. Blood tests for whole-blood thiamine diphosphate (the quantity of biologically active thiamine present) and erythrocyte transketolase activity (the functional impact of thiamine) are not always readily available in areas where thiamine deficiency is common. Treatment is safe and effective, although dosing guidelines vary widely; 50 mg daily for 5 days is probably effective for treating acute thiamine deficiency disorders, and ongoing adequate thiamine intake is also needed. Prevention efforts depend on local and regional circumstances, including dietary diversification, food fortification, and/or supplementation of children and women at risk.Abbreviations: HIC: high-income countries; LMIC: low- and middle-income countries; MRI: magnetic resonance imaging; TDD: thiamine deficiency disorders.

Fortification of condiments and seasonings with iron for preventing anaemia and improving health

BACKGROUND

Anaemia affects approximately 1.8 billion people worldwide; over 60% of anaemia cases globally are due to iron deficiency (ID). Iron deficiency and anaemia contribute to the global burden of disease and affect physical and cognitive development in children, and work productivity and economic well-being in adults. Fortification of food with iron, alone or in combination with other nutrients, is an effective intervention to control ID. Condiments and seasonings are ideal food vehicles for iron fortification in countries where they are commonly used.

OBJECTIVES

To determine the effects and safety of condiment and seasoning fortification with iron alone or iron plus other micronutrients on iron deficiency, anaemia, and health-related outcomes in the general population.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, and other databases up to 24 January 2023. We also searched the International clinical trials registry platform (ICTRP) for any ongoing trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) (randomisation at individual or cluster level), non-randomised controlled trials, interrupted time series with at least three measure points both before and after intervention, and controlled before-after studies. Participants were populations of any age (including pregnant women), from any country, excluding those with critical illness or severe co-morbidities. We included interventions in which condiments or seasonings have been fortified with any combination of iron and other vitamins and minerals, irrespective of the fortification technology used.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened and assessed the eligibility of studies. Disagreements were resolved through discussion or input from a third review author. Two review authors extracted the data and assessed the risk of bias in all the included studies. We followed the methods laid out by Cochrane and used GRADE criteria for assessing certainty of the evidence.

MAIN RESULTS

Our search identified 15,902 records after removal of duplicates. We included 16 studies with 20,512 participants (18,410 participants after adjusting for clustering effects). They were all carried out in upper-middle- and lower-middle-income countries. Three studies were controlled before-after studies, one was non-randomised trial, and 12 were RCTs (including three cluster RCTs). Six studies took place in schools; seven in communities; and one each in a nursery/kindergarten, tea estate, and factory. Three studies involved only women, one study involved both women and their children, and all other studies focused on children and/or adolescents. Nine studies used salt as a vehicle for iron fortification, three used fish sauce, two used soy sauce, one used curry powder, and one a "seasoning powder". The dose of iron received by participants ranged from 4.4 mg to 55 mg/day. The sample sizes in the trials ranged from 123 to 14,398, and study durations ranged from three months to two years. Twelve RCTs contributed data for meta-analysis. Six trials compared iron-fortified condiments versus the unfortified condiment, and six trials provided data comparing iron fortification in combination with other micronutrients versus the same condiment with other micronutrients, but no added iron. In one trial, the fortificant contained micronutrients that may have affected the absorption of iron. Overall no studies were assessed as having a low risk of bias. All included studies were assessed to have a high overall risk of bias, with the most concerns being around allocation concealment, blinding, and random sequence generation. There was very high heterogeneity amongst studies in almost all examined outcomes. Condiments/seasonings fortified with iron versus unfortified condiments/seasonings We are uncertain about whether consuming condiments/seasonings fortified with iron in comparison to the same unfortified condiment reduces anaemia at the end of intervention (risk ratio (RR) 0.34, 95% confidence interval (CI) 0.18 to 0.65; 2328 participants; 4 studies; very low-certainty of evidence). We are uncertain about whether consuming iron-fortified condiments increases haemoglobin concentrations (mean difference (MD) 6.40 (g/L), 95% CI -0.62 to 13.41; 2808 participants; 5 studies; very low-certainty evidence). Fortification of condiments/seasonings with iron probably slightly reduces ID (RR 0.33, 95% CI 0.11 to 1.01; 391 participants; 2 studies; moderate-certainty evidence). We are uncertain about whether fortification with iron increases ferritin concentration (MD 14.81 (µg/L), 95% CI 5.14 to 24.48; 4459 participants; 6 studies; very low-certainty evidence). Condiments/seasonings fortified with iron plus other micronutrients versus condiments/seasonings fortified with other micronutrients except iron Consuming condiments/seasonings fortified with iron plus other micronutrients may reduce anaemia (RR 0.59, 95% CI 0.40 to 0.89; 1007 participants; 4 studies; low-certainty evidence). We are uncertain about whether fortification of condiments/seasonings with iron plus other micronutrients will improve haemoglobin concentration (MD 6.22 g/dL, 95% CI 1.60 to 10.83; 1270 participants; 5 studies; very low-certainty evidence). It may reduce ID (RR 0.36, 95% CI 0.19 to 0.69; 1154 participants; 4 studies; low-certainty evidence). We are uncertain about whether fortification with iron plus other micronutrients improves ferritin concentration (MD 10.63 µg/L, 95% CI 2.40 to 18.85; 1251 participants; 5 studies; very low -certainty evidence). Condiments/seasonings fortified with iron versus no intervention No trial reported data on this comparison. No studies reported adverse effects. Funding sources do not appear to have distorted the results in any of the assessed trials.

AUTHORS' CONCLUSIONS

We are uncertain whether consuming iron-fortified condiments/seasonings reduces anaemia, improves haemoglobin concentration, or improves ferritin concentration. It may reduce ID. Findings about ferritin should be interpreted with caution since its concentrations increase during inflammation. Consuming condiments/seasonings fortified with iron plus other micronutrients may reduce anaemia, and we are uncertain whether this will improve haemoglobin concentration or ferritin concentration. More studies are needed to determine the true effect of iron-fortified condiments/seasonings on preventing anaemia and improving health. The effects of this intervention on other health outcomes like malaria incidence, growth and development are unclear.

Global Coverage of Mandatory Large-Scale Food Fortification Programs: A Systematic Review and Meta-Analysis

Food fortification with micronutrients is widely implemented to reduce micronutrient deficiencies and related outcomes. Although many factors affect the success of fortification programs, high population coverage is needed to have a public health impact. We aimed to provide recent global coverage estimates of salt, wheat flour, vegetable oil, maize flour, rice, and sugar among countries with mandatory fortification legislation. The indicators were the proportion of households consuming the: food, fortifiable food (that is, industrially processed), fortified food (to any extent), and adequately fortified food (according to national or international standards). We estimated the number of individuals reached with fortified foods. We systematically retrieved and reviewed all applicable evidence from: published reports and articles from January 2010 to August 2021, survey lists/databases from key organizations, and reports/literature received from key informants. We analyzed data with R statistical package using random-effects meta-analysis models. An estimated 94.4% of households consumed salt, 78.4% consumed fortified salt (4.2 billion people), and 48.6% consumed adequately fortified salt in 64, 84, and 31 countries, respectively. Additionally, 77.4% of households consumed wheat flour, 61.6% consumed fortifiable wheat flour, and 47.1% consumed fortified wheat flour (66.2 million people) in 15, 8, and 10 countries, respectively, and 87.0% consumed vegetable oil, 86.7% consumed fortifiable oil, and 40.1% consumed fortified oil (123.9 million people) in 10, 7, and 5 countries, respectively. Data on adequately fortified wheat flour and vegetable oil and coverage indicators for maize flour, rice, and sugar were limited. There are major data gaps on fortification coverage for most foods except salt. All countries with mandatory fortification programs should generate and use more coverage data to assess program performance and adjust programs as needed to realize their potential to reduce micronutrient deficiencies (PROSPERO CRD42021269364).

Applications of nanotechnology to combat the problems associated with modern food

Currently, modern lifestyle diseases (LSD) such as cancer, diabetes, hypertension, cardiovascular and thyroid disease are commonly seen among people of different age groups. One of the root causes of this LSD is the type of food that we are eating. Staple crops like rice, sugarcane, vegetables and wheat are grown with the application of agrochemicals (e.g., glyphosate), traces of which are found in our food; after that, it gets ultra-processed in factories; e.g., chips and snacks are fried using saturated fats (trans fat); sugar and wheat (derivatives bread, buns, cookies) are processed using toxic chemicals (bleaching agents). As a result, the nutritional value of food is compromised due to low dietary fiber content and synthetic additives - e.g., sucralose (artificial sweetener) - which promotes inflammation and weakens our immune system, causing our body to become sensitive to microbial infection and many other LSDs. To strengthen the immune system, people start taking synthetically prepared supplements and drugs for a prolonged time, which further deteriorates the body organs and their normal function; e.g., prolonged medication for hypothyroidism poses a risk of heart attack and joint pain. Nanotechnology solves the above problems in the food, nutraceuticals and agriculture sectors. Nanotechnology-based naturally processed products such as nano-nutraceuticals, nanofood, nanofertilizers and nanopesticides will benefit our health. They possess desirable properties such as high bioavailability, targeted delivery, least processing and sustained release. With the help of nanotechnology, we can get nutritional and agrochemical-free food. © 2022 Society of Chemical Industry.

The Potential of Condiments, Seasonings, and Bouillon Cubes to Deliver Essential Micronutrients in Asia: Scenario Analyses of Iodine and Iron Fortification

Micronutrient deficiencies are still highly prevalent in Asia. Fortification of cooking aids, such as condiments (fish and soy sauces), seasonings, and bouillon cubes, may be an additional strategy to improve micronutrient intake. The current study evaluated the potential impact of iodine and iron fortification of cooking aids on micronutrient intake in Asian countries. A systematic literature search was performed to collect consumption data from different countries in Asia. Data from 18 studies in nine Asian countries were included. Scenario analyses were performed using different fortification levels based on regulations and literature. Mean intake of cooking aids ranged from 3.2-15.9 g/day for condiments and 0.4-11.7 g/day for seasonings and bouillon cubes. When replacing salt with iodized salt (30 µg of iodine/g of salt), iodine intake would increase by 13-119 µg/day for soy and fish sauces (9-80% of the Nutrient Reference Value (NRV)), and 5-83 µg/day for bouillon cubes and seasonings (4-56% of the NRV). Fortification with iron 0.5 mg/g food product for condiments or 1 mg/g food product for bouillon cubes and seasonings improved iron intake for soy and fish sauces by 1.6-8.0 mg/day (11-57% of the NRV), and for bouillon cubes and seasonings by 0.4-5.6 mg/day (3-40% of the NRV). These results indicate that, depending on the consumption pattern, fortification of cooking aids can be a suitable strategy to increase intake of micronutrients.

Nutritional characterization of the extrusion-processed micronutrient-fortified corn snacks enriched with protein and dietary fiber

The current study focused on developing protein- and dietary fiber-enriched, micronutrient-fortified corn snacks using extrusion technology. Corn, soybean, and chickpea flour were used to develop micronutrient-fortified (Fe, Zn, I, and vitamin A, and C) extruded snacks, followed by an exploration of their nutritional traits. Soybean and chickpea were supplemented discretely (20-40/100 g) or in a combination of both (10:10, 15:15, and 20:20/100 g). According to the results, the relative proportion of the raw material composition was reflected in corn snacks' proximate composition and mineral and vitamin levels. Corn snacks with 40/100 g soy flour showed the best nutrient profile, with a maximum percent increase in protein (171.9%) and fiber (106%), as compared to the snacks developed using chickpea and/or mixed supplementation with soy and chickpea. Total dietary fiber (18.44 ± 0.34%), soluble dietary fiber (10.65 ± 0.13%), and insoluble dietary fiber (7.76 ± 0.38%) were also found to be highest in the soy-supplemented snacks (40/100 g). It was discovered that 100 g of corn snacks could provide 115-127% of the RDA for iron, 77-82% of the RDA for zinc, 90-100% of the RDA for vitamin A, and 45-50% of the RDA for vitamin C. The results for the effect of extrusion processing on amino acids showed a 2.55-45.1% reduction in essential amino acids, with cysteine and valine showing the greatest decrease and leucine and tryptophan remaining relatively stable during extrusion.

Systematic Process Framework for Conducting Implementation Science Research in Food Fortification Programs

Many challenges still exist to fully scaling up food fortification in lower resource settings. To address this need, a collective group of experts in the fields of food fortification and implementation science developed a systematic process framework to provide a tool for identifying and working through challenges.

Food fortification has proven to be an effective approach for preventing micronutrient deficiencies in many settings. Factors that lead to successful fortification programs are well established. However, due to the multisectoral nature of fortification and the added complexities present in many settings, the barriers to success are not always evident and the strategies to address them are not always obvious. We developed a systematic process for identifying and addressing gaps in the implementation of a food fortification program. The framework is composed of 4 phases: (1) connect program theory of change to program implementation; (2) develop an implementation research agenda; (3) conduct implementation research; and (4) analyze findings and develop/disseminate recommendations for next steps. We detail steps in each phase to help guide teams through the process. To our knowledge, this is the first attempt to outline a systematic process for applying implementation science research to food fortification. The development of this framework is intended to promote implementation research in the field of food fortification, thus improving access to and effectiveness of this key public health intervention.

Potential for elimination of folate and vitamin B12 deficiency in India using vitamin-fortified tea: a preliminary study

Introduction

The majority of Indian women have a poor dietary folate and vitamin B₁₂ intake resulting in their chronically low vitamin status, which contributes to anaemia and the high incidence of folate-responsive neural-tube defects (NTDs) in India. Although many countries have successfully deployed centrally-processed folate-fortified flour for prevention of NTDs, inherent logistical problems preclude widespread implementation of this strategy in India. Because tea-the second most common beverage worldwide (after water)-is consumed by most Indians every day, and appeared an ideal vehicle for fortification with folate and vitamin B₁₂, we determined if daily consumption of vitamin-fortified tea for 2 months could benefit young women of childbearing-age in Sangli, India.

Methods

Women (average age=20±2 SD) used teabags spiked with therapeutic doses of 1 mg folate plus either 0.1 mg vitamin B₁₂ (Group-1, n=19) or 0.5 mg vitamin B₁₂ (Group-2, n=19), or mock-fortified teabags (Group-0, n=5) to prepare a cup of tea every day for 2 months, following which their pre-intervention and post-intervention serum vitamin and haemoglobin concentrations were compared.

Results

Most women had baseline anaemia with low-normal serum folate and below-normal serum vitamin B₁₂ levels. After 2 months, women in both Group-1 and Group-2 exhibited significant increases in mean differences in pre-intervention versus post-intervention serum folate levels of 8.37 ng/mL (95% CIs 5.69 to 11.04, p<0.05) and 6.69 ng/mL (95% CI 3.93 to 9.44, p<0.05), respectively; however, Group-0 experienced an insignificant rise of 1.26 ng/mL (95% CI -4.08 to 0.16). In addition, over one-half and two-thirds of women in Group-1 and Group-2, respectively, exhibited increases in serum vitamin B₁₂ levels over 300 pg/mL. There was also a significant post-interventional increase in the mean haemoglobin concentration in Group-1 of 1.45 g/dL (95% CI 0.64 to 2.26, p=0.002) and Group-2 of 0.79 g/dL (95% CI 0.11 to 1.42, p=0.027), which reflected a bona fide clinical response.

Conclusion

Tea is an outstanding scalable vehicle for fortification with folate and vitamin B₁₂ in India, and has potential to help eliminate haematological and neurological complications arising from inadequate dietary consumption or absorption of folate and vitamin B₁₂.

Examining Heterogeneity of Food Fortification and Biofortification Business Models: Emerging Evidence for a Typology

Efforts to address Micronutrient deficiencies (MNDs) in lower-and middle-income countries (LMICs) have been gaining pace in recent years. Commodities such as staple foods (e.g., cereals, roots, and tubers) and condiments (e.g., salt) have been targeted as ‘vehicles’ for fortification and biofortification through numerous projects and initiatives. To date, there have been mixed experiences with delivery and coverage with very little documented on the range of business models applied in different geographies, business conditions and polities and this makes classification and measurement of success and failure difficult. This research aims to address this gap in knowledge through proposing a typology that clarifies similarities (internal heterogeneity) and differences (external heterogeneity) between models and that can allow all types to be defined by the combination of attributes. Building on a comprehensive literature review; NVivo was used to code initiatives from 34 key references (955 cases in total) which have been grouped into 17 categories. Using non-metric multidimensional scaling (NMDS) we find evidence of four business model groupings that typify fortification initiatives: (1) Large-scale private, unregulated, (2) Mixed-Scale, private, unregulated (3) Large-scale, public-private, regulated; and (4) Large-scale, private, regulated. We characterise these four groups with country examples and suggest that this typology can help the discourse around viability of food fortification initiatives.

Snack Development for School Feeding Programs in Africa: A Scoping Review

The benefits of school feeding have been well documented. As such, school feeding programs have continuously gained popularity in developing countries. However, challenges and potential opportunities persist, calling for a review of school feeding for long-term sustainability. South Africa has an opportunity to improve their National School Nutrition Program (NSNP) by including an energy-dense snack that would increase the recommended dietary allowance (RDA) of school children to meet at least 25% of their energy requirements. The objective of this scoping review was to conduct a review and an appraisal of studies on snack food development for school feeding programs in Africa. Eligible studies had to report snack development for school feeding programs in Africa. We conducted an electronic search in National Research Foundation (NRF) NEXUS, Elton B. Stephens Company (EBSCO), International Food Information Service (IFIS), Nutrition and Food Sciences Center for Agriculture and Bioscience International (CABI.ORG), and Google Scholar. Of the 429 articles identified, nine studies were included in the final review-five from within South Africa and four from elsewhere in Africa. Data extracted included the study design, intervention, outcomes, relevant findings, and limitations. Results were presented in a narrative summary. The review findings showed that energy-rich staple foods and food fortification were commonly used in snack development. The popular snack products developed included porridges and biscuits. While most studies reported nutritional outcomes, few studies reported on sensory acceptability tests and only two studies conducted a cost analysis. This review of previous snack development initiatives for school feeding programs in Africa underscores the importance of establishing the sustainability of any food product developed. The findings of this review have the potential to inform future snack product development for school feeding programs.

Dietary Intake of Vitamin D from Dairy Products Reduces the Risk of Osteoporosis

Background: Vitamin D and calcium are important dietary compounds that affect bone mass, even if other minerals (potassium, zinc, etc.) and vitamins (A, C and K) are also involved. Vitamin D and certain minerals, in fact, play an important role in calcium homeostasis and calcium absorption. Hip fracture incidence is higher in Europe and the United States, where calcium is frequently included in the human diet; while the occurrence of these fractures is lower in developing countries, where diets are often poor in calcium. This condition is named the “calcium paradox”, and may be partially explained by phosphate toxicity, which can negatively affect mineral metabolism. It is important to maintain correct dietary calcium-phosphate balance in order to have a healthy life, reducing the risk of osteoporotic fractures in older people. Vitamin D can also act as a hormone; vitamin D2 (ergocalciferol) is derived from the UV-B radiation of ergosterol, the natural vitamin D precursor detected in plants, fungi, and invertebrates. Vitamin D3 (cholecalciferol) is synthesized by sunlight exposure from 7-dehydrocholesterol, a precursor of cholesterol that can also act as provitamin D3. Dietary intake of vitamin D3 is essential when the skin is exposed for short periods to ultraviolet B light (UV-B), a category of invisible light rays such as UV-A and UV-C. This can be considered the usual situation in northern latitudes during the winter season, or the typical lifestyle for older people and/or for people with very white delicate skin. The actual recommended daily intake of dietary vitamin D is strictly correlated with age, ranging from 5 μg for infants, children, teenagers, and adults—including pregnant and lactating women—to 15 μg for people over 65 years.

Food Fortification: The Level of Awareness among Kenyan Consumers

More than half of the morbidity and mortality cases among children in Kenya are as a result of micronutrient deficiencies (MNDs). Food fortification is considered by the Government of Kenya as a feasible strategy for addressing MNDs. Worldwide, fortification has been proven to be effective since it does not require any change in dietary habits. Success of large-scale food fortification however may depend on consumer awareness of the fortification benefits. A cross-sectional study was conducted in 13 counties to collect information on fortification awareness using structured questionnaires. 1435 respondents were selected using the Lot Quality Assurance Sampling method. Data were analyzed using Stata version 14.0 and statistical significance p < 0.05. The study participants were described using descriptive statistics. The association of sociodemographic characteristics and awareness of fortification was performed using binary logistic regression analysis. The median age of the study participants was 35 years. Only 28% of the respondents were aware of the term “fortification.” Of the respondents, about 27% heard of food fortification through radio. Vernacular radio emerged as the most preferred channel for communicating fortification information among 24.9% of the respondents. Although awareness of vitamins (32%) and minerals (1.5%) was limited, most (76%) respondents reported of existence of health risks for lacking micronutrients. Awareness of food fortification was significantly associated with respondents' occupation (p <  0.001), household size (p=0.012), education levels (p < 0.001), and age (p=0.025). There is need for a wider use of broadcast media sources to modify information and education materials to promote fortification awareness among Kenyan consumers.

Which Choice of Delivery Model(s) Works Best to Deliver Fortified Foods?

Micronutrient deficiencies (MNDs) occur as a result of insufficient intake of minerals and vitamins that are critical for body growth, physical/mental development, and activity. These deficiencies are particularly prevalent in lower-and middle-income countries (LMICs), falling disproportionately on the poorest and most vulnerable segments of the society. Dietary diversity is considered the most effective method in reducing this deficiency but is often a major constraint as most foods rich in micronutrients are also expensive and thereby inaccessible to poorer members of society. In recent years, affordable commodities such as staple foods (e.g., cereals, roots, and tubers) and condiments (e.g., salt and oil) have been targeted as "vehicles" for fortification and biofortification. Despite efforts by many countries to support such initiatives, there have been mixed experiences with delivery and coverage. An important but little understood driver of success and failure for food fortification has been the range of business models and approaches adopted to promote uptake. This review examines the different models used in the delivery of fortified food including complementary foods and biofortified crops. Using a keyword search and pearl growing techniques, the review located 11,897 texts of which 106 were considered relevant. Evidence was found of a range of business forms and models that attempt to optimise uptake, use, and impact of food fortification which are specific to the 'food vehicle' and environment. We characterise the current business models and business parameters that drive successful food fortification and we propose an initial structure for understanding different fortification business cases that will offer assistance to future designers and implementors of food fortification programmes.

The search for candidate genes associated with natural variation of grain Zn accumulation in barley

Combating hidden hunger through molecular breeding of nutritionally enriched crops requires a better understanding of micronutrient accumulation. We studied natural variation in grain micronutrient accumulation in barley (Hordeum vulgare L.) and searched for candidate genes by assessing marker-trait associations (MTAs) and by analyzing transcriptional differences between low and high zinc (Zn) accumulating cultivars during grain filling. A collection of 180 barley lines was grown in three different environments. Our results show a pronounced variation in Zn accumulation, which was under strong genotype influence across different environments. Genome-wide association mapping revealed 13 shared MTAs. Across three environments, the most significantly associated marker was on chromosome 2H at 82.8 cM and in close vicinity to two yellow stripe like (YSL) genes. A subset of two pairs of lines with contrasting Zn accumulation was chosen for detailed analysis. Whole ears and flag leaves were analyzed 15 days after pollination to detect transcriptional differences associated with elevated Zn concentrations in the grain. A putative α-amylase/trypsin inhibitor CMb precursor was decidedly higher expressed in high Zn cultivars in whole ears in all comparisons. Additionally, a gene similar to barley metal tolerance protein 5 (MTP5) was found to be a potential candidate gene.

Thiamin deficiency in low- and middle-income countries: Disorders, prevalences, previous interventions and current recommendations

BACKGROUND

Thiamin deficiency is a major public health concern in several low- and middle-income countries (LMICs)-current attention to the problem is lacking.

AIM

This review discusses prevalence of thiamin insufficiency and thiamin-deficiency disorders (TDDs) in LMICs, outlines programmatic experience with thiamin interventions, and offers recommendations to improve public-health and research attention to thiamin in LMICs.

DISCUSSION

Thiamin insufficiency, i.e. low-blood-thiamin status, is endemic among several Southeast Asian countries: Cambodia (70-100% of infants and 27-100% of reproductive-age women); Laos (13% of hospitalized infants); Thailand (16-25% of children and 30% of elderly adults). Thiamin deficiency accounts for up to 45% of under-5 deaths in Cambodia, 34% of infant deaths in Laos, and 17% of infant deaths in Myanmar. Deficiency also exists in Africa, Asia, and the Americas, but these instances have typically been isolated. Exclusively breastfed infants of thiamin-deficient mothers are at highest risk for TDD and related death. Intervention strategies that have been employed to combat thiamin deficiency include food processing, fortification, supplementation, dietary diversification, and dietary behaviors, all of which have shown varying levels of effectiveness.

CONCLUSIONS

We recommend universal thiamin-fortification of context-specific staple-foods in LMICs as a promising solution, as well as thiamin supplementation, particularly for pregnant and lactating women. Food processing regulations, dietary diversification, and modification of dietary behaviors to increase consumption of thiamin-rich foods may provide benefits in some circumstances, especially in countries without universal fortification programs or in populations dependent on food aid.

The development and release of maize fortified with provitamin A carotenoids in developing countries

Micronutrient deficiencies have been identified as major public health problems affecting a large part of the world's population. Biofortification of staple crops like maize has been proposed as one of the most cost effective and feasible approaches to combat micronutrient deficiencies. Studies have shown that provitamin A from biofortified crops is highly bioavailable and has the capacity to improve vitamin A status of vulnerable groups. Most people in sub-Saharan Africa subsist on maize and many people may benefit from consumption of provitamin A carotenoid biofortified maize, especially women and children. With the exception of transgenic golden rice, biofortified crops have received considerable acceptance by most communities. Negative perceptions associated with yellow maize do not affect orange maize, which is, for example, well-liked in rural Zambia. With proper policy frameworks and full commercialization, provitamin A maize can address the problem of vitamin A deficiencies among poor nations with maize-based diets.

Iron Fortification of Lentil (Lens culinaris Medik.) to Address Iron Deficiency

Iron (Fe) deficiency is a major human health concern in areas of the world in which diets are often Fe deficient. In the current study, we aimed to identify appropriate methods and optimal dosage for Fe fortification of lentil (Lens culinaris Medik.) dal with FeSO₄·7H₂O (ferrous sulphate hepta-hydrate), NaFeEDTA (ethylenediaminetetraacetic acid iron (III) sodium salt) and FeSO₄·H₂O (ferrous sulphate mono-hydrate). We used a colorimetric method to determine the appearance of the dal fortified with fortificants at different Fe concentrations and under different storage conditions. Relative Fe bioavailability was assessed using an in vitro cell culture bioassay. We found that NaFeEDTA was the most suitable fortificant for red lentil dal, and at 1600 ppm, NaFeEDTA provides 13–14 mg of additional Fe per 100 g of dal. Lentil dal sprayed with fortificant solutions, followed by shaking and drying at 75 °C, performed best with respect to drying time and color change. Total Fe and phytic acid concentrations differed significantly between cooked unfortified and fortified lentil, ranging from 68.7 to 238.5 ppm and 7.2 to 8.0 mg g⁻¹, respectively. The relative Fe bioavailability of cooked fortified lentil was increased by 32.2–36.6% compared to unfortified cooked lentil. We conclude that fortification of lentil dal is effective and could provide significant health benefits to dal-consuming populations vulnerable to Fe deficiency.

Meeting nutritional needs in the first 1000 days: a place for small-quantity lipid-based nutrient supplements

The first 1000 days of life is marked by intense metabolic activity and tissue deposition. The increased nutritional needs during this period, and the challenges to meeting them, are often not understood or appreciated. Here, we describe the nutritional needs during the first 1000 days, highlight the challenges to meeting these needs in developing countries, outline intervention strategies, and examine the consumption of small-quantity lipid-based nutrient supplements (SQ-LNS) as a promising strategy. In low-income settings, the challenge to meeting nutritional needs during the first 1000 days is worsened by overreliance on cereal-based diets of low nutrient density and high prevalence of infections and infestations. Dietary diversification is the ideal long-term solution to nutritional deficiencies, but difficulties with obtaining adequate amounts of iron, zinc, and certain vitamins may still remain. Several other interventions are available, but applying them is often fraught with challenges, including cost and contextual factors limiting efficacy. Evidence suggests that SQ-LNS supplementation may help reduce inadequate gestational weight gain and promote fetal and child growth and development in some populations. More research is needed to evaluate the effectiveness of SQ-LNS and other fortified products in different contexts and within integrated programs that address other determinants of maternal and child undernutrition.

Dietary gap assessment: an approach for evaluating whether a country's food supply can support healthy diets at the population level

OBJECTIVE

Dietary diversity, and in particular consumption of nutrient-rich foods including fruits, vegetables, nuts, beans and animal-source foods, is linked to greater nutrient adequacy. We developed a 'dietary gap assessment' to evaluate the degree to which a nation's food supply could support healthy diets at the population level. Design/Setting In the absence of global food-based dietary guidelines, we selected the Dietary Approaches to Stop Hypertension (DASH) diet as an example because there is evidence it prevents diet-related chronic disease and supports adequate micronutrient intakes. We used the DASH guidelines to shape a hypothetical 'healthy' diet for the test country of Cameroon. Food availability was estimated using FAO Food Balance Sheet data on country-level food supply. For each of the seven food groups in the 'healthy' diet, we calculated the difference between the estimated national supply (in kcal, edible portion only) and the target amounts.

RESULTS

In Cameroon, dairy and other animal-source foods were not adequately available to meet healthy diet recommendations: the deficit was -365 kcal (-1527 kJ)/capita per d for dairy products and -185 kcal (-774 kJ)/capita per d for meat, poultry, fish and eggs. Adequacy of fruits and vegetables depended on food group categorization. When tubers and plantains were categorized as vegetables and fruits, respectively, supply nearly met recommendations. Categorizing tubers and plantains as starchy staples resulted in pronounced supply shortfalls: -109 kcal (-457 kJ)/capita per d for fruits and -94 kcal (-393 kJ)/capita per d for vegetables.

CONCLUSIONS

The dietary gap assessment illustrates an approach for better understanding how food supply patterns need to change to achieve healthier dietary patterns.

Inadequate dietary intake of minerals: prevalence and association with socio-demographic and lifestyle factors

This cross-sectional, population-based study aimed to estimate the prevalence of dietary mineral inadequacies among residents in urban areas of Sao Paulo, to identify foods contributing to mineral intake and to verify possible associations between socio-demographic and lifestyle factors and mineral intake. Data were obtained from the 2008 Health Survey of Sao Paulo (n 1511; mean age 43·6 (sd 23·2), range 14–97 years). Dietary intake of minerals was measured using two 24-h dietary recalls. Socio-demographic and lifestyle data were collected. The prevalence of inadequate intake was estimated according to Dietary Reference Intakes methods. Associations between mineral intake and baseline factors were determined using multiple linear regression. Na, Ca and Mg showed the highest dietary inadequacies. Some age/sex groups had lower intakes of P, Zn, Cu and Se. Rice, beans and bread were the main foods contributing towards mineral intake. Female sex was negatively associated with K, Na, P, Mg, Zn and Mn intakes. All age groups were positively associated with the intakes of K, P, Mg and Mn. Family income above one minimum wage was positively associated with Se intake. Living in a household whose head completed ≥10 years of education was positively associated with Ca and negatively associated with Na intake. Former smoker status was negatively associated with Ca intake. Current smoker status was inversely associated with K, Ca, P and Cu intakes. Sufficient physical activity was positively associated with K, Ca and Mg intakes. Overall, the intakes of all major minerals were inadequate and were influenced by socio-demographic and lifestyle factors.

Safety and Mortality Benefits of Delivering Vitamin A Supplementation at 6 Months of Age in Sub-Saharan Africa

Background:

Vitamin A supplementation (VAS) among children 6 to 59 months of age reduces vitamin A deficiency (VAD)-related mortality. Child health days (CHDs) only reach an estimated 16.7% of children at exactly 6 months, leaving uncovered children at risk of VAD-related mortality; similarly, VAS provided at 9 months of age with measles-containing vaccine leaves infants unprotected for 3 months.

Objective:

Using data from sub-Saharan Africa, we estimated the mortality benefits and safety of providing VAS at age 6 months, compared to delivery through CHDs and at 9 months.

Methods:

We modeled VAS-preventable mortality benefits at 6 months as a function of published VAS effect sizes, intervention coverage, and proportion of infant deaths occurring between 6 and 11 months. To evaluate safety, we modeled the effect of different VAS coverage scenarios on maximum hepatic vitamin A concentrations (HVACs).

Results:

VAS linked to a 6-month visit could reduce infant mortality by an additional 1.95 (95% confidence interval [CI]: 1.38-2.52) and 1.63 (95% CI: 1.15-2.11) percentage points compared to VAS through CHDs and at 9 months, respectively. The HVAC models indicate that VAS at 6 months is safe even in the presence of a second VAS dose 1 month later and other food-based vitamin A control strategies.

Conclusion:

Advancing the first VAS dose to 6 months should be considered in settings where VAS is currently given first at 9 months. A 6-month VAS dose should also be considered in settings where VAS is delivered through CHDs. VAS delivery at 6 months could also serve as a platform to deliver other high-impact interventions.

Lactic acid bacteria as a cell factory for riboflavin production

Consumers are increasingly becoming aware of their health and nutritional requirements, and in this context, vitamins produced in situ by microbes may suit their needs and expectations. B groups vitamins are essential components of cellular metabolism and among them riboflavin is one of the vital vitamins required by bacteria, plants, animals and humans. Here, we focus on the importance of microbial production of riboflavin over chemical synthesis. In addition, genetic abilities for riboflavin biosynthesis by lactic acid bacteria are discussed. Genetically modified strains by employing genetic engineering and chemical analogues have been developed to enhance riboflavin production. The present review attempts to collect the currently available information on riboflavin production by microbes in general, while placing greater emphasis on food grade lactic acid bacteria and human gut commensals. For designing riboflavin‐enriched functional foods, proper selection and exploitation of riboflavin‐producing lactic acid bacteria is essential. Moreover, eliminating the in situ vitamin fortification step will decrease the cost of food production.

Economic evaluation of vitamin D and calcium food fortification for fracture prevention in Germany

OBJECTIVE

The study evaluates the economic benefit of population-wide vitamin D and Ca food fortification in Germany.

DESIGN

Based on a spreadsheet model, we compared the cost of a population-wide vitamin D and Ca food-fortification programme with the potential cost savings from prevented fractures in the German female population aged 65 years and older.

SETTING

The annual burden of disease and the intervention cost were assessed for two scenarios: (i) no food fortification; and (ii) voluntary food fortification with 20 µg (800 IU) of cholecalciferol (vitamin D3) and 200 mg of Ca. The analysis considered six types of fractures: hip, clinical vertebral, humerus, wrist, other femur and pelvis.

SUBJECTS

Subgroups of the German population defined by age and sex.

RESULTS

The implementation of a vitamin D and Ca food-fortification programme in Germany would lead to annual net cost savings of €315 million and prevention of 36 705 fractures in the target population.

CONCLUSIONS

Vitamin D and Ca food fortification is an economically beneficial preventive health strategy that has the potential to reduce the future health burden of osteoporotic fractures in Germany. The implementation of a vitamin D and Ca food-fortification programme should be a high priority for German health policy makers because it offers substantial cost-saving potential for the German health and social care systems.

Assessing Alternative Industrial Fortification Portfolios: A Bangladesh Case Study

Background

Approximately 1.2 million disability-adjusted life years (DALYs) are lost annually in Bangladesh due to deficiencies of vitamin A, iron, and zinc.

Objective

To provide evidence on the coverage, costs, and cost-effectiveness of alternative fortification interventions to inform nutrition policy-making in Bangladesh.

Methods

Combining the 2005 Bangladesh Household Income and Expenditure Survey with a Bangladesh food composition table, apparent intakes of energy, vitamin A, iron, and zinc, and the coverage and apparent consumption levels of fortifiable vegetable oil and wheat flour are estimated. Assuming that fortification levels are those established in official regulations, the costs and cost-effectiveness of the two vehicles are assessed independently and as a two-vehicle portfolio.

Results

Vegetable oil has a coverage rate of 76% and is estimated to reduce the prevalence of inadequate vitamin A intake from 83% to 64%. The coverage of wheat flour is high (65%), but the small quantities consumed result in small reductions in the prevalence of inadequate intakes: 1.5 percentage points for iron, less than 1 for zinc, and 2 for vitamin A, while reducing average Estimated Average Requirement (EAR) gaps by 8%, 9%, and 15%, respectively. The most cost-effective 10-micronutrient wheat flour formulation costs US$1.91 million annually, saving 129,212 DALYs at a unit cost of US$14.75. Fortifying vegetable oil would cost US$1.27 million annually, saving 406,877 DALYs at an average cost of US$3.25. Sensitivity analyses explore various permutations of the wheat flour formulation. Divisional variations in coverage, cost, and impact are examined.

Conclusions

Vegetable oil fortification is the most cost-effective of the three portfolios analyzed, but all three are very cost-effective options for Bangladesh.

Bioavailability of iron in multiple fortified milk

The objectives of the study were to evaluate the bioavailability of iron in milk fortified with ferric pyrophosphate (FPP) soluble and vitamin A acetate and to establish the role of vitamin A in enhancement of iron absorption. Balance indices viz. apparent digestibility coefficient, % retention/intake of iron and haematological parameters viz. blood haemoglobin, plasma ferritin, plasma transferrin and iron content in rat livers were analyzed to evaluate iron bioavailability. Anaemia was induced in one group of rats to evaluate the effect of iron status of body on iron absorption from diet. The results of in vivo study showed that feeding of rats with lyophilates of milk fortified with FPP soluble and FPP soluble + vitamin A acetate had a significant effect on the balance indices of the iron as well as on the haematological parameters and iron liver status. The utilization of iron in the body, as indicated by the results of balance indices, haematological parameters and iron status of livers was significantly higher in anaemic rats compared to control group rats. Vitamin A appeared to be playing role in enhancement of iron absorption and utilization in body.

Concept of double salt fortification; a tool to curtail micronutrient deficiencies and improve human health status

Fortification of food with micronutrients such as vitamins and minerals is one of the main strategies used to combat micronutrient deficiencies. Fortification in common salt is a fruitful strategy because of the daily consumption of 5-12 g salt per person globally. Therefore double fortification of salt with iodine and iron could be a reasonable approach to prevent both iodine and iron deficiencies. It is reckoned that about two billion people are iodine-deficient worldwide. Iodine deficiency during pregnancy may affect the health status of both mother and fetus and increase infant mortality. Deficiencies of both these micronutrients during childhood affect somatic growth and cognitive and neurological function. Thyroid metabolism is negatively affected by iron deficiency and reduced effectiveness of iodine prophylaxis in areas of endemic goiter. High prevalence of iron deficiency among children may be reduced by the application of effective iodized salt programs. However, ensuring the stability and bioavailability of both iron and iodine as double-fortified salt is difficult. Iodine present in iodide or iodate form in dual-fortified salt is oxidized to free iodine in the presence of ferrous ions and oxygen and consequently loses its characteristics. Moreover, ferrous iron is more bioavailable but is readily oxidized to the less bioavailable ferric form. However, both forms of iron may lead to discoloration of the final product, which can be reduced by providing a physical barrier around the iron. Salt encapsulation is one of the best tools to provide a physical barrier for undesirable reactions and interactions during storage. In this review the concept of dual salt fortification, the impact of fortification on curing various life-threatening maladies, latest assessments of mineral deficiencies and the choice of fortificants are discussed.

Fortification of foods with vitamin D in India

Vitamin D deficiency is widely prevalent in India, despite abundant sunshine. Fortification of staple foods with vitamin D is a viable strategy to target an entire population. Vitamin D fortification programs implemented in the United States and Canada have improved the vitamin D status in these countries, but a significant proportion of the population is still vitamin D deficient. Before fortification programs are designed and implemented in India, it is necessary to study the efficacy of the American and Canadian vitamin D fortification programs and then improve upon them to suit the Indian scenario. This review explores potential strategies that could be used for the fortification of foods in the Indian context. These strategies have been proposed considering the diverse dietary practices necessitated by social, economic, cultural and religious practices and the diverse climatic conditions in India. Fortification of staple foods, such as chapati flour, maida, rice flour and rice, may be more viable strategies. Targeted fortification strategies to meet the special nutritional needs of children in India are discussed separately in a review entitled, "Fortification of foods with vitamin D in India: Strategies targeted at children".

[Hemoglobin curves during pregnancy before and after fortification of flours with iron]

OBJECTIVE

To assess the level of hemoglobin-Hb during pregnancy before and after fortification of flours with iron.

METHOD

A cross-sectional study with data from 12,119 pregnant women attended at a public prenatal from five macro regions of Brazil. The sample was divided into two groups: Before-fortification (birth before June/2004) and After-fortification (last menstruation after June/2005). Hb curves were compared with national and international references. Polynomial regression models were built, with a significance level of 5%.

RESULTS

Although the higher levels of Hb in all gestational months after-fortification, the polynomial regression did not show the fortification effect (p=0.3). Curves in the two groups were above the references in the first trimester, with following decrease and stabilization at the end of pregnancy.

CONCLUSION

Although the fortification effect was not confirmed, the study presents variation of Hb levels during pregnancy, which is important for assistencial practice and evaluation of public policies.

Equity in access to fortified maize flour and corn meal

Mass fortification of maize flour and corn meal with a single or multiple micronutrients is a public health intervention that aims to improve vitamin and mineral intake, micronutrient nutritional status, health, and development of the general population. Micronutrient malnutrition is unevenly distributed among population groups and is importantly determined by social factors, such as living conditions, socioeconomic position, gender, cultural norms, health systems, and the socioeconomic and political context in which people access food. Efforts trying to make fortified foods accessible to the population groups that most need them require acknowledgment of the role of these determinants. Using a perspective of social determinants of health, this article presents a conceptual framework to approach equity in access to fortified maize flour and corn meal, and provides nonexhaustive examples that illustrate the different levels included in the framework. Key monitoring areas and issues to consider in order to expand and guarantee a more equitable access to maize flour and corn meal are described.

Legislative frameworks for corn flour and maize meal fortification

Corn flour and maize meal fortification can benefit the consumer when the added nutrient contents are in amounts appropriate to address nutrient gaps. Legislative instruments (standards and regulations) are needed to provide guidance to the producers and food control authorities. We reviewed a number of national standards and regulations of fortified corn flour and maize meal and identified constraints; contrary to current belief, the practice of using minimum contents or ranges of nutrients has caused confusion, misinterpretation, and conflict, and should therefore be abandoned. On the basis of the findings, a model of fortification legislation is proposed, in which the additional content and the expected average nutrient content in a final product are recommended as the main parameters for quality control and enforcement. For labeling, the average content, or one adjusted to the expected content of the product at the market, can be applied. Variation in micronutrient contents should still be checked to ensure homogeneity but with adherence to clear procedures of sampling and testing, which should be part of the standards and regulations.

Rapid quantification of iron content in fish sauce and soy sauce: a promising tool for monitoring fortification programs

BACKGROUND

In a number of Southeast Asian countries and China, fish sauce and soy sauce produced at the industrial level are fortified with iron. Unfortunately, the food producers and regulatory agencies implementing fortification programs do not always have the capacity to monitor the programs on an ongoing basis.

OBJECTIVE

To assess a new portable device for the quantitative measurement of iron content of fortified sauces that could be used to control fortification levels.

METHODS

The linearity, detection limits, and inter- and intraassay variability of this device were assessed on fish sauce and soy sauce fortified with ferrous sulfate, ferrous fumarate, and sodium iron ethylenediaminetetraacetate (NaFeEDTA); the accuracy of the results was determined by comparing them with the results obtained by atomic absorption spectrophotometry.

RESULTS

Measurements required a minimum incubation time of 1 hour for iron sulfate or iron fumarate and 24 hours for NaFeEDTA. Linearity of the results ranged from 2 to 10 mg iron/L for ferrous sulfate or ferrous fumarate and from 1 to 10 mg iron/L for NaFeEDTA, implying the need for proper dilution, as the iron contents of fortified sauce are usually in the range of 150 to 1,000 mg/L. Depending on incubation time, iron compounds, and sauces, the coefficient of variation (CV) of intraassay precision was between 1.5% and 7.6% and the CV of interassay precision was between 2.9% and 7.4%. Comparison with results from atomic absorption spectrophotometry showed high agreement between both methods, with R = 0.926 and R = 0.935 for incubation times of 1 hour and 24 hours, respectively. The Bland-Altman plots showed limits of agreement between the two methods of +/- 70 mg/L in the range of fortification levels tested (100 to 500 mg/L). CONCLUSIONS; This device offers a viable method for field monitoring of iron fortification of soy and fish sauces after incubation times of 1 hour for ferrous sulfate or ferrous fumarate and 24 hours for NaFeEDTA.

Lessons learned from national food fortification projects: experiences from Morocco, Uzbekistan, and Vietnam

BACKGROUND

Fortification of staple foods has been repeatedly recommended as an effective approach to reduce micronutrient deficiencies. With the increased number of fortification projects globally, there is a need to share practical lessons learned relating to their implementation and responses to project-related and external challenges.

OBJECTIVE

To document the achievements, challenges, lessons learned, and management responses associated with national fortification projects in Morocco, Uzbekistan, and Vietnam.

METHODS

Independent end-of-project evaluations conducted for each project served as the primary data source and contain the history of and project activities undertaken for, each fortification project. Other sources, including national policy documents, project reports from the Global Alliance for Improved Nutrition (GAIN) and other stakeholders, industry assessments, and peer-reviewed articles, were used to document the current responses to challenges and future project plans.

RESULTS

All projects had key achievements related to the development of fortification standards and the procurement of equipment for participating industry partners. Mandatory fortification of wheat flour was a key success in Morocco and Uzbekistan. Ensuring the quality of fortified foods was a common challenge experienced across the projects, as were shifts in consumption patterns and market structures. Adjustments were made to the projects' design to address the challenges faced.

CONCLUSIONS

National fortification projects are dynamic and must be continually modified in response to specific performance issues and broader shifts in market structure and consumption patterns.

The application of GMOs in agriculture and in food production for a better nutrition: two different scientific points of view

This commentary is a face-to-face debate between two almost opposite positions regarding the application of genetic engineering in agriculture and food production. Seven questions on the potential benefits of the application of genetic engineering in agriculture and on the potentially adverse impacts on the environment and human health were posed to two scientists: one who is sceptical about the use of GMOs in Agriculture, and one who views GMOs as an important tool for quantitatively and qualitatively improving food production.

Plant calcium content: ready to remodel

By identifying the relationship between calcium location in the plant cell and nutrient bioavailability, the plant characteristics leading to maximal calcium absorption by humans can be identified. Knowledge of plant cellular and molecular targets controlling calcium location in plants is emerging. These insights should allow for better strategies for increasing the nutritional content of foods. In particular, the use of preparation-free elemental imaging technologies such as synchrotron X-ray fluorescence (SXRF) microscopy in plant biology may allow researchers to understand the relationship between subcellular location and nutrient bioavailability. These approaches may lead to better strategies for altering the location of calcium within the plant to maximize its absorption from fruits and vegetables. These modified foods could be part of a diet for children and adults identified as at-risk for low calcium intake or absorption with the ultimate goal of decreasing the incidence and severity of inadequate bone mineralization.

Effects of micronutrient fortified milk and cereal food for infants and children: a systematic review

BACKGROUND

Micronutrient deficiency is a common public health problem in developing countries, especially for infants and children in the first two years of life. As this is an important time window for child development, micronutrient fortified complementary feeding after 6 months of age, for example with milk or cereals products, in combination with continued breastfeeding, is recommended. The overall effect of this approach is unclear.

METHODS

We performed a Systematic Review and Meta-analysis to assess the impact of micronutrient fortified milk and cereal food on the health of infants and little children (aged 6 months to 5 years) compared to non-fortified food. We reviewed randomized controlled trials using electronic databases (MEDLINE and Cochrane library searches through FEB 2011), reference list screening and hand searches. Three reviewers assessed 1153 studies for eligibility and extracted data. One reviewer assessed risk of bias using predefined forms.

RESULTS

We included 18 trials in our analysis (n = 5'468 children; range of mean hemoglobin values: 9.0 to 12.6 g/dl). Iron plus multi micronutrient fortification is more effective than single iron fortification for hematologic outcomes. Compared to non-fortified food, iron multi micronutrient fortification increases hemoglobin levels by 0.87 g/dl (95%-CI: 0.57 to 1.16; 8 studies) and reduces risk of anemia by 57% (relative risk 0.43; 95%-CI 0.26 to 0.71; absolute risk reduction 22%; number needed to treat 5 [95%-CI: 4 to 6]; 6 Studies). Compared to non-fortified food, fortification increases serum levels of vitamin A but not of zinc. Information about functional health outcomes (e.g. weight gain) and morbidity was scarce and evidence is inconclusive. Risk of bias is unclear due to underreporting, but high quality studies lead to similar results in a sensitivity analysis.

CONCLUSIONS

Multi micronutrient fortified milk and cereal products can be an effective option to reduce anemia of children up to three years of age in developing countries. On the basis of our data the evidence for functional health outcomes is still inconclusive.

Externalities from grain consumption: a survey

The US Department of Agriculture (USDA) publishes their MyPyramid plan as a recommended eating model for all Americans. As part of this model, grain consumption is emphasized. This grain consumption has the potential to generate positive externalities, such as reduced rates of obesity, diabetes and other chronic diseases. Such positive externalities can potentially produce tangible economic benefits in terms of public health. In contrast, newer nutritional research shows that grain consumption may have negative effects on health for certain population groups. Celiac disease is four times as common as it was 50 years ago and is often under-diagnosed. Other population groups exhibit gluten sensitivity which can impact the development of asthma, allergies and neurological difficulties. This survey intends to provide a comprehensive description of both the positive and negative externalities associated with grain consumption and the resulting impact on human health.

Nutritious crops producing multiple carotenoids--a metabolic balancing act

Plants and microbes produce multiple carotenoid pigments with important nutritional roles in animals. By unraveling the basis of carotenoid biosynthesis it has become possible to modulate the key metabolic steps in plants and thus increase the nutritional value of staple crops, such as rice (Oryza sativa), maize (Zea mays) and potato (Solanum tuberosum). Multigene engineering has been used to modify three different metabolic pathways simultaneously, producing maize seeds with higher levels of carotenoids, folate and ascorbate. This strategy may allow the development of nutritionally enhanced staples providing adequate amounts of several unrelated nutrients. By focusing on different steps in the carotenoid biosynthesis pathway, it is also possible to generate plants with enhanced levels of several nutritionally-beneficial carotenoid molecules simultaneously.

Effect of multiple fortification on the bioavailability of minerals in wheat meal bread

Bioavailability of calcium, iron and zinc as calcium carbonate (CaCO3), ferrous sulfate (FeSO4) and zinc sulphate (ZnSO4) @ 1,000, 40 and 20 mg kg(-1) respectively from fortified bread of 72% extraction straight grade flour was assessed. Fortified bread diets were fed to 64 female Sprague-Dawley Albino rats for a period of 28 days. The retention of Ca, Fe and Zn was measured in plasma, femur and liver tissues of rats. The results showed that the feed intake and live body weight of the experimental animals increased significantly with the time period. The Ca levels in plasma and liver did not change significantly while in femur, Ca retention changed significantly with changing type of the fortificants. Similarly, the results for percent apparent absorption (AA) of Ca also remained unchanged (P < 0.05). The Fe and Zn levels were significantly higher in the plasma, liver and femur of rats fed Fe and Zn fortified bread. Interaction of Ca, Fe and Zn resulted in their decreased bioavailability. However Ca, Fe and Zn absorption was higher in the rats fed triple fortified diet compared with those fed unfortified bread diet. This negative interaction did not appear to be great enough to discourage multiple fortification of flour to address minerals malnutrition in the vulnerable groups.

Active food packaging evolution: transformation from micro- to nanotechnology

Predicting which attributes consumers are willing to pay extra for has become straightforward in recent years. The demands for the prime necessity of food of natural quality, elevated safety, minimally processed, ready-to-eat, and longer shelf-life have turned out to be matters of paramount importance. The increased awareness of environmental conservation and the escalating rate of foodborne illnesses have driven the food industry to implement a more innovative solution, i.e. bioactive packaging. Owing to nanotechnology application in eco-favorable coatings and encapsulation systems, the probabilities of enhancing food quality, safety, stability, and efficiency have been augmented. In this review article, the collective results highlight the food nanotechnology potentials with special focus on its application in active packaging, novel nano- and microencapsulation techniques, regulatory issues, and socio-ethical scepticism between nano-technophiles and nano-technophobes. No one has yet indicated the comparison of data concerning food nano- versus micro-technology; therefore noteworthy results of recent investigations are interpreted in the context of bioactive packaging. The next technological revolution in the domain of food science and nutrition would be the 3-BIOS concept enabling a controlled release of active agents through bioactive, biodegradable, and bionanocomposite combined strategy.

Community-level micronutrient fortification of school lunch meals improved vitamin A, folate, and iron status of schoolchildren in Himalayan villages of India

Anemia and micronutrient deficiencies are common among Indian schoolchildren. We assessed the effectiveness of micronutrient fortification of meals cooked and fortified at school on anemia and micronutrient status of schoolchildren in Himalayan villages of India. In this placebo-controlled, cluster-randomized study, 499 schoolchildren (6-10 y) received either multiple micronutrients (treatment group) or placebo (control group) as part of school meals (6 d/wk) for 8 mo. Both groups were dewormed at the beginning of the study. The micronutrient premix provided 10 mg iron, 375 microg vitamin A, 4.2 mg zinc, 225 microg folic acid, and 1.35 microg vitamin B-12 for each child per day (approximately 75% recommended dietary allowance). Blood samples drawn before and after the intervention were analyzed for hemoglobin, ferritin, retinol, zinc, folate, and vitamin B-12. Baseline prevalence of anemia (37%), iron deficiency anemia (10%), low serum ferritin (24%), retinol (56%), zinc (74%), folate (68%), and vitamin B-12 (17%) did not differ between groups. Postintervention, fewer in the treatment group had lower serum retinol [odds ratio (OR) (95% CI): 0.57 (0.33-0.97)] and folate [OR (95% CI): 0.47 (0.26-0.84)] than the control group. The serum vitamin B-12 concentration decreased in both groups, but the magnitude of change was less in the treatment than in the control group (P < 0.05). Total body iron (TBI) increased in both groups; however, the change was greater in the treatment than in the control group (P < 0.05). Micronutrient fortification of school meals by trained school personnel was effective in improving vitamin A, folate, and TBI status while also reducing the magnitude of a decrease in vitamin B-12 status.

Food nanotechnology: New leverage against iron deficiency

Reducing the particle size of some iron compounds can improve their bioavailability in rats, without increasing their tendency to cause colour and odour changes when added to foods.