Triple fortification of salt with microcapsules of iodine, iron, and vitamin A

Modeling the Contribution of Multiple Micronutrient Fortification of Salt to Daily Nutrient Intake Among the Ethiopian Population

Background

Salt is an affordable commodity and has wide coverage regardless of economic and social status and, hence, could be suitable vehicle for multiple micronutrient fortification.

Objectives

This study aimed to simulate the contribution folic acid and zinc fortification of iodized salt to nutrient intake among the Ethiopian population.

Methods

The 2013 Ethiopian National Food Consumption Survey and various food composition tables were used to estimate baseline individual-level micronutrient intake. Usual intake was estimated using the Simulating Intake of Micronutrients for Policy Learning and Engagement macro tool. Discretionary salt consumption was calculated from total salt intake estimated using urinary sodium excretion. Fortificant addition rates were set to obtain maximum nutrient intake while simultaneously constraining that population with intake above the tolerable upper intake level to <5%. Addis Ababa and Somali (N = 2271), the regions with relatively the lowest and highest micronutrient deficiency prevalence in Ethiopia, were selected.

Result

Baseline median intake of Zn was below the estimated average requirement for all demographic groups. Inadequate Zn intake ranged from 73% to 99%, the highest prevalence being observed among women in lower class of wealth quintiles from Somali region. Dietary folate inadequacy was as low as 2% among men in Addis Ababa but almost all (99%) women from Somali region had inadequate folate intake. Calculated discretionary salt intake was 7.5 g/d for adult men and women and 3.4 g/d for children. With addition 0.8 mg Zn and 30 μg of folic acid per gram of salt, multiple salt fortification is estimated to reduce Zn inadequacy by 38 percentage points in urban areas and19 percentage points in rural areas. Modeled reduction in folate inadequacy were 18% in urban areas and 22% in rural areas.

Conclusions

Multiple salt fortification could be an effective approach to address micronutrient adequacy in Ethiopia given efficacious, technological, and economical feasibility.

The relationship between maternal thyroid volume, TSH levels, and Healthy Eating Index scores in BMI-matched pregnant women with hyperemesis gravidarum

OBJECTIVE

The aim is to investigate the relationship between thyroid volume measurement and healthy nutrition questionnaire scoring in pregnant women diagnosed with hyperemesis gravidarum (HEG).

METHODS

One hundred and fifty pregnant women with a BMI of 15-25 kg/m² and between the ages of 17 and 42 who were diagnosed with HEG at 11-14 weeks of gestation were included in the study. Patients with a history of any disease, drug use, and previously diagnosed eating disorders were excluded. All patients were subjected to the Healthy Eating Index (HEI) questionnaire. The cutoff value for HEI score was determined as 80 points. Patients were evaluated in two groups: group 1 (HEI <80 score) and group 2 (HEI ≥80 score). Complete urine analysis including ketonuria, and thyroid function tests including TSH, T3, and T4 levels were performed for all patients. In addition, the thyroid gland volume of every patient was measured by the same radiologist.

RESULTS

Increased thyroid gland volume was significantly associated with lower TSH levels (p = .02) and lower HEI scores (p < .001). On the other hand, it was not significantly associated with ketonuria (p = .47), and parity status (p = .82).

CONCLUSIONS

In our study, we found that there may be an increase in thyroid volume in pregnant women with HEG with lower TSH levels and eating scores. Thyroid volume may predict the patients with probable eating disorders and further studies on thyroid volume in patients with HEG may contribute to the literature.

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.

Preparation and characterization of an iron-β-cyclodextrin inclusion complex: factors influencing the host-guest interaction

Cyclodextrins have received attention recently due to their superior binding with countless hydrophobic molecules. The host-guest interaction between the cyclodextrin cavity and the hydrophobic component not only facilitates the formation of a strong inclusion complex (IC), but also improves its stability against thermal degradation. The functionality of cyclodextrins for the delivery of hydrophilic components is less explored in comparison. This study discusses the application of β-cyclodextrin (βCD) for the delivery of highly bioavailable and hydrophilic iron, ferric sodium EDTA, which exhibits great functionality in the presence of polyphenols and phytates with potential application in food fortification. The formation of IC was dependent on the cyclodextrin amount and alcoholic co-solvent and was influenced by the stirring duration. For ferric sodium EDTA, the highest inclusion rate (IR) of ∼77% was obtained after 72 hours of mixing in 25.4% (v/v) alcohol at a ratio of iron : βCD of 1 : 6. A higher IR (∼96%) was obtained after 6 hours of stirring with less soluble ferrous ammonium phosphate in comparison. The melting temperature (T_m) of the ferrous ammonium phosphate complex increased from ∼172 to ∼294 °C. The high IR and enhanced thermal resistance of the complex make βCDs potential carriers for ferrous ammonium phosphate delivery and fortification of foods processed at high temperatures.

Optimizing Growth: The Case for Iodine

Iodine is an essential micronutrient and component of thyroid hormone. An adequate dietary iodine intake is critical to maintain and promote normal growth and development, especially during vulnerable life stages such as pregnancy and early infancy. The role of iodine in cognitive development is supported by numerous interventional and observational studies, and when iodine intake is too low, somatic growth is also impaired. This can be clearly seen in cases of untreated congenital hypothyroidism related to severe iodine deficiency, which is characterized, in part, by a short stature. Nevertheless, the impact of a less severe iodine deficiency on growth, whether in utero or postnatal, is unclear. Robust studies examining the relationship between iodine and growth are rarely feasible, including the aspect of examining the effect of a single micronutrient on a process that is reliant on multiple nutrients for optimal success. Conversely, excessive iodine intake can affect thyroid function and the secretion of optimal thyroid hormone levels; however, whether this affects growth has not been examined. This narrative review outlines the mechanisms by which iodine contributes to the growth process from conception onwards, supported by evidence from human studies. It emphasizes the need for adequate iodine public health policies and their robust monitoring and surveillance, to ensure coverage for all population groups, particularly those at life stages vulnerable for growth. Finally, it summarizes the other micronutrients important to consider alongside iodine when seeking to assess the impact of iodine on somatic growth.

Optimization of the color masking and coating unit operations for microencapsulating ferrous fumarate for double fortification of salt

A new coating formulation was developed to eliminate the factor that caused black spots on the iron premix surface, used for making Double Fortified Salt. The formulation is a suspension of titanium dioxide in soy stearin, prepared with ethanol and dichloromethane and applied with a glass sprayer and pan coater. 0–20% ^w/_w titanium dioxide was suspended in 10% ^w/_w soy stearin/hydroxypropyl methylcellulose. Coating with a suspension of 15% ^w/_w TiO₂ in 10% ^w/_w soy stearin ensured that all the TiO₂ adheres to the premix surface, giving no chance for the recycling of iron contaminated TiO₂, which caused the black spot. The new coating formulation ensured that over 90% iodine in Double Fortified Salt was retained after 6 months at 45 °C, 60–70% RH. The whiteness of the premix (L* = 86.4) matched the Double Fortified Salt whiteness (L* = 86.8). Thus, making the new coating method as effective as the previous in desirable characteristics. More so, the new coating method simplifies the existing method by merging the previous color masking, and double coating steps into one step.

Vitamin A fortification: Recent advances in encapsulation technologies

Vitamin A is an essential micronutrient whose deficiency is still a major health concern in many regions of the world. It plays an essential role in human growth and development, immunity, and vision, but may also help prevent several other chronic diseases. The total amount of vitamin A in the human diet often falls below the recommended dietary allowance of approximately 900-1000 μ $ \umu $ g/day for a healthy adult. Moreover, a significant proportion of vitamin A may be degraded during food processing, storage, and distribution, thereby reducing its bioactivity. Finally, the vitamin A in some foods has a relatively low bioavailability, which further reduces its efficacy. The World Health Organization has recommended fortification of foods and beverages as a safe and cost-effective means of addressing vitamin A deficiency. However, there are several factors that must be overcome before effective fortified foods can be developed, including the low solubility, chemical stability, and bioavailability of this oil-soluble vitamin. Consequently, strategies are required to evenly disperse the vitamin throughout food matrices, to inhibit its chemical degradation, to avoid any adverse interactions with any other food components, to ensure the food is palatable, and to increase its bioavailability. In this review article, we discuss the chemical, physical, and nutritional attributes of vitamin A, its main dietary sources, the factors contributing to its current deficiency, and various strategies to address these deficiencies, including diet diversification, biofortification, and food fortification.

Valorizing okara waste into nutritionally rich polysaccharide/protein-extracts for co-encapsulation of β-carotene and ferrous sulphate as a potential approach to tackle micronutrient malnutrition

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Okara was upcycled into encapsulation materials using microwave assisted technique.

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Okara and zein as excipient used as encapsulation substrate for micronutrients.

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The formulation produced desirable sequential release of micronutrients in SGF and SIF.

Colossal amounts of food waste are generated and discarded daily at the expense of financial resources and at a detriment to the environment. One such food waste, okara – a soybean by-product, is valorized in this study by upcycling it into nutritional extracts for micronutrients encapsulation. Micronutrient malnutrition, particularly in the developing world, is a major public health challenge. Herein, okara extracts were obtained through a low-cost extraction process and was subsequently developed as an encapsulant material for micronutrients β-carotene, and ferrous sulphate encapsulation, using zein as an excipient. Spray-drying, as a scalable technique, was employed to produce various formulations which were assessed for release profiles, shelf-life, β-carotene antioxidant activity and cell cytotoxicity. Finally, an optimized dual-micronutrient formulation displayed a sequential release with ferrous sulphate releasing in simulated gastric fluid, and β-carotene releasing predominantly in simulated intestinal fluid. This sequential release profile favors the absorption of both the micronutrients and could potentially enhance their bioavailability.

Folic acid fortification of double fortified salt

The addition of folic acid to Double Fortified Salt (with iron and iodine) aims to simultaneously ameliorate three major micronutrient deficiencies in vulnerable populations. To make Triple Fortified Salt, we added folic acid to the iodine solution (first method) and the iron premix (second method) that are used to fortify salt with iron and iodine. When added through the solution, sodium carbonate was needed to dissolve folic acid and to adjust pH. Alternately, folic acid was added either to the iron core or sandwiched between the core and TiO₂ layer of the iron premix. Folic acid and iodine were stable in all cases, retaining more than 70% of the added micronutrients after six months at 45 °C/60-70% relative hu. Adding folic acid to the premix's iron core is preferred as folic acid retention was slightly higher, and the added folic acid did not impact the salt's colour. The additional cost for adding the micronutrients to salt is about 27¢/person per year. Folic acid in the fortified salt made with the preferred method was stable in cooking and did not affect selected cooked foods' sensory properties. The technology is a cost-effective approach for simultaneously combating iron, iodine, and folic acid deficiencies.

Iron supplementation and iron-fortified foods: a review

About one-third of the world population is suffering from iron deficiency. Delivery of iron through diet is a practical, economical, and sustainable approach. Clinical studies have shown that the consumption of iron-fortified foods is one of the most effective methods for the prevention of iron deficiency. However, supplementing iron through diet can cause undesirable side-effects. Thus, it is essential to develop new iron-rich ingredients, iron-fortified products with high bioavailability, better stability, and lower cost. It is also essential to develop newer processing technologies for more effective fortification. This review compared the iron supplementation strategies used to treat the highly iron-deficient population and the general public. We also reviewed the efficacy of functional (iron-rich) ingredients that can be incorporated into food materials to produce iron-fortified foods. The most commonly available foods, such as cereals, bakery products, dairy products, beverages, and condiments are still the best vehicles for iron fortification and delivery.Scope of reviewThe manuscript aims at providing a comprehensive review of the latest publications that cover three aspects: administration routes for iron supplementation, iron-rich ingredients used for iron supplementation, and iron-fortified foods.

Lesser mealworm (Alphitobius diaperinus) powder as a novel baking ingredient for manufacturing high-protein, mineral-dense snacks

Increasing interest in consuming foods that are high in protein, vitamin, amino acid, and mineral contents is steering growth in the market for fortified snacks. The aim of the present study was to evaluate the use of lesser mealworm (Alphitobius diaperinus) powder (LP) (at 10 or 30% substitution for wheat flour) for the protein and mineral fortification of crunchy snacks (rusks). Hence, the technological, microbiological, nutritional, and sensory characteristics of the fortified rusks were evaluated. The protein content was enriched up to 99.3% in rusks with 30% substitution; moreover, a notable increase in the essential amino acids content was observed, with histidine fortification reaching up to 129.1% in rusks with 30% substitution. The incorporation of LP has led to an enrichment of almost all the minerals considered here, and especially Fe, P and Zn, with Zn showing fortification percentages of up to 300% in rusks with 30% substitution for LP. The experimental rusks showed pleasant sensory traits and low a_w values. In view of the potential industrial manufacturing of insect-based rusks, the proposed product can be assigned to level 4 (validation in a laboratory environment) of the Technology Readiness Level (TRL) scale, and it is thus ready to be tested in a simulated production environment.

Performance Factors Influencing Efficacy and Effectiveness of Iron Fortification Programs of Condiments for Improving Anemia Prevalence and Iron Status in Populations: A Systematic Review

Iron fortification of staple foods is a common practice around the world to reduce the prevalence of iron-deficiency anemia. More recently, fortified condiments, including salts, sauces, and powders, have been tested in various efficacy trials. However, there is limited information on how nutritional, environmental, and experimental factors affect their efficacy and effectiveness. The purpose of the present work was to systematically review performance factors affecting the efficacy of condiment fortification trials. Three databases were searched using a standardized keyword search and included based on four-point inclusion criteria. Studies were evaluated against a quality assessment tool and effect sizes were calculated. Studies were ranked as low or high performing, based on whether or not they significantly improved iron-deficiency outcomes (hemoglobin, anemia prevalence, and ferritin levels). Of the 955 retrieved studies, 23 were included-of which, nine performed poorly, eight performed highly, and six were classified as neither because they did not meet the criteria of assessing the three iron outcomes. Results showed that unsuccessful trials did not consider environmental factors such as parasitic infections, nutritional factors such as micronutrient deficiencies other than iron, consumer acceptability of the product or experimental factors such as monitoring and adherence to the trials. Two common performing factors identified among those studies performing highly vs. those that did not were the control of sensory changes and monitoring of consumption compliance (i.e., dose delivery). The present work can be used as decision-making support for nutrition policy makers when determining the appropriate implementation of condiment fortification programs.

Food fortification with multiple micronutrients: impact on health outcomes in general population

BACKGROUND

Vitamins and minerals are essential for growth and maintenance of a healthy body, and have a role in the functioning of almost every organ. Multiple interventions have been designed to improve micronutrient deficiency, and food fortification is one of them.

OBJECTIVES

To assess the impact of food fortification with multiple micronutrients on health outcomes in the general population, including men, women and children.

SEARCH METHODS

We searched electronic databases up to 29 August 2018, including the Cochrane Central Register of Controlled Trial (CENTRAL), the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register and Cochrane Public Health Specialised Register; MEDLINE; Embase, and 20 other databases, including clinical trial registries. There were no date or language restrictions. We checked reference lists of included studies and relevant systematic reviews for additional papers to be considered for inclusion.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-RCTs, quasi-randomised trials, controlled before-after (CBA) studies and interrupted time series (ITS) studies that assessed the impact of food fortification with multiple micronutrients (MMNs). Primary outcomes included anaemia, micronutrient deficiencies, anthropometric measures, morbidity, all-cause mortality and cause-specific mortality. Secondary outcomes included potential adverse outcomes, serum concentration of specific micronutrients, serum haemoglobin levels and neurodevelopmental and cognitive outcomes. We included food fortification studies from both high-income and low- and middle-income countries (LMICs).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened, extracted and quality-appraised the data from eligible studies. We carried out statistical analysis using Review Manager 5 software. We used random-effects meta-analysis for combining data, as the characteristics of study participants and interventions differed significantly. We set out the main findings of the review in 'Summary of findings' tables, using the GRADE approach.

MAIN RESULTS

We identified 127 studies as relevant through title/abstract screening, and included 43 studies (48 papers) with 19,585 participants (17,878 children) in the review. All the included studies except three compared MMN fortification with placebo/no intervention. Two studies compared MMN fortification versus iodised salt and one study compared MMN fortification versus calcium fortification alone. Thirty-six studies targeted children; 20 studies were conducted in LMICs. Food vehicles used included staple foods, such as rice and flour; dairy products, including milk and yogurt; non-dairy beverages; biscuits; spreads; and salt. Fourteen of the studies were fully commercially funded, 13 had partial-commercial funding, 14 had non-commercial funding and two studies did not specify the source of funding. We rated all the evidence as of low to very low quality due to study limitations, imprecision, high heterogeneity and small sample size. When compared with placebo/no intervention, MMN fortification may reduce anaemia by 32% (risk ratio (RR) 0.68, 95% confidence interval (CI) 0.56 to 0.84; 11 studies, 3746 participants; low-quality evidence), iron deficiency anaemia by 72% (RR 0.28, 95% CI 0.19 to 0.39; 6 studies, 2189 participants; low-quality evidence), iron deficiency by 56% (RR 0.44, 95% CI 0.32 to 0.60; 11 studies, 3289 participants; low-quality evidence); vitamin A deficiency by 58% (RR 0.42, 95% CI 0.28 to 0.62; 6 studies, 1482 participants; low-quality evidence), vitamin B2 deficiency by 64% (RR 0.36, 95% CI 0.19 to 0.68; 1 study, 296 participants; low-quality evidence), vitamin B6 deficiency by 91% (RR 0.09, 95% CI 0.02 to 0.38; 2 studies, 301 participants; low-quality evidence), vitamin B12 deficiency by 58% (RR 0.42, 95% CI 0.25 to 0.71; 3 studies, 728 participants; low-quality evidence), weight-for-age z-scores (WAZ) (mean difference (MD) 0.1, 95% CI 0.02 to 0.17; 8 studies, 2889 participants; low-quality evidence) and weight-for-height/length z-score (WHZ/WLZ) (MD 0.1, 95% CI 0.02 to 0.18; 6 studies, 1758 participants; low-quality evidence). We are uncertain about the effect of MMN fortification on zinc deficiency (RR 0.84, 95% CI 0.65 to 1.08; 5 studies, 1490 participants; low-quality evidence) and height/length-for-age z-score (HAZ/LAZ) (MD 0.09, 95% CI 0.01 to 0.18; 8 studies, 2889 participants; low-quality evidence). Most of the studies in this comparison were conducted in children. Subgroup analyses of funding sources (commercial versus non-commercial) and duration of intervention did not demonstrate any difference in effects, although this was a relatively small number of studies and the possible association between commercial funding and increased effect estimates has been demonstrated in the wider health literature. We could not conduct subgroup analysis by food vehicle and funding; since there were too few studies in each subgroup to draw any meaningful conclusions. When we compared MMNs versus iodised salt, we are uncertain about the effect of MMN fortification on anaemia (R 0.86, 95% CI 0.37 to 2.01; 1 study, 88 participants; very low-quality evidence), iron deficiency anaemia (RR 0.40, 95% CI 0.09 to 1.83; 2 studies, 245 participants; very low-quality evidence), iron deficiency (RR 0.98, 95% CI 0.82 to 1.17; 1 study, 88 participants; very low-quality evidence) and vitamin A deficiency (RR 0.19, 95% CI 0.07 to 0.55; 2 studies, 363 participants; very low-quality evidence). Both of the studies were conducted in children. Only one study conducted in children compared MMN fortification versus calcium fortification. None of the primary outcomes were reported in the study. None of the included studies reported on morbidity, adverse events, all-cause or cause-specific mortality.

AUTHORS' CONCLUSIONS

The evidence from this review suggests that MMN fortification when compared to placebo/no intervention may reduce anaemia, iron deficiency anaemia and micronutrient deficiencies (iron, vitamin A, vitamin B2 and vitamin B6). We are uncertain of the effect of MMN fortification on anthropometric measures (HAZ/LAZ, WAZ and WHZ/WLZ). There are no data to suggest possible adverse effects of MMN fortification, and we could not draw reliable conclusions from various subgroup analyses due to a limited number of studies in each subgroup. We remain cautious about the level of commercial funding in this field, and the possibility that this may be associated with higher effect estimates, although subgroup analysis in this review did not demonstrate any impact of commercial funding. These findings are subject to study limitations, imprecision, high heterogeneity and small sample sizes, and we rated most of the evidence low to very low quality. and hence no concrete conclusions could be drawn from the findings of this review.

Iodine deficiency status in the WHO Eastern Mediterranean Region: a systematic review

Iodine deficiency is a global public health issue because iodine plays a major role in the thyroid hormone synthesis and is essential for normal neurological development. This review summarizes the publications on iodine status in the WHO Eastern Mediterranean Region (EMR) countries. All related studies available in main national and international databases were systematically searched using some specific keywords to find article published between 1909 and 2015. The prevention of iodine deficiency disorders (IDDs) in the WHO EMR countries is currently under control without significant side effects. Mild to severe IDDs exist in some countries of the Middle East, due to lack of effective iodine supplementation program, but the Islamic Republic of Iran, Jordan, Bahrain and Tunisia have achieved the goal of universal salt iodization. Overall, despite enormous efforts to control IDDs, still IDD remains a serious public health problem in some countries of the region, requiring urgent control and prevention measures.

Subclinical inflammation influences the association between vitamin A- and iron status among schoolchildren in Ghana

BACKGROUND AND OBJECTIVE

In resource-poor settings, micronutrient deficiencies such as vitamin A deficiency may co-exist with iron-deficiency. In this study we assessed the iron and vitamin A status of schoolchildren and the association between vitamin A and iron status.

METHODS

A cross-sectional design using the baseline data of a dietary intervention trial conducted among randomly selected 5-12 years old schoolchildren (n = 224) from 2 rural schools in northern Ghana. Hemoglobin (Hb), serum ferritin (SF) and serum transferrin receptor (sTfR) concentrations were used as measures of iron status. Retinol binding protein (RBP) was used as a measure of vitamin A status. Subclinical inflammation (SCI) was measured using C-reactive protein (CRP) and α1-acid glycoprotein (AGP) concentrations. We examined the cross-sectional association between vitamin A and iron status biomarkers with multiple linear regressions.

RESULTS

The proportions of schoolchildren with anemia (WHO criteria), iron-deficiency (ID, SF <15μg/l and/or sTfR >8.5mg/l) and iron-deficiency anemia (IDA, concurrent anemia and ID) were 63.8%, 68.3% and 46.4% respectively. Low or marginal vitamin A status (0.70 μmol/l ≤ RBP < 1.05μmol/l) was present in 48.2% while 37.5% of the schoolchildren had vitamin A deficiency (VAD, RBP <0.70 μmol/l). The prevalence of SCI as well as concurrent VAD and ID were 48.7% and 25% respectively. RBP was associated with Hb (β = 7.2, P = 0.05) but not SF (β = 20.7, P = 0.33) and sTfR concentration (β = 12.0, P = 0.63). In the presence of SCI, RBP was not associated with hemoglobin status but a significant positive association was observed among children without SCI.

CONCLUSIONS

The study shows that RBP is significantly associated with Hb concentration but not with SF and sTfR. The observed relationship between RBP and Hb is only significant in the absence of SCI.

Sodium pyrophosphate enhances iron bioavailability from bouillon cubes fortified with ferric pyrophosphate

Fe fortification of centrally manufactured and frequently consumed condiments such as bouillon cubes could help prevent Fe deficiency in developing countries. However, Fe compounds that do not cause sensory changes in the fortified product, such as ferric pyrophosphate (FePP), exhibit low absorption in humans. Tetra sodium pyrophosphate (NaPP) can form soluble complexes with Fe, which could increase Fe bioavailability. Therefore, the aim of this study was to investigate Fe bioavailability from bouillon cubes fortified with either FePP only, FePP+NaPP, ferrous sulphate (FeSO4) only, or FeSO4+NaPP. We first conducted in vitro studies using a protocol of simulated digestion to assess the dialysable and ionic Fe, and the cellular ferritin response in a Caco-2 cell model. Second, Fe absorption from bouillon prepared from intrinsically labelled cubes (2·5 mg stable Fe isotopes/cube) was assessed in twenty-four Fe-deficient women, by measuring Fe incorporation into erythrocytes 2 weeks after consumption. Fe bioavailability in humans increased by 46 % (P<0·005) when comparing bouillons fortified with FePP only (4·4 %) and bouillons fortified with FePP+NaPP (6·4 %). Fe absorption from bouillons fortified with FeSO4 only and with FeSO4+NaPP was 33·8 and 27·8 %, respectively (NS). The outcome from the human study is in agreement with the dialysable Fe from the in vitro experiments. Our findings suggest that the addition of NaPP could be a promising strategy to increase Fe absorption from FePP-fortified bouillon cubes, and if confirmed by further research, for other fortified foods with complex food matrices as well.

Bioavailability of iron, vitamin A, zinc, and folic acid when added to condiments and seasonings

Seasonings and condiments can be candidate vehicles for micronutrient fortification if consumed consistently and if dietary practices ensure bioavailability of the nutrient. In this review, we identify factors that may affect the bioavailability of iron, vitamin A, zinc, and folic acid when added to seasonings and condiments and evaluate their effects on micronutrient status. We take into consideration the chemical and physical properties of different forms of the micronutrients, the influence of the physical and chemical properties of foods and meals to which fortified seasonings and condiments are typically added, and interactions between micronutrients and the physiological and nutritional status of the target population. Bioavailable fortificants of iron have been developed for use in dry or fluid vehicles. For example, sodium iron ethylenediaminetetraacetic acid (NaFeEDTA) and ferrous sulfate with citric acid are options for iron fortification of fish and soy sauce. Furthermore, NaFeEDTA, microencapsulated ferrous fumarate, and micronized elemental iron are potential fortificants in curry powder and salt. Dry forms of retinyl acetate or palmitate are bioavailable fortificants of vitamin A in dry candidate vehicles, but there are no published studies of these fortificants in fluid vehicles. Studies of zinc and folic acid bioavailability in seasonings and condiments are also lacking.

Fortification of instant coffee beverages - influence of functional ingredients, packaging material and storage time on physical properties of newly formulated, enriched instant coffee powders

BACKGROUND

Consumer demands for healthy, functional foods are growing rapidly nowadays. Coffee, as one of the most widespread commodities, represents an interesting aspect for enrichment, since it is consumed by millions of people on a daily basis. The aim of this study was to formulate enriched instant coffee powders with the purpose of estimating the influence of storage time, functional ingredients and packaging material on physical and sensory properties of the mixtures.

RESULTS

Storage time of 6 months significantly (P <0.05) influenced moisture content of the mixtures, which rose linearly with an increase in storage time. Packaging material proved to be an important variable affecting moisture content, particle size, colour and cohesion index. Functional ingredients (vitamins A and C, iron, inulin and oligofructose) influenced particle size, dispersibility, wettability and, in terms of sensory analysis, grades for aftertaste, chemical taste and overall acceptability.

CONCLUSION

Addition of functional ingredients significantly influenced some particle size distribution parameters and reconstitution properties, causing an increase in wettability and dispersibility times. Furthermore, in sensory terms, it influenced aftertaste and chemical taste grades. Packaging material significantly influenced moisture content, some particle size distribution parameters, colour and cohesion index.

Food-grade submicrometer particles from salts prepared using ethanol-in-oil mixtures

A simple method for preparing food-grade particles in the submicrometer range of ethanol soluble salts using ethanol-in-oil (E/O) mixtures is described. Salts CaCl2·2H2O and MgCl2·6H2O were dissolved in ethanol that subsequently was mixed with a medium-chain triglyceride oil phase. It was found that type and concentration of salt have a significant influence on the miscibility of ethanol and oil phase and on the stability of E/O mixtures. The ethanol phase was evaporated from the mixture at elevated temperatures, and salt particles with dimensions in the submicrometer range (6-400 nm) remained suspended in the oil phase. It was found that the concentration of salt and volume fraction of ethanol in MCT oil have a significant influence on the size distribution of salt particles. The size of CaCl2 and MgCl2 submicrometer particles was ascertained by scanning electron microscopy and dynamic light scattering.

The use and interpretation of serum retinol distributions in evaluating the public health impact of vitamin A programmes

Objective

Developing countries have adopted universal, high-potency vitamin A (VA) supplementation and food fortification as major strategies to control deficiency, prevent nutritional blindness and reduce child mortality. Yet questions persist regarding how best to measure impact and when to phase out supplementation. The present paper provides guidance on the use and interpretation of serum retinol (SROL) distributions as indicators of both programme impact and adequate VA intake in a population.

Design

We reviewed extant data on SROL's response to high-potency VA supplementation and VA-fortified foods in children.

Results

Supplementation virtually eliminates xerophthalmia and reduces child mortality; however, it shifts the SROL distribution only transiently (<2 months). Regular consumption of VA-fortified foods prevents xerophthalmia, lowers mortality and sustainably improves SROL distributions, from which both compliance and public health impact can be inferred.

Conclusions

Given SROL's limited responsiveness to high-potency VA supplementation, target population coverage remains the preferred performance indicator. However, periodic SROL surveys do reflect underlying dietary risk and can guide programming: low or marginal SROL distributions in areas with high supplementation coverage do not signify programme failure, but rather suggest the need to continue supplementation while working to effectively raise dietary VA intakes. We propose that a sustained rise in the SROL distribution, defined as ≤5 % prevalence of SROL < 0·70 μmol/l among vulnerable population groups in at least two consecutive surveys (≥1 year apart), be used as an indicator of stable and adequate dietary VA intake and status in a population, at which point programmes may re-evaluate the need for continued universal supplementation.

The historical evolution of thought regarding multiple micronutrient nutrition

Multiple micronutrient nutrition is an idea that originated in the 1940s and exemplifies the iterative nutritional paradigm. In the first four decades of the 20th century, scientists sought to separate and characterize the vitamins that were responsible for xerophthalmia, rickets, pellagra, scurvy, and beriberi. The dietary requirements of the different micronutrients began to be established in the early 1940s. Surveys showed that multiple micronutrient deficiencies were widespread in industrialized countries, and the problem was addressed by use of cod-liver oil, iodized salt, fortified margarine, and flour fortification with multiple micronutrients, and, with rising living standards, the increased availability and consumption of animal source foods. After World War II, surveys showed that multiple micronutrient deficiencies were widespread in developing countries. Approaches to the elimination of multiple micronutrient deficiencies include periodic vitamin A supplementation, iodized salt, targeted iron/folate supplementation, fortified flour, other fortified foods, home fortification with micronutrient powders, and homestead food production. The prevention of multiple micronutrient malnutrition is a key factor in achieving the Millennium Development Goals, given the important effects of micronutrients on health and survival.

Can multi-micronutrient food fortification improve the micronutrient status, growth, health, and cognition of schoolchildren? A systematic review

Micronutrient deficiencies compromise the health and development of many school-age children worldwide. Previous research suggests that micronutrient interventions might benefit the health and development of school-age children and that multiple micronutrients might be more effective than single micronutrients. Fortification of food is a practical way to provide extra micronutrients to children. Earlier reviews of (multiple) micronutrient interventions in school-age children did not distinguish between supplementation or fortification studies. The present review includes studies that tested the impact of multiple micronutrients provided via fortification on the micronutrient status, growth, health, and cognitive development of schoolchildren. Twelve eligible studies were identified. Eleven of them tested the effects of multiple micronutrients provided via fortified food compared to unfortified food. One study compared fortification with multiple micronutrients to fortification with iodine alone. Multi-micronutrient food fortification consistently improved micronutrient status and reduced anemia prevalence. Some studies reported positive effects on morbidity, growth, and cognitive outcomes, but the overall effects on these outcomes were equivocal.

Random serial sampling to evaluate efficacy of iron fortification: a randomized controlled trial of margarine fortification with ferric pyrophosphate or sodium iron edetate

BACKGROUND

Random serial sampling is widely used in population pharmacokinetic studies and may have advantages compared with conventional fixed time-point evaluation of iron fortification.

OBJECTIVE

Our objective was to validate random serial sampling to judge the efficacy of iron fortification of a low-fat margarine.

DESIGN

We conducted a 32-wk placebo-controlled, double-blind, iron-intervention trial in 18-40-y-old Swiss women (n = 142) with serum ferritin (SF) concentrations <25 μg/L. Women were randomly assigned to 3 groups to receive 20 g margarine, with 14 mg added iron as either micronized ground ferric pyrophosphate (MGFePP) or sodium iron edetate (NaFeEDTA), or placebo daily. We measured hemoglobin and iron status of subjects at 2 fixed time points (at baseline and the endpoint) plus 3 randomly assigned time points between 4 and 28 wk. With the use of bootstrapping, the number of observations per individual was reduced to 3 and then compared with the 5-time-point data. Mixed-effects models were used to estimate iron repletion over time for random sampling, and analysis of covariance was used for fixed time-point sampling.

RESULTS

Body iron stores increased in women who received MGFePP or NaFeEDTA compared with women who received placebo (P < 0.05). The increase in body iron stores with NaFeEDTA fortification was 2-3 times the increase with MGFePP fortification (P < 0.05); the difference was more marked in women with baseline SF concentrations <15 μg/L (P < 0.05). Random serial sampling reduced the required sample size per group to one-tenth of that for 2 fixed time points. Compared with the 5-time-point analysis, the 3-time-point sparse sampling generated comparable estimates of efficacy.

CONCLUSIONS

When used to evaluate the efficacy of iron fortificants, random serial sampling can reduce the sample size, invasiveness, and costs while increasing sensitivity. Random serial sampling more clearly describes the pattern of iron repletion and may prove useful in evaluating other micronutrient interventions.

Effectiveness of communication campaign on iron deficiency anemia in Kyzyl-Orda region, Kazakhstan: a pilot study

Background

In 2004, wheat flour fortification (WFF) with iron was implemented in Kazakhstan as a public health strategy to increase the iron intake of all women of childbearing age and of children. In 2003, before starting the flour fortification program, a communication campaign on health education took place in a region with a high prevalence of iron deficiency anemia (IDA). The present study aimed to evaluate the prevalence of anemia, iron deficiency and IDA before and after the campaign. In addition, knowledge about IDA and its prevention, as well as awareness about fortified wheat flour, was assessed.

Methods

The subjects of the study were women aged 15-49 years and children aged 2-14 years. The study was carried out in urban and rural areas of Kyzyl-Orda region in 2003 before (March) and after (December) the campaign. Blood samples were collected in order to measure hemoglobin and serum ferritin. In March 80 women and 57 children in the urban area, and 41 women and 41 children in the rural area, participated in the IDA testing. The corresponding participants in December numbered 62, 52, 52, and 57, respectively. The impacts of the communications and information received by participants during the campaign was surveyed with a questionnaire for 195 women in March and 198 women in December including some who participated in the IDA testing.

Results

In March, the prevalence of anemia was 52.0% among 121 women and 58.1% among 98 children, and those with low iron reserve were 63.6%, 49.1% and IDA 40.5%, 11.0%, respectively. In December, the prevalence of anemia had significantly decreased among rural women (from 65.9% to 48.0%, p < 0.05) and among urban children (from 63.1% to 11.5%, p < 0.001). The prevalence of iron deficiency was significantly reduced among the children (from 51.1% to 24.8%, p < 0.001). IDA prevalence was meaningfully decreased among women in urban and combined areas (from 37.5% to 15.0% and 40.5 to 14.8%, respectively, p < 0.001) and among urban children (from 7.1% to 2.1%, p < 0.05). The surveys found that most women knew about IDA and its prevention and that the numbers were similar both in March and in December. The knowledge of the anti-anemic effect of wheat fortified flour improved significantly over the period of the campaign among women both in urban (from 48.5% to 80.9%, p < 0.001) and rural (from 69.8% to 88.6%, p < 0.001) areas.

Conclusion

The study demonstrated that the communication campaign before implementation of WFF program was effectively carried out, giving a biological impact on hematological indices.

Revised Recommendations for Iron Fortification of Wheat Flour and an Evaluation of the Expected Impact of Current National Wheat Flour Fortification Programs

Background

Iron fortification of wheat flour is widely used as a strategy to combat iron deficiency.

Objective

To review recent efficacy studies and update the guidelines for the iron fortification of wheat flour.

Methods

Efficacy studies with a variety of iron-fortified foods were reviewed to determine the minimum daily amounts of additional iron that have been shown to meaningfully improve iron status in children, adolescents, and women of reproductive age. Recommendations were computed by determining the fortification levels needed to provide these additional quantities of iron each day in three different wheat flour consumption patterns. Current wheat flour iron fortification programs in 78 countries were evaluated.

Results

When average daily consumption of low-extraction (≤ 0.8% ash) wheat flour is 150 to 300 g, it is recommended to add 20 ppm iron as NaFeEDTA, or 30 ppm as dried ferrous sulfate or ferrous fumarate. If sensory changes or cost limits the use of these compounds, electrolytic iron at 60 ppm is the second choice. Corresponding fortification levels were calculated for wheat flour intakes of < 150 g/day and > 300 g/day. Electrolytic iron is not recommended for flour intakes of < 150 g/day. Encapsulated ferrous sulfate or fumarate can be added at the same concentrations as the non-encapsulated compounds. For high-extraction wheat flour (> 0.8% ash), NaFeEDTA is the only iron compound recommended. Only nine national programs (Argentina, Chile, Egypt, Iran, Jordan, Lebanon, Syria, Turkmenistan, and Uruguay) were judged likely to have a significant positive impact on iron status if coverage is optimized. Most countries use non-recommended, low-bioavailability, atomized, reduced or hydrogen-reduced iron powders.

Conclusion

Most current iron fortification programs are likely to be ineffective. Legislation needs updating in many countries so that flour is fortified with adequate levels of the recommended iron compounds.

Critical evaluation of strategies for mineral fortification of staple food crops

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

Efficacy of wheat-based biscuits fortified with microcapsules containing ferrous sulfate and potassium iodate or a new hydrogen-reduced elemental iron: a randomised, double-blind, controlled trial in Kuwaiti women

Adverse sensory changes prevent the addition of highly bioavailable ferrous sulfate (FeSO4) to most wheat flours. Poorly absorbable reduced Fe powders are commonly used. Encapsulation of FeSO4can overcome these sensory changes, but the particle size of commercial compounds is too large to be used by flour mills. The first objective of the study was to measure the efficacy in wheat flour of two newly developed Fe compounds, an H-reduced Fe powder (NutraFine™ RS; North America Höganäs High Alloys LLC, Johnstown, PA, USA) and small particle-sized (40 μm) encapsulated FeSO4. As a second objective, the microcapsules were evaluated as a vehicle for iodine fortification. A randomised, double-blind controlled intervention trial was conducted in Kuwaiti women (n279; aged 18–35 years) with low body Fe stores (serum ferritin (SF) < 25 μg/l) randomly assigned to one of three groups (20 mg Fe as NutraFine™ RS, 10 mg Fe as encapsulated FeSO4and 150 μg iodine, or no fortification Fe) who consumed wheat-based biscuits 5 d per week. At baseline and 22 weeks, Hb, SF, transferrin receptor, urinary iodine and body Fe stores were measured. Relative to control, mean SF in the encapsulated FeSO4group increased by 88 % (P < 0·001) and body Fe stores increased from − 0·96 to 2·24 mg/kg body weight (P < 0·001), while NutraFine™ RS did not significantly increase SF or body Fe stores. The median urinary iodine concentration increased from 140 to 213 μg/l (P < 0·01). NutraFine™ RS added at double the amount of Fe as FeSO4was not efficacious in improving Fe status. The newly developed microcapsules were highly efficacious in improving both Fe stores and iodine status.

Dual fortification of salt with iodine and iron: a randomized, double-blind, controlled trial of micronized ferric pyrophosphate and encapsulated ferrous fumarate in southern India

BACKGROUND

Dual fortification of salt with iodine and iron could be a sustainable approach to combating iodine and iron deficiencies.

OBJECTIVE

We compared the efficacy of dual-fortified salt (DFS) made by using 2 proposed contrasting formulas-one fortifying with iron as micronized ground ferric pyrophosphate (MGFePP) and the other with iron as encapsulated ferrous fumarate (EFF)-with the efficacy of iodized salt (IS) in schoolchildren in rural southern India.

DESIGN

After stability and acceptability testing, a double-blind, household-based intervention was conducted in 5-15-y-old children (n = 458) randomly assigned into 3 groups to receive IS or DFS with iron as MGFePP or EFF, both at 2 mg/g salt. We measured hemoglobin, iron status, and urinary iodine at baseline, 5 mo, and 10 mo.

RESULTS

Median serum ferritin and calculated median body iron improved significantly in the 2 groups receiving iron. After 10 mo, the prevalence of anemia decreased from 16.8% to 7.7% in the MGFePP group (P < 0.05) and from 15.1% to 5.0% in the EFF group (P < 0.01). The median urinary iodine concentration increased significantly in the IS and EFF groups (P < 0.001) but not in the MGFePP group. Losses of iodine in salt with 1.8% moisture were high for MGFePP, whereas the EFF segregated in salt with 0.5% moisture and caused color changes in some local foods.

CONCLUSIONS

Both DFSs were efficacious in reducing the prevalence of anemia and iron deficiency in school-age children. Local salt characteristics should be taken into consideration when choosing an iron fortificant for DFS to achieve optimal iodine stability and color.

The importance of bioavailability of dietary iron in relation to the expected effect from iron fortification

BACKGROUND

The most common method of combating iron deficiency is iron fortification, especially in developing countries. However, few studies have shown a significant effect on iron status following iron fortification of low bioavailability diets.

OBJECTIVE

To investigate how iron fortification and dietary modifications affect iron absorption and rates of changes in iron stores.

METHODS

Research has made it possible to predict both iron absorption and the effects of iron fortification and diet modifications on iron stores using recently developed algorithms. Iron absorption and rate of change in iron stores were calculated from nine diets representing a broad range of iron bioavailability and iron contents. The calculations were related to the main target group for iron fortification, that is, women of reproductive age having empty stores but normal haemoglobin concentrations.

RESULTS

As the only measure, iron fortification has practically no effect on iron status if the original diet has low bioavailability. However, after dietary modifications such a diet shows a positive effect on iron stores. The combined action of fortification (6 mg/day) and modest bioavailability changes in a low bioavailability diet results approximately in 40 and 70% greater increases in iron stores than through iron fortification or dietary modification alone.

CONCLUSIONS

It is difficult to achieve good effects on iron status from iron fortification as the only measure if the diet has low bioavailability. Both dietary modifications as well as iron fortification are required to improve effectively the iron status of a population.

Wheat flour fortification is unlikely to benefit the neediest in Guatemala

The potential impact of wheat flour fortification with iron and folic acid was assessed using data about food purchases from the nationally representative 2000 Guatemalan Living Standards Measurement Survey. Of 7265 households, 35% were indigenous and 57% rural; 11% were extremely poor, 35% were poor, and 54% were nonpoor. The percentage of households that purchased wheat flour, sweet bread, French rolls, and sliced bread in the previous 15 d was 10, 88, 59, and 11%, respectively. The median amount of fortified wheat flour equivalents in purchased foods was 50 g/d per adult equivalent; fortified wheat flour equivalents were 7, 25, and 110 g/d for the poverty groups, 16 g/d in indigenous households and 24 g/d in rural households. Wheat flour fortification contributed 2.3 mg/d of iron and 90 microg/d of folic acid per adult equivalent. Assuming 5% bioavailability, wheat flour fortification provided 2% of the recommended dietary allowance (RDA) and 6% of estimated average requirement (EAR) iron levels for women of reproductive age; values were 1, 3, and 12% of EAR levels for the poverty groups, respectively. Wheat flour fortification met 26% of folic acid RDA and 33% of EAR levels for women; values were 5, 16, and 71% of EAR levels for the poverty groups, respectively. In conclusion, the impact of fortification is likely to be substantial for folate status in nonpoor and urban women but limited in the case of iron status among all social groups. The poorest, rural, indigenous populations who suffer the highest burden of nutritional deficiencies likely benefit least from wheat flour fortification.

Treatment of iodine deficiency in school-age children increases insulin-like growth factor (IGF)-I and IGF binding protein-3 concentrations and improves somatic growth

CONTEXT

Iodine deficiency in utero impairs fetal growth, but the relationship between iodine deficiency and postnatal growth is less clear.

OBJECTIVE

The objective of the study was to determine whether iodine repletion improves somatic growth in iodine-deficient children and investigate the role of IGF-I and IGF binding protein (IGFBP)-3 in this effect.

DESIGN, PARTICIPANTS, AND INTERVENTIONS

Three prospective, double-blind intervention studies were done: 1) in a 10-month study, severely iodine-deficient, 7- to 10-yr-old Moroccan children (n = 71) were provided iodized salt and compared with children not using iodized salt; 2) in a 6-month study, moderately iodine-deficient, 10- to 12-yr-old Albanian children (n = 310) were given 400 mg iodine as oral iodized oil or placebo; 3) in a 6-month study, mildly iodine-deficient 5- to 14-yr-old South African children (n = 188) were given two doses of 200 mg iodine as oral iodized oil or placebo. At baseline and follow-up, height, weight, urinary iodine (UI), total T4 (TT4), TSH, and IGF-I were measured; in Albania and South Africa, IGFBP-3 was also measured.

RESULTS

In all three studies, iodine treatment increased median UI to more than 100 microg/liter, whereas median UI in the controls remained unchanged. In South Africa, iodine repletion modestly increased IGF-I but did not have a significant effect on IGFBP-3, TT4, or growth. In Albania and Morocco, iodine repletion significantly increased TT4, IGF-I, IGFBP-3, weight-for-age z scores, and height-for-age z scores.

CONCLUSION

This is the first controlled study to clearly demonstrate that iodine repletion in school-age children increases IGF-I and IGFBP-3 concentrations and improves somatic growth.

Vitamin A supplementation in children with poor vitamin A and iron status increases erythropoietin and hemoglobin concentrations without changing total body iron

BACKGROUND

Vitamin A deficiency impairs iron metabolism; vitamin A supplementation of vitamin A-deficient populations may reduce anemia. The mechanism of these effects is unclear. In vitro and in animal models, vitamin A treatment increases the production of erythropoietin (EPO), a stimulant of erythropoiesis.

OBJECTIVE

We measured the effect of vitamin A supplementation on hemoglobin, iron status, and circulating EPO concentrations in children with poor iron and vitamin A status.

DESIGN

In a double-blind, randomized trial, Moroccan schoolchildren (n = 81) were given either vitamin A (200,000 IU) or placebo at baseline and at 5 mo. At baseline, 5 mo, and 10 mo, hemoglobin, indicators of iron and vitamin A status, and EPO were measured.

RESULTS

At baseline, 54% of children were anemic; 77% had low vitamin A status. In the vitamin A group at 10 mo, serum retinol improved significantly compared with the control group (P < 0.02). Vitamin A treatment increased mean hemoglobin by 7 g/L (P < 0.02) and reduced the prevalence of anemia from 54% to 38% (P < 0.01). Vitamin A treatment increased mean corpuscular volume (P < 0.001) and decreased serum transferrin receptor (P < 0.001), indicating improved iron-deficient erythropoiesis. Vitamin A decreased serum ferritin (P < 0.02), suggesting mobilization of hepatic iron stores. Calculated from the ratio of transferrin receptor to serum ferritin, overall body iron stores remained unchanged. In the vitamin A group at 10 mo, we observed an increase in EPO (P < 0.05) and a decrease in the slope of the regression line of log10(EPO) on hemoglobin (P < 0.01).

CONCLUSION

In children deficient in vitamin A and iron, vitamin A supplementation mobilizes iron from existing stores to support increased erythropoiesis, an effect likely mediated by increases in circulating EPO.

Effects of administration of iron, iodine and simultaneous iron-plus-iodine on the thyroid hormone profile in iron-deficient adolescent Iranian girls

OBJECTIVE

To investigate whether iron supplementation can improve thyroid hormone function in iron-deficient adolescent girls.

DESIGN

A double-blind randomized intervention study.

SETTING

The study was performed from 2002 through 2003 in the Islamic Republic of Iran.

SUBJECTS

103 iron-deficient non-anaemic girls who fulfilled all inclusion criteria were included, and 94 subjects successfully completed the study.

INTERVENTIONS

Patients were randomly assigned to one of four groups and treated with a single oral dose of 190 mg iodine plus 300 mg ferrous sulphate 5 times/week (n=24), 300 mg ferrous sulphate 5 times/week (n=23), a single oral dose of 190 mg iodine (n=25), or a placebo (n=22) for 12 weeks.

RESULTS

All groups were comparable at baseline. After the intervention, there was a significant increase in ferritin and transferrin saturation in the iron+iodine group (17.6 vs 8.7 microg/dl, and 18.8 vs 7.2%, respectively, P<0.001 for both) and in the iron group (P<0.001 for both). Urinary iodine doubled in the iron+iodine group and in the iodine group (P<0.001 for both). Thyroid indices tT4, tT3 and T3RU increased and reverse RT3 decreased in the iron+iodine group (10 vs 8.9 microg/dl, P< 0.001; 143 vs 138 microg/dl, P<0.05; 32.3 vs 28.4%, P<0.001 and 24.8 vs 44.2 ng/dl, P<0.001, respectively) and in the iron group. These two groups did not differ for any of the four indices, but both differed significantly from the iodine and placebo groups.

CONCLUSIONS

Our results indicate that improvement of iron status was accompanied by an improvement in some indices of thyroid hormones.

SPONSORSHIP

This study was supported by the Dean of Research Affairs of the Tehran University of Medical Sciences.

The concentration of free holo-retinol binding protein is higher in vitamin A-sufficient than in deficient Nepalese women in late pregnancy

Free holo-retinol binding protein (RBP) [i.e., unbound to transthyretin (TTR)] plays a role in transporting vitamin A across the placenta during pregnancy. In a cross-sectional study of clinically healthy urban women, we assessed the association among clinical and biochemical factors on estimated concentrations of free holo-RBP during the last trimester of pregnancy. Serum samples obtained from a subsample of women (n = 259), who had participated in the Night Vision Threshold Test study in Nepal, were analyzed for determinations of retinol by HPLC, and RBP, TTR, and alpha-1 acid glycoprotein by radial immunodiffusion. Free holo-RBP concentrations were calculated using dissociation constants for free holo- and apo-RBP. Among these women, 30% were vitamin A deficient based on either the RBP:TTR index < or = 0.36 or serum retinol < 1.05 micromol/L. Using stepwise regression analyses, the RBP:TTR index explained 75% of the variance in free holo-RBP concentrations, whereas retinol explained only 14%. Women were classified as vitamin A sufficient (n = 185) or deficient (n = 74) using the RBP:TTR index and were stratified into 3 gestational groups (I: 24-28 wk, II: 29-33 wk, III: >33 wk). Concentrations of free holo-RBP were higher in vitamin A-sufficient women than in vitamin A-deficient women (mean +/- SEM, 48.1 +/- 1.2 vs. 27.6 +/- 0.8 nmol/L; P < 0.001), and in a 3 x 2 factorial analysis, the interaction between gestational group and vitamin A status was significant. These results demonstrate that the RBP:TTR index is a useful proxy for free holo-RBP concentration and that vitamin A status affects its distribution.

Malnutrition and health in developing countries

Malnutrition, with its 2 constituents of protein-energy malnutrition and micronutrient deficiencies, continues to be a major health burden in developing countries. It is globally the most important risk factor for illness and death, with hundreds of millions of pregnant women and young children particularly affected. Apart from marasmus and kwashiorkor (the 2 forms of protein- energy malnutrition), deficiencies in iron, iodine, vitamin A and zinc are the main manifestations of malnutrition in developing countries. In these communities, a high prevalence of poor diet and infectious disease regularly unites into a vicious circle. Although treatment protocols for severe malnutrition have in recent years become more efficient, most patients (especially in rural areas) have little or no access to formal health services and are never seen in such settings. Interventions to prevent protein- energy malnutrition range from promoting breast-feeding to food supplementation schemes, whereas micronutrient deficiencies would best be addressed through food-based strategies such as dietary diversification through home gardens and small livestock. The fortification of salt with iodine has been a global success story, but other micronutrient supplementation schemes have yet to reach vulnerable populations sufficiently. To be effective, all such interventions require accompanying nutrition-education campaigns and health interventions. To achieve the hunger- and malnutrition-related Millennium Development Goals, we need to address poverty, which is clearly associated with the insecure supply of food and nutrition.