Iron and folate in fortified cereals

Clinical and Echocardiographic Correlates of Iron Status in Chronic Heart Failure Patients: A Cross-Sectional Descriptive Study

BACKGROUND

 Chronic heart failure (HF) is one of the conditions commonly seen in the medical outpatient departments, and iron deficiency (ID) has been reported as the commonest nutritional deficiency in these patients. The presence of ID may interfere with the clinical parameters of chronic HF. The relationship between iron status and chronic HF needs more attention and should be given more consideration in the evaluation of patients with chronic HF.

AIM

The aim of the study was to determine the relationship, if any, between iron status and clinical/echocardiographic variables in chronic HF.

METHODS AND MATERIALS

A cross-sectional descriptive study was carried out at the Lagos University Teaching Hospital (LUTH), Nigeria, where 88 patients with chronic HF were recruited to participate in this study. The participants underwent clinical and laboratory assessments. Iron status was assessed with full blood count parameters; serum ferritin and transferrin saturation (Tsat) and its relationship with clinical parameters among these participants were also studied.

RESULTS

No correlations existed between the duration of chronic HF and iron status when compared using Tsat. However, a significant weak negative correlation was observed between the duration of HF and the serum ferritin levels. The clinical characteristics of the HF participants with and without ID were compared. There was no significant difference in the frequency of prior hospitalization in both groups. However, a higher proportion of participants with severe HF (New York Heart Association (NYHA) classes III/IV) (n = 14; 46.7%) were iron-deficient compared to those with moderate chronic HF (NYHA II) (n = 11; 36.7%). This relationship was statistically significant. Left ventricular ejection fraction (LVEF) was similar in the iron-deficient and iron-replete groups (using serum ferritin or Tsat) both when compared as means and when compared after categorizing LVEF as HF with preserved ejection fraction (HFpEF) vs HF with reduced ejection fraction (HFrEF). There was no statistically significant correlation between the severity of ID and LVEF.  Conclusion: A spectrum of clinical changes occurs in patients with chronic HF. ID can make these changes more profound and the condition less amenable to standard HF treatments. These patients may therefore benefit from further evaluation for this nutritional deficiency. Laboratory measurements including Tsat and serum ferritin may help in further assessment of select patients with worse and/or non-responsive clinical parameters.

Nutrition and hair

Healthy hair results from a combination of good generalized health and mindful health care practices. Many nutritional deficiencies lead to poor hair health and include changes to hair structure, texture, and viability. Although the mechanisms by which individual nutrients contribute to hair growth and maintenance have yet to be fully resolved, there are a variety of risk factors that predispose an individual to a nutritional deficiency; age, malnutrition, malabsorption, and medication use are among the most common. A thorough history should be taken in a patient with a hair disturbance to identify risk factors for a nutritional deficiency, which will then guide directed laboratory testing and treatment.

Development of the Hellenic Food Thesaurus (HelTH), a branded food composition database: Aims, design and preliminary findings

The Hellenic Food Thesaurus (HelTH) is the first systematic attempt to create a Greek Branded Food Composition Database. Data on the nutritional composition of foods for up to 45 nutrients, on-pack claims (health, nutrition, social, environmental), quality indicators, and prices were recorded for more than 4,000 foods as they appear on the photographs of their packages available on retailers' websites. A group of trained researchers carried out data collection and classification using LanguaL. HelTH highlights the variability in nutritional compositions of packaged foods in Greece and the need for better labelling of key nutrients such as trans fatty acids. According to a preliminary analysis of on-pack communications (n = 2008 products), health claims are used rarely (4.1% of products analyzed) with greater prevalence of nutrition (~32%) and natural claims (~24%). HelTH is a key infrastructure for the implementation of food and nutrition policies, new product development, and nutrition and consumer research.

Fruit and vegetable consumption before and during pregnancy and birth weight of new-borns in Japan: the Tohoku medical megabank project birth and three-generation cohort study

BACKGROUND

Associations of fruit and vegetable consumption before and during pregnancy with birth weight of new-borns and the risk of low birth weight (LBW) remain unclear.

METHODS

Between July 2013 and March 2017, we recruited 23,406 pregnant women in the Tohoku Medical Megabank Project Birth and Three-Generation Cohort Study (TMM BirThree Cohort Study). Fruit and vegetable consumption before and during pregnancy was calculated using food frequency questionnaires. Information regarding birth weight was obtained from medical records, and LBW was defined as < 2500 g. We used a multivariable linear regression model and a multivariate logistic regression model to assess associations between fruit and vegetable consumption and birth weight/risk of LBW.

RESULTS

In total, 17,610 women were included in the analysis. Mean birth weight was 3061.8 ± 354.1 g, and 5.4% of the new-borns had LBW. Compared to women in the lowest quartile of fruit consumption between pre- and early pregnancy, women in the highest quartile had heavier new-borns (β = 49.4; 95% CI: 34.1-64.7) and lower risk of LBW (OR: 0.79; 95% CI: 0.65-0.95). Women in the highest quartile of fruit consumption from early to mid-pregnancy also had heavier new-borns (β = 32.3; 95% CI: 17.1-47.6), and they tended to have lower risk of LBW (OR: 0.83; 95% CI: 0.69-1.01). Results of analysing the association between changes in fruit consumption from pre- to mid-pregnancy and birth outcomes revealed that women with continuous high fruit consumption from pre- to mid-pregnancy had heavier new-borns (β = 37.6; 95% CI: 25.0-50.3), but they did not have lower risk of LBW (OR: 0.90; 95% CI: 0.77-1.06). Associations involving vegetable consumption and birth weight/risk of LBW were not observed.

CONCLUSIONS

Fruit consumption before and during pregnancy was positively associated with birth weight of new-borns and negatively associated with risk of LBW.

Folate dietary insufficiency and folic acid supplementation similarly impair metabolism and compromise hematopoiesis

While dietary folate deficiency is associated with increased risk for birth defects and other diseases, evidence suggests that supplementation with folic acid can contribute to predisposition to some diseases, including immune dysfunction and cancer. Herein, we show that diets supplemented with folic acid both below and above the recommended levels led to significantly altered metabolism in multiple tissues in mice. Surprisingly, both low and excessive dietary folate induced similar metabolic changes, which were particularly evident for nucleotide biosynthetic pathways in B-progenitor cells. Diet-induced metabolic changes in these cells partially phenocopied those observed in mice treated with anti-folate drugs, suggesting that both deficiency and excessive levels of dietary folic acid compromise folate-dependent biosynthetic pathways. Both folate deficiency and excessive dietary folate levels compromise hematopoiesis, resulting in defective cell cycle progression, persistent DNA damage, and impaired production of lymphocytes. These defects reduce the reconstitution potential in transplantation settings and increase radiation-induced mortality. We conclude that excessive folic acid supplementation can metabolically mimic dietary folate insufficiency, leading to similar functional impairment of hematopoiesis.

Establishing Safe and Potentially Efficacious Fortification Contents for Folic Acid and Vitamin B12

Determining the micronutrient contents in fortified foods depends not only on the health goal (additional intake to complement the diet), but also on ensuring that fortification does not raise micronutrient intakes beyond the Tolerable Upper Intake Level (UL), i.e., the safe limit. Technological incompatibility and cost may also restrict the fortification contents. For folic acid, the limiting factor is safety, while for vitamin B12, it is cost. However, adequate fortification contents that are both safe and efficacious can be estimated for both nutrients. In order to obtain the maximum benefit from the fortification programs, three different formulas responding to three categories of consumption, as specified by the median and 95th percentile of consumption, are proposed.

The model presented is based on the estimation of a Feasible Fortification Level (FFL), which then is used to determine the average, minimum, and maximum contents of the nutrients during production, taking into consideration the acceptable variation of the fortification process. Finally, the regulatory parameters, which support standards and enforcement, are calculated by reducing the proportion of the nutrient that is degraded during the usual marketing process of the fortified food. It is expected that this model will establish a common standard for food fortification, and improve the reliability and enforcement procedures of these programs.

The model was applied to flours as vehicles for folic acid in the United States, Guatemala, and Chile. Analysis of the data revealed that, with the exception of Chile, where wheat flour consumption is very high and probably within a narrow range, supplementation with folic acid is still needed to cover individuals at the low end of consumption. This is especially true when the difference in flour consumption is too wide, as in the case of Guatemala, where the proportional difference between consumption at the 95th percentile of the nonpoor group is as high as 100 times the consumption at the 5th percentile of the extremely poor group. Adoption of fortification content for staple foods near the safe limit brings together the need of restricting the voluntary addition of the specific nutrient to other foods and to dietary supplements.

Impact of Breakfast Skipping and Breakfast Choice on the Nutrient Intake and Body Mass Index of Australian Children

Recent data on breakfast consumption among Australian children are limited. This study examined the impact of breakfast skipping and breakfast type (cereal or non-cereal) on nutrient intakes, likelihood of meeting nutrient targets and anthropometric measures. A secondary analysis of two 24-h recall data from the 2007 Australian National Children’s Nutrition and Physical Activity Survey was conducted (2–16 years; n = 4487) to identify (a) breakfast skippers and (b) breakfast consumers, with breakfast consumers further sub-divided into (i) non-cereal and (ii) cereal consumers. Only 4% skipped breakfast and 59% of skippers were 14–16 years. Breakfast consumers had significantly higher intakes of calcium and folate, and significantly lower intakes of total fat than breakfast skippers. Cereal consumers were more likely to meet targets and consume significantly higher fibre, calcium, iron, had significantly higher intakes of folate, total sugars and carbohydrate, and significantly lower intakes of total fat and sodium than non-cereal consumers. The prevalence of overweight was lower among breakfast consumers compared to skippers, and among cereal consumers compared to-cereal consumers (p < 0.001), while no significant differences were observed for mean body mass index (BMI), BMI z-score, waist circumference and physical activity level across the categories. Breakfast and particularly breakfast cereal consumption contributes important nutrients to children’s diets.

Voluntary fortification of breakfast cereals with folic acid: contribution to dietary intake in Australia

Ready-to-eat breakfast cereals have been voluntarily fortified with folic acid since 1995, with the purpose of reducing the prevalence of neural tube defects in utero. Using data from the recent Australian Health Survey, this study aimed to estimate folate intake from one serving of breakfast cereals (median amount). Various commercial brands were purchased in 2002 (n = 19) and in 2014 (n = 14); folate was determined by microbiological assay and high-pressure liquid chromatography (HPLC). Total folate (μg/100 g) in 2002 and 2014 selections were 144-633 and 147-564, respectively, and mostly comparable to nutrition labels. Folic acid (2014 selection) using HPLC, ranged from 85 to 411 μg/100 g. Intake of 51 g cereals/serving by individuals ≥ 2 years could contribute 75-288 μg dietary folate equivalent. It seems that folic acid intake among children (2-3 years) exceeds the recommended dietary intake, when certain brands of breakfast cereals are consumed. Accordingly, the benefits and potential detrimental effects of the voluntary fortification need to be further explored.

Intake of dietary folate and folic acid in Germany based on different scenarios for food fortification with folic acid

PURPOSE

Besides the adverse health effects of a low folate intake, the risks of high intakes of folic acid have moved into the focus. The aim of this study was to investigate the potential range of folate and folic acid intake of the German population under consideration of different fortification scenarios.

METHODS

Food consumption data of 13,926 participants of the German National Nutrition Survey II (NVS II), collected with two 24-h recalls, were used to calculate the nutrient intake. The nutrient data are based on the German Nutrient Database (BLS), information from a market survey and analyses of multivitamin juices. The scenarios were modelled without, as well as with low and high fortification levels of folic acid.

RESULTS

The median intake of dietary folate equivalents ranged from 191 µg/d (men) and 168 µg/d (women) without fortification to 425 µg/d (men) and 334 µg/d (women) in the highest fortification scenario. Thus, 12.4-68.2% (men) and 5.9-56.1% (women) met the 300 µg/d recommended by the nutrition societies of Germany, Austria and Switzerland. In the highest fortification scenario, 1.9% (men) and 0.8% (women) exceeded the tolerable upper intake level (UL) of 1,000 µg/d folic acid given by the European Food Safety Authority. For supplement users, this proportion was 5.2 and 5.4%.

CONCLUSIONS

Only a high fortification of several foods leads to a marked increase of the proportion of population reaching the recommendation. Simultaneously, with a high fortification a higher proportion exceeds the UL, especially in combination with supplements.

Iron, human growth, and the global epidemic of obesity

Iron is an essential nutrient utilized in almost every aspect of cell function and its availability has previously limited life. Those same properties which allow iron to function as a catalyst in the reactions of life also present a threat via generation of oxygen-based free radicals. Accordingly; life exists at the interface of iron-deficiency and iron-sufficiency. We propose that: (1) human life is no longer positioned at the limits of iron availability following several decades of fortification and supplementation and there is now an overabundance of the metal among individuals of many societies; (2) this increased iron availability exerts a positive effect on growth by targeting molecules critical in regulating the progression of the cell cycle; there is increased growth in humans provided greater amounts of this metal; and indices of obesity can positively correlate with body stores of iron; and (3) diseases of obesity reflect this over-abundance of iron. Testing potential associations between iron availability and both obesity and obesity-related diseases in populations will be difficult since fortification and supplementation is so extensively practiced.

Vitamin food fortification today

Historically, food fortification has served as a tool to address population-wide nutrient deficiencies such as rickets by vitamin D fortified milk. This article discusses the different policy strategies to be used today. Mandatory or voluntary fortification and fortified foods, which the consumer needs, also have to comply with nutritional, regulatory, food safety and technical issues. The ‘worldwide map of vitamin fortification’ is analysed, including differences between develop and developing countries. The vitamins, folate and vitamin D, are taken as practical examples in the review of the beneficial effect of different strategies on public health. The importance of the risk–benefit aspect, as well as how to identify the risk groups, and the food vehicles for fortification is discussed.

Folate analysis in foods by UPLC-MS/MS: development and validation of a novel, high throughput quantitative assay; folate levels determined in Australian fortified breads

An ultra-performance liquid chromatography-tandem mass spectrometry method was developed, optimised and validated for the quantification of synthetic folic acid (FA), also called pteroyl-L: -glutamic acid or vitamin B9 and naturally occurring 5-methyltetrahydrofolate (5-MTHF) found in folate-fortified breads. Optimised sample preparation prior to analysis involved addition of (13)C(5) labelled internal standards, treatments with α-amylase and rat serum, solid-phase extraction using aromatic-selective cartridges and ultra-filtration. Analytes were separated on a Waters ACQUITY HSS T3 column during a 6-min run and analysed by positive ion electrospray selected reaction monitoring MS/MS. Standard calibration curves for the two analytes were linear over the range of 0.018-14 μg FA/g of fresh bread (r(2) = 0.997) and 9.3-900 ng 5-MTHF/g of fresh bread (r(2) = 0.999). The absolute recoveries were 90% and 76% for FA and 5-MTHF, respectively. Intra-day coefficients of variation were 3% for FA and 18% for 5-MTHF. The limit of detection was 9.0 ng/g for FA and 4.3 ng/g for 5-MTHF, determined using pre-extracted tapioca starch as the blank matrix. The assay is rugged, fast, accurate and sensitive, applicable to a variety of food matrices and is capable of the detection and quantification of the naturally occurring low levels of 5-MTHF in wheat breads. The findings of this study revealed that the FA range in Australian fortified breads was 79-110 μg/100 g of fresh bread and suggest that the flour may not have the mandated FA fortification level (200-300 μg/100 g of flour), though this cannot be determined conclusively from experimental bread data alone, as variable baking losses have been documented by other authors.

Do breakfast skipping and breakfast type affect energy intake, nutrient intake, nutrient adequacy, and diet quality in young adults? NHANES 1999-2002

OBJECTIVE

To assess the impact of breakfast skipping and type of breakfast consumed on energy/nutrient intake, nutrient adequacy, and diet quality.

DESIGN

Cross-sectional.

SETTING

The National Health and Nutrition Examination Survey (NHANES), 1999-2002.

SUBJECTS

Young adults (20-39 years, n = 2615).

MEASURES

A 24-hour dietary recall was used, with breakfast defined as self-reported. Covariate-adjusted sample-weighted means for the entire day's energy/nutrient intakes, mean adequacy ratio (MAR) for nutrient intakes, and diet quality (i.e., Healthy Eating Index [HEI]-2005) scores were compared using analysis of variance and Bonferroni's correction (p < 0.0167) among breakfast skippers (BS), ready-to-eat-cereal breakfast consumers (RTECC), and other breakfast consumers (OBC). Energy/nutrient intakes and food consumption at breakfast were also compared (p ≤ 0.05).

RESULTS

Twenty-five percent of young adults were BS, 16.5% were RTECC, and 58.4% were OBC. Intakes of total energy, percent energy from carbohydrate, and dietary fiber were higher in RTECC than in BS and OBC. Percent energy intake from added sugars was higher in BS than in RTECC and OBC. Compared with BS and RTECC, OBC consumed a lower percent energy from carbohydrates and total sugars, but consumed a higher percent energy from total fat and discretionary solid fats and had a higher cholesterol intake. Intakes of several micronutrients were higher in RTECC than in BS and OBC. Both MAR and total HEI scores were the highest in RTECC and higher in OBC than in BS. The HEI scores for intakes of whole fruits, total/whole grains, milk, and percent energy from solid fat/alcohol/added sugar were the highest in RTECC and higher in OBC than in BS. Compared with OBC, RTECC had a higher HEI score for the intake of saturated fat. At breakfast, RTECC consumed higher intakes of total fruits, whole grains, dairy products, carbohydrates and total sugars, dietary fiber, and several micronutrients than OBC, who consumed higher intakes of meat/poultry/fish, eggs, total fat, discretionary oils/solid fats, cholesterol, and sodium than RTECC.

CONCLUSION

Thus, RTECC had more favorable nutrient intakes and better diet quality than BS and OBC.

Ready-to-eat cereals and the burden of obesity in the context of their nutritional contribution: are all ready-to-eat cereals equally healthy? A systematic review

A significant increase in the prevalence of obesity has occurred worldwide and the importance of considering the role of diet in the prevention and treatment of obesity is widely acknowledged. A growing body of evidence encourages the consumption of ready-to-eat cereals (RTEC) as part of a healthful diet. Research has shown an inverse association between the consumption of RTEC and the rate of obesity. However, other findings claim that this association was only attributed to the consumption of whole-grain cereals and not the refined-grain ones. Although meta-analyses of clinical trials support the use of a low-glycaemic index diet on weight loss, findings from other studies on the effect of the dietary glycaemic index on body weight have not been consistent. Thus, further research into the role of glycaemic index in the prevention and management of obesity and chronic disease is needed. Moreover, significant differences have been observed in composition among the marketed RTEC. In light of the revealing protective role of whole-grain, fibre-rich, low-energy-dense and low-glycaemic index/glycaemic load foods against obesity, public health professionals could drive their efforts towards the promotion of even more healthier RTEC when issuing advice on weight management. It seems, however, that despite any differences in their composition, the frequent consumption of RTEC due to their nutritional contribution is recommended in moderation and under the current recommendations in the context of a healthy balanced diet.

Folic acid intake among U.S. women aged 15-44 years, National Health and Nutrition Examination Survey, 2003-2006

BACKGROUND

In 1998, the IOM recommended all women capable of becoming pregnant consume 400 microg of folic acid daily to prevent neural tube defects (NTDs).

PURPOSE

This paper aims to describe how different sources of folic acid contribute to achieving the recommended usual daily intake.

METHODS

Data on 2617 nonpregnant U.S. women aged 15-44 years from the 2003-2004 and 2005-2006 National Health and Nutrition Examination Surveys were analyzed in 2009. The usual daily folic acid intake from diet and supplements accounting for measurement error; the proportion of women consuming the recommended usual intake; and the adjusted associations of recommended intake with multiple characteristics were estimated.

RESULTS

Overall, 24% of nonpregnant U.S. women of childbearing age consumed the recommended usual intake (95% CI=20%, 27%). Intake was highest among non-Hispanic white women (30%), followed by Mexican-American (17%) and non-Hispanic black women (9%). Among women who used supplements with folic acid, 72% (95% CI=65%, 79%) consumed the recommended usual intake. Use of supplements was the strongest determinant (unadjusted prevalence ratio [PR]: 10.2, 95% CI=7.1, 14.7) of recommended intake, mediating associations of other characteristics. Among the 68% of women who did not use supplements, consumption of cereals with folic acid and having diabetes were the strongest determinants of recommended usual intake (PRs=20.2 and 0.10, respectively).

CONCLUSIONS

Given that consumption of folic acid is an important public health goal to prevent NTDs, an evaluation of strategies, beyond recommendations that women consume supplements, is needed.

Dietary iron intake and risk of endometrial cancer: a population-based case-control study in Shanghai, China

Dietary red meat and animal fat have been linked to endometrial cancer (EC) risk, but the impact of bioavailable iron in animal-derived foods has been less well studied. Our objective was to investigate the effects of iron and fats on the risk of EC in a large, population-based, case-control study. The Shanghai Endometrial Cancer Study enrolled 1,204 EC cases and 1,212 controls who completed in-person interviews, including a food frequency questionnaire. Animal-derived iron and fat intakes were calculated from dietary intakes and food composition tables. Logistic regression models were used to evaluate independent and joint effects of iron and fat on EC risk. Animal-derived iron intake was positively associated with EC risk [adjusted OR = 1.9; 95% CI = 1.4-2.7, P(trend) < 0.01, highest vs. lowest quartile], predominantly after menopause (OR = 2.2; 95%CI = 1.4-3.4, P(trend) < 0.01) and in women with BMI >or= 25 kg/m(2)(OR = 3.2; 95% CI = 1.4-7.5 in postmenopausal obese women, P(trend) < 0.01). Animal-derived fat was also associated with postmenopausal EC risk (OR = 1.7; 95% CI = 1.2-2.5, P(trend) < 0.01). Multiplicative interactions between animal-derived iron and BMI or animal-derived fat intake were not observed. Animal-derived iron intake is associated with increased risk of EC after menopause and among obese women. Avoidance of animal-derived (heme) iron may reduce the risk of EC in these women.

Folic acid food fortification prevents inadequate folate intake among preschoolers from Ontario

Objective

Folic acid food fortification has successfully reduced neural tube defect-affected pregnancies across Canada. The effect of this uncontrolled public health intervention on folate intake among Canadian children is, however, unknown. Our objectives were to determine folic acid intake from food fortification and whether fortification promoted adequate folate intakes, and to describe folic acid-fortified food usage among Ontario preschoolers.

Design

Cross-sectional data were used from the NutriSTEP™ validation project with preschoolers recruited using convenience sampling. Mean daily total folate and folic acid intakes were estimated from 3 d food records, which included multivitamin supplement use. Comparisons were made to Dietary Reference Intakes, accounting for and excluding fortificant folic acid, to determine the prevalence of inadequate and excessive intakes.

Setting

Canada.

Subjects

Two hundred and fifty-four preschoolers (aged 3–5 years).

Results

All participants (130 girls, 124 boys) ate folic acid-fortified foods and 30 % (n76) used folic acid-containing supplements. Mean (se) fortificant folic acid intake was 83 (2) μg/d, which contributed 30 % and 50 % to total folate intake for supplement users and non-users, respectively. The prevalence of total folate intakes below the Estimated Average Requirement was <1 %; however, excluding fortificant folic acid, the prevalence was 32 %, 54 % and 47 % for 3-, 4- and 5-year-olds, respectively. The overall prevalence of folic acid (fortificant and supplemental) intakes above the Tolerable Upper Intake Level was 2 % (7 % among supplement users).

Conclusions

Folic acid food fortification promotes dietary folate adequacy and did not appear to result in excessive folic acid intake unless folic acid-containing supplements were consumed.

Ready-to-Eat Cereal Breakfasts Are Associated with Improved Nutrient Intake and Dietary Adequacy but Not Body Mass Index in Black Adolescents

The goal of this study was to determine whether nutrient intake, dietary adequacy, and weight status were associated with type of breakfast consumption: skipping breakfast, consuming ready-to-eat cereal (RTEC) at breakfast, or consuming other types of foods at breakfast. Data from black adolescents 13 to 18 years of age (n = 988) participating in the 1999-2002 National Health and Nutrition Examination Survey were used in a secondary data analysis. Thirty-seven percent of black adolescents skipped breakfast, 19% consumed RTEC at breakfast, and 44% consumed other breakfasts. RTEC breakfast and other breakfast consumers had higher mean energy intakes than breakfast skippers (P ≤ .05). After adjusting for gender and energy intake, RTEC breakfast consumers had higher intakes of thiamin, riboflavin, niacin, folate, calcium, phosphorus, magnesium, iron, zinc, potassium, and vitamins A, B6, and B12 than breakfast skippers and other breakfast consumers (P ≤ .05). RTEC breakfast consumers had the highest mean adequacy ratio, followed by other breakfast consumers, then breakfast skippers (P ≤ .05). Those consuming RTEC at breakfast had lower mean body mass index (P ≤ .05) and waist circumference (P ≤ .05) than breakfast skippers; however, there was no difference between those consuming RTEC and other breakfasts. If confirmed in prospective studies, consuming a breakfast meal with RTEC may be a useful strategy to encourage in black adolescents as a way to improve nutrient intake and dietary adequacy without increasing weight.

Is addition of iron to processed foods safe for iron replete consumers?

The great majority of US adults are iron replete; indeed, some are burdened with an excessive amount of the metal. Nevertheless, iron continues to be added by food processors to such items as flour, other grains and ready-to-eat cereals. In some cases, actual added quantities exceed the labeled amounts. Iron is a dangerous pro-oxidant as well as a mutagen and carcinogen. The metal is a serious risk factor for a variety of cardiovascular, endocrine, infectious, neoplasmic, neurodegenerative, orthopedic and respiratory diseases. For many of the conditions, iron can be a sole initiator or a cofactor in promoting the disease. For others, iron deposits are found in relevant tissue sites. For numerous additional diseases, iron is associated with elevated disease incidence. Accordingly, critical evaluation of the indiscriminate practice of adding the metal to processed foods is overdue.

Nutritional anemias and the elderly

Nutritional anemias are important because they are easily reversed and because their underlying causes, most often unrelated to dietary intake, require individualized assessment. Iron-deficiency anemia (IDA) usually results from iron losses accompanying chronic bleeding, including loss to intestinal parasites, or from gastric disorders or malabsorption in the elderly. Cobalamin-deficiency anemia, the only nutritional anemia with predilection for the elderly, nearly always stems from failure of intrinsic factor (IF)-related absorption. Folate-deficiency anemia, the only nutritional anemia usually caused by poor intake, has nearly disappeared in countries that fortify food with folic acid. Copper-deficiency anemia, which usually results from malabsorptive disorders or from medical or nutritional interventions that provide inadequate copper or excess zinc, is uncommon but increasingly recognized. The prevalences of nutritional anemias, which are not always distinguished from non-anemic deficiency, are uncertain. The mean corpuscular volume (MCV) provides an essential diagnostic tool leading to judicious matching of relevant biochemical changes with relevant anemia. Nutritional anemias usually feature abnormal MCV, whereas the predominant anemias in the aged, especially the anemias of chronic disease/chronic inflammation (ACD/ACI), of renal failure, and of unknown causes, are typically normocytic.

Nutritional deficiencies in morbidly obese patients: a new form of malnutrition? Part A: vitamins

It is a common belief that clinical vitamin or mineral deficiencies are rare in Western countries because of the low cost and unlimited diversity of food supply. However, many people consume food that is either unhealthy or of poor nutritional value that lacks proteins, vitamins, minerals, and fiber. In this, article we reviewed the literature and highlighted the vitamin deficiencies in obese patients before bariatric surgery. Deficiency of dietary minerals is described in the accompanying manuscript. The prevalence of vitamin deficiencies in the morbidly obese population prior to bariatric surgery is higher and more significant than previously believed.

Reassessing folic acid consumption patterns in the United States (1999 2004): potential effect on neural tube defects and overexposure to folate

BACKGROUND

In the United States, folic acid fortification of cereal- grain foods has significantly increased folate status. However, blood folate concentrations have decreased from their postfortification high as a result, in part, of decreasing food fortification concentrations and the popularity of low-carbohydrate weight-loss diets.

OBJECTIVES

The objectives of the study were to quantify changes in folate intake after folic acid fortification and to estimate the effect on neural tube defect (NTD) occurrence.

DESIGN

Expanding on an earlier model, we used data from 11 intervention studies to determine the relation between chronic folate intervention and changes in steady state serum folate concentrations. With serum folate data from the National Health and Nutrition Examination Survey (NHANES), we used reverse prediction to calculate postfortification changes in daily folate equivalents (DFEs). With the use of NHANES red blood cell folate data and a published equation that related NTD risk to maternal red cell folate concentrations, we calculated NTD risk.

RESULTS

Folate intake decreased by approximately 130 microg DFE/d from its postfortification high, primarily as a result of changes seen in women with the highest folate status. This decrease in folate intake was predicted to increase the incidence of NTD by 4-7%, relative to a predicted 43% postfortification decrease. In addition, the number of women consuming >1 mg bioavailable folate/d decreased.

CONCLUSIONS

Folate consumption by women of childbearing age in the United States has decreased. However, the decrease in those women with the lowest folate status was disproportionately small. Consequently, the effect on NTD risk should be less than would be seen if a uniform decrease in folate concentrations had occurred. These results reinforce the need to maintain monitoring of the way fortification is implemented.

Mandatory folic acid fortification in Newfoundland and Labrador

PURPOSE

Dietary folic acid (FA) intakes were analyzed in random samples of 302 young women (aged 18 to 34) and 337 seniors (aged 65 to 74) residing in Newfoundland and Labrador (NL). The analyses were an attempt to estimate the amount of FA they would consume solely because of mandatory fortification of foods.

METHODS

Secondary analysis was performed on raw data collected through single 24-hour recalls as part of a larger study.

RESULTS

The dietary FA contributed by fortified foods eaten in the specified amounts was estimated to be 136 to 148 mcg/day (226 to 247 DFE/day) for young women and 151 to 160 mcg/day (252 to 267 DFE/day) for seniors. Most of this FA was contributed to the diet by enriched white flour.

CONCLUSIONS

Mandatory fortification of foods appears to have improved the total mean intake of folate by young women and seniors residing in NL.

Modification of iron status in young overweight/mildly obese women by two dietary interventions designed to achieve weight loss

AIMS

To determine the modification of iron status in a group of overweight/mildly obese women following two different weight control programs.

METHODS

The study subjects were 57 women who were assigned to one of two slightly hypocaloric diets: V (increased consumption of vegetables), or C (increased consumption of cereals, especially breakfast cereals). All data were determined at the start of the study and at 2 and 6 weeks into the dietary intervention period.

RESULTS

Both diets led to a reduction in body weight and heme iron intake, and an increase in the intake of total and non-heme iron, at 2 and 6 weeks. At 6 weeks, a reduction in transferrin levels was seen in C subjects. Subjects with the worst initial iron status (hemoglobin <P25: 12.6 g/l) following C diet showed an increase of mean corpuscular hemoglobin concentration at 2 and 6 weeks and improved hemoglobin levels at 6. Also at 6 weeks, the C subjects had more erythrocytes than similar V subjects (only considering women with hemoglobin <P25: 12.6 g/l).

CONCLUSIONS

A well-designed hypocaloric diet need not entail a risk of iron deficiency. Breakfast cereals are an important source of non-heme iron and could help to improve iron status, especially in women with poor initial iron levels.

Measuring vitamins and minerals in dietary supplements for nutrition studies in the USA

This article illustrates the importance of having analytical data on the vitamin and mineral contents of dietary supplements in nutrition studies, and describes efforts to develop an analytically validated dietary supplement ingredient database (DSID) by a consortium of federal agencies in the USA. Preliminary studies of multivitamin mineral supplements marketed in the USA that were analyzed as candidates for the DSID are summarized. Challenges are summarized, possible future directions are outlined, and some related programs at the Office of Dietary Supplements, National Institutes of Health are described. The DSID should be helpful to researchers in assessing relationships between intakes of vitamins and minerals and health outcomes.

Impact of daily consumption of iron fortified ready-to-eat cereal and pumpkin seed kernels (Cucurbita pepo) on serum iron in adult women

Iron deficiency, anemia, is the most prevalent nutritional problem in the world today. The objective of this study was to consider the effectiveness of consumption of iron fortified ready-to-eat cereal and pumpkin seed kernels as two sources of dietary iron on status of iron nutrition and response of hematological characteristics of women at reproductive ages. Eight healthy female, single or non pregnant subjects, aged 20-37 y consumed 30 g of iron fortified ready-to-eat cereal (providing 7.1 mg iron/day) plus 30 g of pumpkin seed kernels (providing 4.0 mg iron/day) for four weeks. Blood samples collected on the day 20 of menstrual cycles before and after consumption and indices of iron status such as reticulocyte count, hemoglobin (Hb), hematocrit (Ht), serum ferritin, iron, total iron-binding capacity (TIBC), transferrin and transferrin saturation percent were determined. Better response for iron status was observed after consumption period. The statistical analysis showed a significant difference between the pre and post consumption phase for higher serum iron (60 +/- 22 vs. 85 +/- 23 ug/dl), higher transferrin saturation percent (16.8 +/- 8.0 vs. 25.6 +/- 9.0%), and lower TIBC (367 +/- 31 vs. 339 +/- 31 ug/dl). All individuals had higher serum iron after consumption. A significant positive correlation (r=0.981, p=0.000) between the differences in serum iron levels and differences in transferrin saturation percentages and a significant negative correlation (r=-0.916, p<0.001) between the differences in serum iron levels and differences in TIBC was found, as well. Fortified foods contribute to maintaining optimal nutritional status and minimizing the likelihood of iron insufficiencies and use of fortified ready-to-eat cereals is a common strategy. The results showed that adding another food source of iron such as pumpkin seed kernels improves the iron status. Additional and longer studies using these two food products are recommended to further determine the effect of iron fortification on iron nutrition and status among the target population, and mainly in young children, adolescents, women of reproductive ages and pregnant women.

Adaptation and evaluation of the National Cancer Institute's Diet History Questionnaire and nutrient database for Canadian populations

Background and objective

Despite assumed similarities in Canadian and US dietary habits, some differences in food availability and nutrient fortification exist. Food-frequency questionnaires designed for the USA may therefore not provide the most accurate estimates of dietary intake in Canadian populations. Hence, we undertook to evaluate and modify the National Cancer Institute's Diet History Questionnaire (DHQ) and nutrient database.

Methods

Of the foods queried on the DHQ, those most likely to differ in nutrient composition were identified. Where possible these foods were matched to comparable foods in the Canadian Nutrient File. Nutrient values were examined and modified to reflect the Canadian content of minerals (calcium, iron, zinc) and vitamins (A, C, D, thiamin, riboflavin, niacin, B6, folate and B12). DHQs completed by 13 181 Alberta Cohort Study participants aged 35–69 years were analysed to estimate nutrient intakes using the original US and modified versions of the DHQ databases. Misclassification of intake for meeting the Dietary Reference Intake (DRI) was determined following analysis with the US nutrient database.

Results

Twenty-five per cent of 2411 foods deemed most likely to differ in nutrient profile were subsequently modified for folate, 11% for vitamin D, 10% for calcium and riboflavin, and between 7 and 10% for the remaining nutrients of interest. Misclassification with respect to meeting the DRI varied but was highest for folate (7%) and vitamin A (7%) among men, and for vitamin D (7%) among women over 50 years of age.

Conclusion

Errors in nutrient intake estimates owing to differences in food fortification between the USA and Canada can be reduced in Canadian populations by using nutrient databases that reflect Canadian fortification practices.

Responsiveness of homocysteine concentrations to food and supplemental folate intakes in smokers and never‐smokers enrolled in a diet intervention trial

We investigated circulating homocysteine concentrations in relation to smoking, folate intake (from food and supplements), serum folate concentrations, and other dietary variables. The present study is part of a parent trial assessing the effects of increasing vegetable, fruit, and fiber intakes and reducing the percentage of energy obtained from fat on breast cancer recurrence in 3,088 women previously diagnosed with breast cancer. Of the 121 smokers enrolled in the parent trial, 85 were available at baseline for the present study and were randomly matched to 85 never-smokers on baseline folate intake, age, and intervention status. Follow-up data were available on 53 smokers (22 intervention and 31 comparison) and 56 never-smokers (24 intervention and 32 comparison). No significant differences in circulating homocysteine and folate concentrations were observed between smokers and never-smokers at baseline. For smokers, significant decreases in circulating homocysteine and significant increases in folate concentrations (p < .05) from baseline to 12 months were observed in the comparison group. For never-smokers, significant decreases in circulating homocysteine and significant increases in folate concentrations were observed in the intervention and comparison groups (p < .05). In the multivariate analysis, changes in serum folate concentration and supplemental folic acid were significantly associated with change in plasma homocysteine concentrations (p < .05). These findings show that increasing supplemental folic acid can reduce homocysteine concentrations, which may have implications for lowering cardiovascular disease risk for smokers and never-smokers.

Trienzyme extraction in combination with microbiologic assay in food folate analysis: an updated review

For decades, the traditional food folate extraction method involved two steps including heat treatment, to release folate from its binding proteins, and folate conjugase treatment, to hydrolyze polyglutamyl folate to monoglutamyl folate. However, a trienzyme-extraction method of food folate was developed in the mid 1990s. This method involves the use of alpha-amylase, protease, and folate conjugase and allows for a more complete extraction of folate trapped in carbohydrate or protein matrices in food than the traditional method. In the last several years, this extraction method became widely used. However, the method is not uniform among various investigators, and it may be difficult for a new investigator to select the most suitable method in his or her laboratory. Therefore, in the review presented here, we summarize a variety of trienzyme-extraction procedures that were used by various researchers and offer a recommended procedure for food folate extraction. It is our hope that the wide use of an appropriate procedure of the trienzyme-extraction method, in combination with a reasonable detection method, help in establishing accurate and reliable food-folate tables and that this, in turn, makes it possible to accurately assess folate intake in the general population.

Inter-brand differences in iron content of breakfast cereals and their impact on measurement of iron intake

BACKGROUND/AIMS

Fortified breakfast cereals (FBCs) are an important source of iron in the UK diet. In order to quantify their contribution to iron nutrition, food composition data for these products must be accurate. The very large amount of products available, together with inter-brand differences in iron content mean that discrepancies between the iron content of many FBCs and values in standard food composition databases (FCD) exist. The variation in reported iron contents of FBCs was examined and the impact of this variation on measurement of iron intake using standard food composition tables was investigated.

METHOD

Data on the reported iron content of 128 FBCs were collected. Completed food diaries from 291 participants of the UK Women's Cohort study were used in the analysis. Mean iron intake from a 4-day food diary was calculated using UK food tables' values for FBCs. This was repeated using values reported by the manufacturer for each brand of cereal. The two sets of results were then compared.

RESULTS

There is wide variation in iron content of breakfast cereals available in the United Kingdom. Use of FCD values instead of brand-specific values under- or overestimates an individual's iron intake by as much as 28 or 22% respectively. These results suggest that use of FCD values for breakfast cereals is potentially a source of substantial error in measurement of individuals' iron intake.

CONCLUSION

Dietitians need to be aware of inter-brand differences in iron content and formulate advice accordingly. Failure to collect brand-specific data for the iron content of FBCs could lead to measurement error in measuring iron intake in dietary studies.

Fortifying food with folic acid improves folate intake in German infants, children, and adolescents

Folate is a critical nutrient and programs to enhance folate intake have been established or are under consideration. We investigated to what extent consumers (C) profit from folic acid-fortified food and dietary supplements compared to nonconsumers (NC) of these products. A total of 6135 weighed records from 861 subjects (47% males, 53% females, age 6 mo to 18 y) from the Dortmund Nutritional and Anthropometric Longitudinally Designed Study between 1990 and 2001 were evaluated. In 61% of the records, at least 1 item fortified with folic acid was reported, and in total 644 different items with a wide range of fortification levels were found. These were primarily commercial infant food (i.e., infant formula, weaning food) (44%), breakfast cereals (20%), and soft drinks (11%). Median dietary folate equivalents (DFEs) in NC increased from 65 and 62 microg/d in boys and girls at 6-12 mo of age, respectively, to 184 and 143 microg/d in adolescents 15-18 y of age. In C, DFEs increased from 109 and 100 microg/d in boys and girls at 6-12 mo of age, respectively, to 370 and 276 microg/d in adolescents 15-18 y of age. Irrespective of gender, NC had 50-70% the DFE intakes of C with a tendency for higher percentages in younger than in older children and adolescents. Folate intakes by male and female consumers of fortified food or supplements exceeded the upper levels in 1.7 and 1.2% of subjects, respectively. Currently, a fortification program for staple foods (e.g., grain products) does not seem necessary in Germany if children and adolescents consume food already fortified with folic acid.

Micronutrient intakes, micronutrient status and lipid profiles among young people consuming different amounts of breakfast cereals: further analysis of data from the National Diet and Nutrition Survey of Young People aged 4 to 18 years

OBJECTIVE

To examine associations between breakfast cereal consumption and the dietary habits, nutrient intakes and nutritional status of young people, considering both nutrient adequacy and safety issues (fortification).

METHODS

Using archived data from 1688 children in the (British) National Diet and Nutrition Survey of Young People aged 4 to 18 years, nutrient intakes and status were compared across thirds of breakfast cereal consumption (T1 to T3), adjusted for age and energy intake. Cereals provided on average 2%, 6% and 12% of energy in T1, T2 and T3, respectively, for boys; 1%, 4% and 10%, respectively, for girls.

RESULTS

Intakes of iron, B vitamins and vitamin D were around 20-60% higher in T3 compared with T1, with significant linear relationships observed for iron, thiamin, riboflavin and folate (T1<T2<T3). After excluding low energy reporters and the unwell, 14% of girls had iron intakes below the Lower Reference Nutrient Intake and this varied fivefold between T1 and T3 (27%, 12% and 5%; P=0.0001). High consumers of breakfast cereals (T3) had better folate, vitamin B12 and riboflavin status and lower total and low-density lipoprotein cholesterol. There was also an association with thiamin and vitamin B6 status in girls. However, iron status (haemoglobin, ferritin and transferrin saturation) was not significantly different between groups, possibly due to lower meat intakes in T3. Total iron intakes were within tolerable levels (maximum of 32 mg day(-1) in one girl taking supplements).

CONCLUSIONS

The nutritional benefits of breakfast cereals are demonstrated in status measurements as well as in nutrient intakes in this study. Concerns about excessive iron intakes from fortification appear unjustified.

Consumption of folic acid-fortified bread improves folate status in women of reproductive age in Chile

Since January 2000 the Chilean Ministry of Health has required the fortification of wheat flour with folic acid (FA) at a concentration of 2.2 mg FA/kg in order to reduce the risk of neural tube defects (NTD) in newborns. This policy was expected to result in a mean additional intake of approximately 400 microg FA/d. We assessed the effectiveness of the FA flour fortification program on bread folate content and on blood folate concentration in women of childbearing age in Santiago, Chile. The prefortification folate status of 751 healthy women of reproductive age was assessed. The folate content of 100 bread samples bought at retail bakeries was measured, average wheat flour consumption was estimated and postfortification FA dietary intake was calculated. The effect of flour fortification on blood folate concentration in this group of women (n = 605) was evaluated in a follow-up study. Blood folate concentrations of the 605 women in the follow-up group increased (P < 0.0001) following fortification. Before fortification the mean serum and red blood cell folate concentrations were 9.7 +/- 4.3 and 290 +/- 102 nmol/L, respectively, compared with 37.2 +/- 9.5 and 707 +/- 179 nmol/L postfortification, respectively. The mean FA content of bread was 2020 +/- 940 micro g/kg. The median FA intake of the group evaluated postfortification was 427 microg/d (95% CI 409-445) based on an estimated intake of 219 g/d (95% CI 201-229) of wheat flour, mainly as bread. Fortification of wheat flour substantially improved folate status in a population of women of reproductive age in Chile. The effect of the FA fortification program on the occurrence of NTD is currently being assessed.

Folate: a key to optimizing health and reducing disease risk in the elderly

Inadequate folate status is associated with an increased risk for chronic diseases that may have a negative impact on the health of the aging population. Folate, a water-soluble vitamin, includes naturally occurring food folate and synthetic folic acid in supplements and fortified foods. Inadequate folate status may result in hyperhomocysteinemia, a significant risk factor for atherosclerotic vascular disease, changes in DNA that may result in pro-carcinogenic effects and increased risk for cognitive dysfunction. Folate status may be negatively influenced by inadequate intake, genetic polymorphisms and interactions with various drugs. In the US, folic acid is now added to enriched grain products and continues to be included in the majority of ready-to-eat breakfast cereals. Recent data indicate that the folate status in the US population has improved significantly, presumably due to the effects of fortification. Folic acid (not food folate) intake in excess of the Tolerable Upper Intake Level may mask the diagnosis of a vitamin B(12) deficiency, which is more prevalent in the elderly than younger individuals. When folic acid supplements are recommended, a multivitamin that includes vitamin B(12) should also be advised. To safely and effectively increase folate intake in the elderly, naturally occurring folate-rich food sources should be promoted. Folate-rich foods include orange juice, dark green leafy vegetables, asparagus, strawberries and legumes. These foods are also excellent sources of other health-promoting nutrients associated with chronic disease risk reduction.

Effect of food fortification on folic acid intake in the United States

BACKGROUND

The addition of folic acid to all enriched cereal-grain foods, mandated by the Food and Drug Administration (FDA), was initiated in January 1998. Although this program was designed such that typical folate intakes would be increased by approximately 100 micro g/d and that the risk of intakes > 1000 micro g/d (the FDA's safe upper limit of daily intake) would be minimal, its actual effect on folate intake has yet to be determined.

OBJECTIVE

The objective was to estimate the effect of folic acid fortification on the amount of folate consumed by persons in the United States.

DESIGN

Linear regression analysis of data from published studies was used to determine the relation between a chronic folic acid dose and the resulting increase in steady state concentrations of folate in plasma or serum. Using this regression equation and reverse prediction, we quantified the increase in folic acid intake from fortification required to achieve the increase in plasma or serum folate observed in published studies.

RESULTS

The increase in circulating folate concentration was linearly related to folic acid intake over the range of 100-1000 micro g/d (r = 0.984, P < 0.0001). Predicted increases in folic acid intake from fortified food ranged from 215 to 240 micro g/d.

CONCLUSIONS

Typical intakes of folic acid from fortified foods are more than twice the level originally predicted. The effect of this much higher level of fortification must be carefully assessed, especially before calls for higher levels of fortification are considered.